What is the appropriate diagnosis and treatment for a 22-year-old male presenting with dysuria (painful urination) and discharge, who has been experiencing symptoms for 2 days and has only taken over-the-counter (OTC) cranberry medication?

Diagnosis and Treatment of Urethritis in a 22-Year-Old Male

This patient has urethritis, most likely caused by sexually transmitted pathogens (Chlamydia trachomatis and/or Neisseria gonorrhoeae), and should be treated immediately with empiric dual therapy: ceftriaxone 500 mg intramuscularly PLUS doxycycline 100 mg orally twice daily for 7 days. 1, 2

Immediate Diagnostic Approach

Confirm the diagnosis of urethritis by documenting at least one of the following criteria 1, 2:

• Mucopurulent or purulent urethral discharge (already present in this patient)
• Gram stain of urethral secretions showing ≥2 white blood cells per oil immersion field
• First-void urinalysis showing ≥10 white blood cells per high-power field
• Positive leukocyte esterase test on first-void urine

Obtain diagnostic specimens before initiating treatment 1:

• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine
• Urethral Gram stain if available for immediate assessment
• Consider testing for Mycoplasma genitalium if initial tests are negative and symptoms persist 1, 3

Critical Pitfall to Avoid

Do not mistake this for a urinary tract infection requiring cranberry supplements or simple UTI antibiotics. 3, 4 In a sexually active 22-year-old male with dysuria and discharge, urethritis from sexually transmitted pathogens is the primary diagnosis, not cystitis. The 2-day symptom duration and presence of discharge strongly indicate sexually transmitted urethritis rather than a bladder infection. 1, 2

First-Line Empiric Treatment

Initiate treatment immediately without waiting for test results when urethritis is clinically diagnosed 1, 2:

Dual Therapy Regimen:

• Ceftriaxone 500 mg intramuscularly as a single dose (covers N. gonorrhoeae) 1
  • Can be given intravenously if intramuscular injection is not feasible 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days (covers C. trachomatis and M. genitalium) 1, 2

Alternative if Fluoroquinolone Resistance is Low (<10%):

• Ciprofloxacin may be considered only if local resistance rates are <10% and the patient has not used fluoroquinolones in the last 6 months 1

Partner Management and Sexual Activity

All sexual partners from the past 60 days must be evaluated and treated 1:

• Partners should receive the same empiric dual therapy regimen
• Maintain patient confidentiality while ensuring partner notification 1
• Expedited partner treatment (providing prescriptions for partners without examination) is advocated by CDC guidelines 4

The patient must abstain from sexual activity 2:

• For 7 days after starting treatment
• Until all partners have been adequately treated
• Until symptoms have completely resolved

Follow-Up Strategy

Do not perform repeat testing earlier than 3 weeks after treatment completion because false-positive results are common during this period 2

Schedule repeat screening at 3 months after treatment for all patients treated for sexually transmitted urethritis 2

If symptoms persist after appropriate treatment 1:

• Consider Mycoplasma genitalium as the causative organism
• For persistent non-gonococcal urethritis after doxycycline: Add azithromycin 500 mg orally on day 1, then 250 mg orally for 4 days 1
• If macrolide-resistant M. genitalium is detected: Use moxifloxacin 400 mg orally daily for 7-14 days 1
• Rule out reinfection from untreated partners 5

Additional Testing Considerations

Offer HIV counseling and testing to all patients diagnosed with urethritis 1, 4

Screen for syphilis with serology testing 1

Consider testing for Trichomonas vaginalis if initial tests are negative and symptoms persist, as this is another cause of non-gonococcal urethritis 1

Key Clinical Distinctions

This presentation differs from complicated UTI or prostatitis 1, 6:

• Absence of fever, systemic symptoms, or flank pain argues against upper tract infection
• No suprapubic tenderness or obstructive symptoms to suggest prostatitis
• The presence of urethral discharge is pathognomonic for urethritis, not cystitis

The 2-day symptom duration is typical for acute urethritis and does not require extended antibiotic courses beyond the standard 7-day doxycycline regimen 1, 2