What is the likely diagnosis and treatment for a patient with a one-month history of white penile discharge, dysuria (painful urination), and skin irritation at the urethral opening?

Likely Diagnosis and Treatment

This patient has urethritis, most likely caused by Chlamydia trachomatis and/or Neisseria gonorrhoeae, and should be treated empirically with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7-10 days. 1, 2

Diagnostic Confirmation

The clinical presentation strongly suggests urethritis based on the classic triad of symptoms present for one month:

• White penile discharge (mucopurulent material) 3, 4
• Dysuria (burning with urination) 3, 2
• Urethral meatal irritation (skin irritation at the opening) 4, 5

Objective Documentation Required

Before initiating treatment, confirm urethritis using at least one of these criteria:

• Mucopurulent or purulent discharge on examination 3, 4
• Gram stain of urethral secretions showing ≥5 white blood cells per oil immersion field (preferred rapid diagnostic test) 3, 4
• First-void urine with positive leukocyte esterase test OR ≥10 white blood cells per high-power field on microscopy 3, 4

The Gram stain is particularly valuable because it simultaneously documents urethritis AND identifies gonococcal infection if intracellular Gram-negative diplococci are present. 3

Pathogen Identification

The two principal bacterial pathogens causing urethritis are:

• Chlamydia trachomatis (causes 23-55% of nongonococcal urethritis cases) 4
• Neisseria gonorrhoeae (causes gonococcal urethritis with purulent discharge) 3, 4

Nucleic acid amplification tests (NAAT) on first-void urine or urethral swab are the preferred diagnostic method for both organisms, with sensitivities of 86.1-100% and specificities of 97.1-100%. 4, 6

Other less common causes include Mycoplasma genitalium (20-40% of nonchlamydial NGU), Ureaplasma urealyticum, Trichomonas vaginalis (2-5% of cases), and herpes simplex virus. 4 However, specific testing for these organisms is not routinely indicated unless standard therapy fails. 3

Treatment Regimen

Empiric dual therapy is mandatory because:

• Coinfection with both gonorrhea and chlamydia is common 7, 5
• Delaying treatment while awaiting test results increases transmission risk 3
• Single-organism treatment leads to treatment failures 7

First-Line Empiric Treatment:

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

Alternative for Chlamydia Coverage:

• Azithromycin 1 g orally as a single dose can replace doxycycline 1

This regimen provides complete coverage against both N. gonorrhoeae and C. trachomatis. 7, 6

Critical Management Requirements

Sexual Abstinence and Partner Treatment:

• Patient must abstain from sexual intercourse for 7 days after therapy initiation AND until symptoms completely resolve AND until partners are adequately treated 1, 2
• All sexual partners within the preceding 60 days must be evaluated and treated with the same empiric regimen, even if asymptomatic 1, 4
• Asymptomatic infections are extremely common—many partners have transmissible infection without symptoms 1

Follow-Up Evaluation:

• Re-evaluate if no improvement within 3 days of treatment initiation 1
• Failure to improve requires reassessment of diagnosis and consideration of alternative pathogens like Trichomonas vaginalis, Mycoplasma genitalium, or herpes simplex virus 3, 1
• Repeat screening in 3 months for all patients treated for sexually transmitted infections 2
• Do not repeat testing less than 3 weeks after treatment completion due to risk of false-positive results 2

Additional Testing:

• Offer syphilis serology and HIV testing to all patients diagnosed with a new sexually transmitted infection 1

Common Pitfalls to Avoid

Do not treat empirically without documenting urethritis unless the patient is at high risk for infection and unlikely to return for follow-up. 3 In such cases, empiric treatment is justified to prevent complications and ongoing transmission.

Do not assume treatment failure is due to resistant organisms before confirming treatment compliance and ruling out partner re-exposure. 4 Most apparent treatment failures are due to reinfection from untreated partners.

Do not rely on patient-reported symptoms alone—microscopic confirmation prevents misdiagnosis and inappropriate treatment. 8

In 50% or more of nongonococcal urethritis cases, no causative agent is identified even with comprehensive testing, but empiric treatment remains appropriate. 4