What is the appropriate diagnosis and treatment for a patient presenting with penile discharge, potentially indicating a sexually transmitted infection (STI) such as gonorrhea, chlamydia, or trichomoniasis?

Diagnosis and Treatment of Penile Discharge

For a patient presenting with penile discharge, empirically treat with ceftriaxone 250 mg IM as a single dose PLUS either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia. 1, 2, 3

Diagnostic Approach

Document urethritis before initiating treatment using any of the following criteria: 4, 1

• Visible mucopurulent or purulent discharge 4
• Gram stain of urethral secretions showing ≥5 WBCs per oil immersion field (preferred rapid diagnostic test—highly sensitive and specific for both urethritis and gonococcal infection) 4
• Positive leukocyte esterase test on first-void urine OR ≥10 WBCs per high-power field on microscopic examination 4, 1

Critical diagnostic testing includes: 4, 1

• Nucleic acid amplification testing (NAAT) for both N. gonorrhoeae and C. trachomatis on first-void urine or urethral swab (strongly recommended due to high sensitivity and specificity, and because many infections are asymptomatic or minimally symptomatic) 4, 1
• Syphilis serology at diagnosis (all patients with sexually transmitted urethritis must be tested) 1
• HIV testing (urethritis facilitates HIV transmission) 1, 5

Key Diagnostic Considerations

The absence of visible discharge does not exclude urethritis—many chlamydial infections present with minimal or no discharge. 1 Approximately 70% of some STI infections are asymptomatic or minimally symptomatic. 6 Testing for extragenital sites (pharynx, rectum) may be indicated based on sexual exposure history. 4

Empiric Treatment Regimen

Treat immediately upon diagnosis without waiting for test results: 4, 1, 2

Recommended First-Line Therapy

Dual therapy is mandatory to cover both gonorrhea and chlamydia: 1, 2, 7

• Ceftriaxone 250 mg IM as a single dose 1, 2

PLUS one of the following:

• Azithromycin 1 g orally as a single dose (preferred for compliance—directly observed therapy) 4, 1, 8
• Doxycycline 100 mg orally twice daily for 7 days 4, 1, 3

Alternative Regimens (if first-line unavailable)

• Erythromycin base 500 mg orally four times daily for 7 days 4
• Ofloxacin 300 mg orally twice daily for 7 days 4

Provide medication in the clinic and administer the first dose directly observed whenever possible to ensure compliance. 4, 1

Partner Management

All sexual partners within the preceding 60 days must be evaluated and treated with the same empiric dual therapy regimen as the index patient. 4, 1, 2 If the last sexual contact was more than 60 days before diagnosis, treat the most recent partner. 2

Critical partner management steps: 1, 2

• Both patient and partners must abstain from sexual intercourse for 7 days after treatment initiation and until complete symptom resolution 1, 2
• Partners should receive the same dual therapy regimen (ceftriaxone plus azithromycin or doxycycline) even without testing 1, 2
• Patient-delivered partner therapy should NOT be used in men who have sex with men due to high risk of coexisting undiagnosed STDs or HIV 2

Management of Persistent or Recurrent Symptoms

Do not re-treat based on symptoms alone. 1 Confirm objective signs of urethritis (discharge or pyuria) before re-treating. 1

If symptoms persist after completing therapy: 4, 1

• First, assess treatment compliance and partner treatment status—re-treat with the initial regimen if non-compliant or re-exposed to untreated partner 4
• If compliant and partner treated, perform wet mount and culture for Trichomonas vaginalis 4
• If negative for trichomonas, treat with extended erythromycin regimen (500 mg orally four times daily for 14 days) to cover tetracycline-resistant Ureaplasma 4
• Alternative for persistent urethritis: metronidazole 2 g orally as a single dose PLUS azithromycin 1 g orally as a single dose 1

Follow-Up Recommendations

Patients should return if symptoms persist or recur after completing therapy. 4, 1

• Repeat screening at 3 months is recommended for all patients treated for STIs (high reinfection rates) 1
• Persistence of symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 1

Common Pitfalls and Caveats

Avoid these critical errors: 4, 1, 2

• Never treat for gonorrhea alone without chlamydia coverage—co-infection is extremely common (30-40% of cases), and dual therapy prevents treatment failure and complications 1, 2, 7
• Never defer treatment in high-risk patients unlikely to return for follow-up (e.g., adolescents with multiple partners)—treat empirically even without documented urethritis 4
• Never rely on patient-reported symptoms without objective documentation for re-treatment decisions 4, 1
• Never forget partner treatment—reinfection from untreated partners is the primary cause of treatment failure 2

Special Populations

HIV-infected patients should receive the same treatment regimen as HIV-negative patients. 1 However, urethritis may facilitate HIV transmission, making partner treatment particularly important. 1

For sexual assault victims, empirical treatment of chlamydia, gonorrhea, and trichomoniasis is recommended with consideration of metronidazole or tinidazole for trichomoniasis coverage. 4