How to manage a sexually active adult male with symptoms of a sexually transmitted infection (STI), with no known allergies or medical conditions, in an urgent care setting?

Management of Male with STI Symptoms in Urgent Care

Yes, treat immediately with empiric antibiotics in urgent care—specifically ceftriaxone 125 mg IM plus doxycycline 100 mg orally twice daily for 7-10 days to cover both gonorrhea and chlamydia, without waiting for test results. 1, 2

Immediate Empiric Treatment is Standard of Care

The CDC guidelines explicitly recommend treating STI symptoms presumptively before culture or nucleic acid amplification test (NAAT) results are available 1. This approach prioritizes preventing serious complications including:

• Epididymitis and potential infertility in men 1
• Transmission to sexual partners, particularly preventing pelvic inflammatory disease (PID) in female partners 1
• Reinfection cycles that perpetuate community transmission 1

Approximately 70% of chlamydia infections and 53-100% of extragenital gonorrhea infections are asymptomatic or minimally symptomatic, making empiric treatment critical even when symptoms are mild 2.

Recommended Treatment Regimen

For Heterosexual Men (Standard Regimen):

• Ceftriaxone 125 mg IM single dose 1
• PLUS doxycycline 100 mg orally twice daily for 7 days (for urethritis) or 10 days (for epididymitis) 1

This dual therapy covers both N. gonorrhoeae and C. trachomatis, which frequently co-occur 1.

For Men Who Have Sex with Men (MSM):

• Ceftriaxone 125 mg IM single dose is mandatory (quinolones should NOT be used due to high rates of quinolone-resistant N. gonorrhoeae in MSM populations) 1
• PLUS doxycycline 100 mg orally twice daily for 7-10 days 1

Age-Specific Considerations for Epididymitis:

Men under 35 years (sexually active):

• Use the standard regimen above covering C. trachomatis and N. gonorrhoeae 1, 3

Men over 35 years (or with recent urinary instrumentation):

• Consider ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days to cover enteric Gram-negative organisms like E. coli 1, 3
• This population typically has epididymitis from urinary tract pathogens rather than STIs 3

Critical Diagnostic Steps to Perform Simultaneously

While treating empirically, obtain these tests 1, 4:

• Urethral Gram stain (if urethral discharge present): >5 polymorphonuclear leukocytes per oil immersion field confirms urethritis 1
• NAAT for N. gonorrhoeae and C. trachomatis on urethral swab or first-void urine (sensitivity 86.1-100%, specificity 97.1-100%) 2
• Urinalysis and urine culture if epididymitis suspected (especially in men >35 years) 3, 4
• Syphilis serology (all patients with STI symptoms require screening) 1, 4
• HIV counseling and testing (mandatory for all STI presentations) 1, 4

Common Pitfalls and How to Avoid Them

Pitfall #1: Waiting for Test Results Before Treatment

Avoid this: The majority of patients will not return for follow-up, leading to untreated infection and ongoing transmission 5, 6. Emergency and urgent care settings have particularly poor follow-up rates 5, 6.

Pitfall #2: Treating Only Gonorrhea or Only Chlamydia

Avoid this: Co-infection rates are high, and patient-delivered partner therapy must include treatment for both organisms 1. Single-agent therapy leads to treatment failure and persistent symptoms 1.

Pitfall #3: Using Quinolones in MSM or Travelers

Avoid this: Quinolone-resistant N. gonorrhoeae (QRNG) prevalence is extremely high in MSM, patients with recent foreign travel, and infections acquired in California or Hawaii 1. Always use ceftriaxone in these populations 1.

Pitfall #4: Missing Testicular Torsion

Avoid this: Sudden, severe testicular pain with nausea/vomiting suggests torsion, not epididymitis 4. Torsion requires surgical exploration within 6-8 hours to prevent testicular loss 4. If uncertain, obtain urgent Doppler ultrasound 4.

Pitfall #5: Inadequate Partner Management

Avoid this: Provide expedited partner therapy (EPT)—give the patient prescriptions or medications for their partners 1. All partners within 60 days of symptom onset (or most recent partner if >60 days) must be treated 1.

Adjunctive Measures for Epididymitis

If epididymitis is present, add 1, 3:

• Bed rest until fever and inflammation subside
• Scrotal elevation
• NSAIDs for pain control

When to Hospitalize

Consider hospitalization for 1, 3:

• Severe pain suggesting abscess, testicular infarction, or torsion
• Fever or systemic toxicity
• Inability to tolerate oral medications
• Concern for noncompliance with outpatient therapy

Follow-Up Instructions

• Instruct patients to abstain from sexual intercourse until they and all partners complete therapy and are symptom-free 1
• Retest in 3 months due to high reinfection rates (not test-of-cure, which is not recommended) 1
• Return immediately if symptoms persist after 3 days of treatment, which requires re-evaluation for alternative diagnoses including abscess, tumor, or treatment failure 1, 3

Special Populations

Pregnant partners: Male patients must inform female partners about the critical importance of evaluation for PID, which requires more intensive therapy during pregnancy 1.

HIV-positive patients: Use the same treatment regimens as HIV-negative patients 1.

Allergy to cephalosporins: Spectinomycin 2 g IM is an alternative, but it is only 52% effective against pharyngeal gonorrhea 1.