What is the diagnosis and treatment for a patient with dysuria and burning sensation during ejaculation?

Dysuria with Burning During Ejaculation: Diagnosis and Treatment

The most likely diagnosis is urethritis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, and you should treat empirically with ceftriaxone 1000 mg IM/IV plus doxycycline 100 mg twice daily for 7 days while awaiting confirmatory testing. 1

Diagnostic Approach

Essential History and Physical Examination

• Document the character and timing of symptoms: burning specifically during ejaculation points to urethral inflammation, while dysuria alone suggests broader urinary tract involvement 1, 2
• Assess for urethral discharge: mucoid or purulent discharge is present in many cases of urethritis, though asymptomatic infections are common 1
• Sexual history is critical: recent unprotected sexual contact, number of partners, and partner symptoms help identify sexually transmitted infection risk 1
• Age matters for pathogen prediction: in men under 35 years, C. trachomatis predominates; in men over 35 years, coliform bacteria are more common 3

Required Laboratory Testing

• Urinalysis and urine culture to document pyuria (≥5 polymorphonuclear leukocytes per oil immersion field on urethral swab) and rule out bacterial cystitis 1
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis using first-void urine or urethral swab—this is the gold standard for diagnosis 1, 2
• If initial testing is negative but symptoms persist, test for Mycoplasma genitalium, which causes 20-40% of nongonococcal urethritis cases 1, 2
• Gram stain of urethral discharge can provide immediate information: intracellular gram-negative diplococci confirm gonorrhea 1

Treatment Algorithm

Empiric Treatment (Before Test Results)

When diagnostic tools are unavailable or while awaiting results, treat for both gonorrhea and chlamydia 1:

• Ceftriaxone 1000 mg IM or IV (single dose) 1
• PLUS doxycycline 100 mg orally twice daily for 7 days 1

This dual therapy is essential because co-infection rates are high and undertreating gonorrhea risks antibiotic resistance 1.

Targeted Treatment (After Test Results)

• If C. trachomatis confirmed: doxycycline 100 mg twice daily for 7 days (or azithromycin 1 g single dose if compliance is a concern) 1
• If N. gonorrhoeae confirmed: ceftriaxone 1000 mg IM/IV plus doxycycline to cover potential chlamydial co-infection 1
• If both tests negative but symptoms persist: consider empiric treatment for Mycoplasma genitalium or Ureaplasma urealyticum 1, 2

Partner Management

• All sexual partners within the past 60 days must be treated with the same regimen, even if asymptomatic 1
• Advise strict pelvic rest (no sexual activity) until both patient and partners complete treatment and symptoms resolve 1

Critical Pitfalls to Avoid

Do Not Miss Complicated Urethritis

• Severe infection with systemic symptoms (fever, chills, malaise) may require parenteral therapy with IV ceftriaxone 1
• Persistent symptoms after appropriate treatment warrant re-evaluation for treatment failure, reinfection, or alternative diagnoses like chronic prostatitis 1

Distinguish from Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Men with pain in the perineum, suprapubic region, or tip of penis exacerbated by ejaculation may have chronic prostatitis (NIH Type III) rather than simple urethritis 1
• The Meares-Stamey 4-glass test can differentiate chronic bacterial prostatitis from urethritis in refractory cases 1
• Treatment overlap exists: some men with chronic prostatitis respond to urethritis-directed therapy, so empiric treatment for STIs is reasonable before pursuing prostatitis-specific management 1

Do Not Overlook Non-Infectious Causes

• Interstitial cystitis/bladder pain syndrome presents with dysuria and pelvic pain but requires ≥6 weeks of symptoms and negative urine cultures 1
• Trauma or chemical irritation from lubricants, spermicides, or vigorous sexual activity can mimic infectious urethritis 2, 4

Follow-Up Requirements

• Test-of-cure is not routinely needed for uncomplicated chlamydial or gonococcal urethritis if symptoms resolve 1
• Re-test in 3 months to detect reinfection, which is common due to untreated partners 1
• If symptoms persist beyond 7 days of appropriate treatment, perform repeat NAAT and consider M. genitalium testing or referral for cystoscopy to rule out structural abnormalities 1, 2