What is the initial management for a male patient presenting with urethritis?

Initial Management of Male Urethritis

When diagnostic tools are unavailable, treat empirically for both gonorrhea and chlamydia with ceftriaxone 250 mg IM once plus either azithromycin 1 g orally once or doxycycline 100 mg orally twice daily for 7 days. 1, 2, 3

Diagnostic Confirmation Before Treatment (When Resources Available)

Document urethritis first using any of these criteria: 1

• Mucopurulent or purulent urethral discharge on examination 1
• Gram stain showing ≥5 white blood cells per oil immersion field (preferred rapid test—also identifies gonorrhea if gram-negative intracellular diplococci present) 1
• Positive leukocyte esterase test on first-void urine OR ≥10 white blood cells per high-power field on urine microscopy 1

Test all patients for both N. gonorrhoeae and C. trachomatis using nucleic acid amplification testing (NAAT) on urethral swab or first-void urine, as specific diagnosis improves partner notification and compliance. 1

First-Line Empiric Treatment Algorithm

When Urethritis is Confirmed or Highly Suspected:

Treat for both gonorrhea and nongonococcal urethritis simultaneously: 1, 3

• Ceftriaxone 250 mg IM as single dose (covers gonorrhea) 1, 3
• PLUS either:
  • Azithromycin 1 g orally as single dose (preferred for compliance—directly observed treatment possible) 1, 4, 3
  • OR Doxycycline 100 mg orally twice daily for 7 days 1, 3

Common pitfall: Do not defer treatment waiting for test results if urethritis is documented—initiate therapy immediately to prevent complications and transmission. 1

Alternative Regimens (When First-Line Not Tolerated)

For nongonococcal urethritis component when azithromycin/doxycycline cannot be used: 1

• Erythromycin base 500 mg orally four times daily for 7 days 1
• OR Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1
• OR Ofloxacin 300 mg orally twice daily for 7 days 1
• OR Levofloxacin 500 mg orally once daily for 7 days 1

If patient cannot tolerate high-dose erythromycin: Use erythromycin base 250 mg orally four times daily for 14 days OR erythromycin ethylsuccinate 400 mg orally four times daily for 14 days. 1

Critical Partner Management

All sexual partners within the preceding 60 days must be evaluated and treated, regardless of symptoms or test results. 1, 5

Both patient and partners must abstain from sexual intercourse for 7 days after treatment initiation (for single-dose regimens) or until completion of multi-day regimens, and only after symptoms have completely resolved. 1, 6, 3

Expedited partner treatment (providing prescriptions for partners without examination) is endorsed and legal in many jurisdictions to improve treatment rates. 2

Follow-Up Strategy

Instruct patients to return only if symptoms persist or recur after completing therapy—symptoms alone without objective signs are insufficient for retreatment. 1

For persistent/recurrent symptoms: 1, 7

• Re-document urethritis with objective findings (discharge, Gram stain, or urine microscopy) 1, 7
• If compliance was poor or partner untreated: Retreat with initial regimen 1
• If compliance was good and partner treated: Test for Trichomonas vaginalis (wet mount and culture/PCR of urethral specimen or first-void urine) 1, 7
• If Trichomonas negative: Treat with metronidazole 2 g orally once PLUS azithromycin 1 g orally once (if not used initially) to cover possible Mycoplasma genitalium and tetracycline-resistant Ureaplasma 7

Test-of-cure is not routinely recommended if asymptomatic after treatment, but repeat screening at 3 months is indicated due to high reinfection rates. 5, 3

Key Pathogens and Their Prevalence

• C. trachomatis: Most frequent cause of nongonococcal urethritis (23-55% of cases) 1
• N. gonorrhoeae: Co-infection common; racial disparities exist with 40-fold higher rates in Black adolescent males 2
• Mycoplasma genitalium: Responds better to azithromycin than doxycycline 1
• Ureaplasma urealyticum: Causes 20-40% of nongonococcal urethritis 1
• Trichomonas vaginalis: Accounts for 2-5% of cases 1

Critical Complications to Prevent

Untreated urethritis leads to: 1

• Epididymitis (especially with C. trachomatis) 1
• Reiter's syndrome 1
• Infertility 8
• Increased HIV transmission (higher HIV concentration in semen with urethritis) 2
• Infection in female partners with risk of pelvic inflammatory disease 1

All patients with sexually transmitted urethritis should receive syphilis serology and HIV counseling/testing at diagnosis. 1