What is the recommended treatment for a sexually active male patient with an unspecified sexually transmitted disease (STD)?

Treatment of Sexually Transmitted Diseases in Men

For sexually active men with suspected STD presenting with urethritis or genital symptoms, immediate empiric dual therapy with ceftriaxone 125 mg IM plus azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days) should be administered to cover both gonorrhea and chlamydia without waiting for test results. 1, 2, 3

Initial Clinical Assessment and Diagnostic Approach

When evaluating men with suspected STD, document urethritis by identifying:

• Mucopurulent or purulent urethral discharge 1
• ≥5 white blood cells per oil immersion field on Gram stain of urethral secretions 1
• Positive leukocyte esterase test or ≥10 WBCs per high-power field on first-void urine microscopy 1

Obtain nucleic acid amplification tests (NAATs) for both N. gonorrhoeae and C. trachomatis on first-void urine or urethral swab specimens, as these tests have sensitivities of 86.1%-100% and specificities of 97.1%-100%. 4 Testing should be performed at all exposure sites—urethra, pharynx, and rectum based on sexual practices—because extragenital infections are frequently asymptomatic. 5, 4

Recommended Treatment Regimens

For Confirmed or Suspected Gonococcal and Chlamydial Urethritis

Primary regimen:

• Ceftriaxone 125 mg intramuscularly as a single dose 1
• PLUS azithromycin 1 g orally as a single dose 1, 2

Alternative for chlamydia coverage (if azithromycin unavailable):

• Doxycycline 100 mg orally twice daily for 7 days 1, 3

This dual therapy approach is critical because:

• 23%-55% of NGU cases are caused by C. trachomatis 1
• Co-infection rates are substantial 1
• Treatment prevents complications including epididymitis and Reiter's syndrome 1

Important Prescribing Considerations

Quinolones (ciprofloxacin) should NOT be used in:

• Men who have sex with men 1
• Patients with recent foreign travel or partners with travel history 1
• Infections acquired in California, Hawaii, or other areas with increased quinolone-resistant N. gonorrhoeae prevalence 1

For these populations, ceftriaxone remains the only recommended first-line option for gonorrhea. 1

Partner Management and Prevention of Reinfection

All sexual partners within the preceding 60 days must be evaluated and treated empirically with the same dual regimen, even if asymptomatic. 1 This is non-negotiable because:

• Male partners of infected individuals often have asymptomatic urethral infections 1
• Untreated partners lead to rapid reinfection 1
• The majority of post-treatment infections result from reinfection rather than treatment failure 1

Patient-delivered partner therapy (expedited partner therapy) is an acceptable alternative when partner treatment cannot be ensured, particularly for heterosexual patients. 1 However, this approach should NOT be routinely used in men who have sex with men due to high rates of coexisting undiagnosed STDs or HIV. 1

Patients must abstain from sexual intercourse until 7 days after completing therapy and until all partners are treated. 1, 5

Follow-Up and Retesting Strategy

Test-of-cure is NOT required for patients treated with recommended regimens who become asymptomatic. 1 However, two critical follow-up points exist:

1. Retest at 3 months post-treatment is mandatory because reinfection rates are extremely high—occurring in 25% of patients within 3.6 months for chlamydia and 6 months for gonorrhea. 5, 4 If patients don't return at 3 months, retest whenever they next present within 12 months. 1

2. Immediate re-evaluation is required if symptoms persist after treatment, with culture and antimicrobial susceptibility testing for N. gonorrhoeae to detect treatment failure or resistant organisms. 1 Persistent symptoms may also indicate M. genitalium, trichomoniasis, or HSV. 1

Screening for Co-Infections

All men with confirmed STD must undergo concurrent testing for:

• Syphilis using both nontreponemal (RPR/VDRL) and treponemal tests at baseline and repeated at 6-12 weeks if initially negative 5, 4
• HIV testing at baseline, with mandatory repeat at 3 months due to window period 5
• Hepatitis B serologic testing if unvaccinated 5

This comprehensive approach is essential because antimicrobial therapy for gonorrhea or chlamydia may mask or delay symptoms of incubating syphilis. 2 Azithromycin at standard STD treatment doses should NOT be relied upon to treat syphilis. 2

Special Populations and Complications

Men with Epididymitis

For sexually active men under 35 with epididymitis (unilateral testicular pain, tenderness, palpable epididymal swelling):

• Same dual therapy as urethritis: ceftriaxone 125 mg IM plus doxycycline 100 mg twice daily for 7 days 1
• Hospitalization is indicated for severe pain, fever, or suspected noncompliance 1
• Emergency surgical consultation if testicular torsion cannot be excluded 1

High-Risk Populations Requiring Intensified Screening

Men with multiple or anonymous partners, substance use during sex, previous STD history, or men who have sex with men require screening every 3-6 months indefinitely, regardless of symptoms. 5 This is based on data showing STI positivity rates of 20% for chlamydia and 17% for gonorrhea with frequent screening in high-risk populations. 5

Critical Pitfalls to Avoid

1. Never delay treatment waiting for test results in symptomatic patients or those unlikely to return for follow-up 5
2. Never treat gonorrhea without also treating chlamydia unless chlamydia is definitively ruled out 1
3. Never accept patient self-report of "always using condoms" as sufficient reassurance to skip comprehensive STD screening, as condom effectiveness varies with correct and consistent use 5, 6
4. Never test only urethral specimens in men who have sex with men—pharyngeal and rectal testing is mandatory as these sites harbor substantial infections 5
5. Never use single-dose azithromycin alone for NGU without gonorrhea coverage, as this misses gonococcal co-infection 1

Prevention Counseling

Provide specific risk reduction instructions:

• Latex condoms, when used correctly and consistently, provide strongest protection against HIV (>80% reduction in serodiscordant couples) but less complete protection against skin-to-skin transmitted infections like HSV and HPV 6, 7
• Correct use requires: applying before any genital contact, using water-based lubricants only, withdrawing while erect, holding base during withdrawal, and using new condom for each act 5, 6
• Initiate hepatitis B vaccination immediately if unvaccinated (3-dose series at 0,1-2, and 6 months) 5
• Consider hepatitis A vaccination for men who have sex with men 5