What could be causing dysuria (painful urination) in a 31-year-old sexually active heterosexual male, particularly when urine first leaves the urethra?

Dysuria in a 31-Year-Old Sexually Active Male

This is most likely urethritis caused by a sexually transmitted infection, specifically Chlamydia trachomatis or Neisseria gonorrhoeae, and you should treat empirically with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 10 days while obtaining diagnostic testing. 1

Immediate Diagnostic Workup

The pain specifically at urethral opening when urination begins is the classic presentation of urethritis rather than cystitis or upper tract infection. 2, 3 In sexually active men under 35 years, sexually transmitted organisms—particularly C. trachomatis—are the predominant cause. 1, 2

Obtain these tests before initiating treatment (but do not delay treatment):

• Gram stain of urethral exudate or intraurethral swab to identify >5 polymorphonuclear leukocytes per oil immersion field (confirms urethritis) and to look for intracellular gram-negative diplococci (presumptive gonorrhea diagnosis) 1
• Nucleic acid amplification test (NAAT) on first-void urine or urethral swab for both N. gonorrhoeae and C. trachomatis 1
• First-void urine microscopy for leukocytes if urethral Gram stain is unavailable 1
• Syphilis serology (all patients with sexually transmitted urethritis require this) 1
• HIV testing with counseling 1

Empiric Treatment Protocol

Start treatment immediately without waiting for culture results because early treatment achieves microbiologic cure, prevents transmission, and reduces complications like epididymitis or infertility. 1

Recommended Regimen for Gonococcal or Chlamydial Urethritis:

• Ceftriaxone 250 mg IM as a single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1

This dual therapy covers both N. gonorrhoeae and C. trachomatis simultaneously, which is critical because coinfection is common and urethritis in young sexually active men is most often caused by these organisms. 1

Critical Follow-Up Actions

• Treat all sexual partners from the past 60 days, even if asymptomatic, to prevent reinfection and ongoing transmission 1
• Advise sexual abstinence until both patient and partners complete treatment and are symptom-free for 7 days 1
• Reassess at 3 days: If no improvement within 3 days of treatment initiation, reevaluate both diagnosis and therapy 1
• Test for Mycoplasma genitalium if symptoms persist after standard treatment with negative initial testing, as this emerging pathogen causes persistent urethritis 1, 4

Important Pitfalls to Avoid

Do not assume this is a simple urinary tract infection from coliform bacteria. In men under 35 who are sexually active, sexually transmitted organisms predominate, not E. coli. 1, 2 Treating with a fluoroquinolone alone (appropriate for E. coli UTI) would miss chlamydial infection entirely.

Do not use fluoroquinolones empirically for suspected STI-related urethritis. The European Association of Urology specifically recommends against ciprofloxacin when local resistance rates exceed 10% or when patients have used fluoroquinolones in the past 6 months. 1 Gonococcal resistance to fluoroquinolones is widespread.

Do not forget that high-dose short-course antibiotics for urethritis may mask incubating syphilis. This is why syphilis serology is mandatory at diagnosis. 1, 5

Do not overlook partner notification. Failure to treat partners leads to reinfection rates exceeding 20% and perpetuates community transmission. 1

When Symptoms Persist

If dysuria continues after completing the 10-day doxycycline course:

• Retest for N. gonorrhoeae and C. trachomatis to confirm microbiologic cure 1
• Test for M. genitalium using NAAT, as this organism causes 15-25% of persistent non-gonococcal urethritis cases 4
• Consider Trichomonas vaginalis testing (causes 2-5% of male urethritis) 1
• Evaluate for urethral stricture or other anatomical abnormalities if infectious workup remains negative 1