What is the appropriate diagnosis and treatment for a 29-year-old male with sharp pain in the urethra during urination, fever, and no discharge?

Diagnosis and Treatment of Urethritis with Fever in a Young Male

This 29-year-old male most likely has urethritis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, and should be treated empirically with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1, 2, 3

Clinical Presentation Analysis

The combination of sharp urethral pain during urination with fever but no discharge is still consistent with urethritis, as asymptomatic infections (including those without visible discharge) are extremely common. 1, 2 The presence of fever raises concern for possible ascending infection such as epididymitis, which in sexually active men under 35 years is most often caused by C. trachomatis or N. gonorrhoeae. 2

Diagnostic Approach

Immediate Testing Required

• Urethral swab for Gram stain: Look for ≥5 polymorphonuclear leukocytes per oil immersion field, which confirms urethritis even without visible discharge. 1, 3
• First-void urine examination: If urethral Gram stain is negative, examine first-void uncentrifuged urine for leukocytes (≥10 WBCs per high-power field) or positive leukocyte esterase test. 1, 2, 3
• NAAT testing: Obtain nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine. 3
• Syphilis serology and HIV testing: Should be offered to all patients diagnosed with a new STI. 2

Key Diagnostic Pitfall

The absence of discharge does not rule out urethritis—many cases present with dysuria and fever alone, particularly with chlamydial infection. 1, 2 The fever component suggests possible epididymitis, which is usually accompanied by urethritis that may be asymptomatic. 2

Empiric Treatment Regimen

First-Line Treatment (Start Immediately)

Ceftriaxone 250 mg IM as a single dose PLUS Doxycycline 100 mg orally twice daily for 7-10 days. 1, 2, 3

• This regimen covers both N. gonorrhoeae and C. trachomatis, the two bacterial pathogens of proven clinical importance in urethritis. 1, 2
• If epididymitis is suspected based on fever and clinical examination, extend doxycycline to 10 days. 2

Alternative Regimen

If doxycycline cannot be tolerated, azithromycin 1 g orally as a single dose can replace doxycycline for chlamydia coverage. 2

For patients who cannot tolerate high-dose regimens, erythromycin base 500 mg orally 4 times daily for 7 days is an alternative, though less convenient. 1

Critical Management Steps

Partner Notification and Treatment

• All sexual partners within the preceding 60 days must be evaluated and treated, as male partners are often asymptomatic carriers. 2
• Expedited partner therapy should be considered where legally permissible. 3

Sexual Activity Restrictions

• Patients must abstain from sexual intercourse for 7 days after therapy initiation and until symptoms resolve and partners are adequately treated. 2, 3

Follow-Up Assessment

• Re-evaluate if no improvement within 3 days—failure to improve requires reassessment of diagnosis and consideration of alternative pathogens like Trichomonas vaginalis or Mycoplasma genitalium. 2, 4, 3
• Repeat testing is not recommended less than 3 weeks after treatment due to risk of false-positive results. 3
• Repeat screening in 3 months is recommended for all patients treated for sexually transmitted infections. 3

Important Clinical Considerations

Why Not Treat as Simple UTI?

In a 29-year-old sexually active male, urethritis from STI is far more likely than a typical urinary tract infection. 2, 5 Treating with typical UTI antibiotics (trimethoprim-sulfamethoxazole or nitrofurantoin) would miss the sexually transmitted pathogens and fail to address the public health need for partner notification. 1, 2

Fever as a Red Flag

The presence of fever suggests possible epididymitis or systemic involvement, which requires the full 10-day course of doxycycline rather than shorter courses used for uncomplicated urethritis. 2 Physical examination should assess for testicular tenderness or swelling.

Reportable Conditions

Both gonorrhea and chlamydia are reportable to state health departments, making specific diagnosis important for public health surveillance. 1