What are the typical symptoms of sexually transmitted infections in men and what is the recommended evaluation and treatment?

Symptoms of Sexually Transmitted Infections in Men

Most Common Presentations

Most men with STIs are completely asymptomatic, making screening based on risk factors more important than waiting for symptoms to develop. 1

When symptoms do occur, they typically present in the following patterns:

Urethritis (Most Common Symptomatic Presentation)

• Urethral discharge (clear, white, or purulent) caused by Chlamydia trachomatis or Neisseria gonorrhoeae 2
• Dysuria (burning with urination) 3
• Urinary frequency or urgency 3
• Many cases show ≥5 polymorphonuclear leukocytes per oil immersion field on Gram-stained urethral smear 2

Epididymitis

In sexually active men aged 14-35 years, epididymitis from C. trachomatis or N. gonorrhoeae presents with:

• Gradual onset of unilateral testicular pain over hours to days (not sudden like torsion) 4, 3
• Pain starting at the lower pole of epididymis progressing upward 3
• Positive Prehn sign (pain relief when elevating scrotum) 3
• Scrotal swelling and tenderness 3
• Often accompanied by urethral discharge or dysuria 3

In men over 35 years, epididymitis is typically from enteric bacteria (E. coli) and associated with:

• Urinary symptoms (weak stream, frequency, urgency) 4
• Recent urinary instrumentation or anatomical abnormalities 4

Genital Warts

• Visible papular lesions on penis, scrotum, or perianal area caused by HPV types 6 or 11 2
• Usually asymptomatic unless large or irritated 2

Pharyngeal and Rectal Infections

Critical point: Most extragenital STIs are asymptomatic 5, 6

• Pharyngeal gonorrhea prevalence is 9.2% in MSM but rarely causes pharyngitis 5
• Rectal chlamydia (7.9%) and gonorrhea (6.9%) are 85% asymptomatic in MSM 5
• Rectal symptoms when present: discharge, pain, bleeding, or tenesmus 5

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Recommended Evaluation Approach

For Men <35 Years (Sexually Active)

Test for STI pathogens even with negative urinalysis, as urethritis-associated epididymitis frequently presents without significant pyuria: 3

1. Urethral Gram stain or intraurethral swab for urethritis diagnosis (≥5 PMNs/field) 2
2. Nucleic acid amplification testing (NAAT) on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 2, 3
3. Syphilis serology 2
4. HIV testing with counseling 2

For MSM specifically, extragenital screening is essential:

• Pharyngeal and rectal NAAT for gonorrhea and chlamydia 5, 7
• >70% of chlamydia and >80% of gonorrhea infections would be missed with urine testing alone 7

For Men >35 Years

1. Urinalysis examining first-void uncentrifuged urine for pyuria 3
2. Urine culture and Gram stain for enteric organisms 4, 3
3. Consider Doppler ultrasound if diagnosis uncertain or to exclude torsion 4

Critical Red Flags Requiring Immediate Surgical Consultation

• Sudden onset of severe testicular pain (suggests torsion, not STI) 2, 3
• Negative Prehn sign 3
• Testicular viability compromised within 6-8 hours if torsion present 3

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Treatment Recommendations

For Urethritis or Epididymitis in Men <35 Years (STI-Related)

Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2, 3

• Covers both N. gonorrhoeae and C. trachomatis 2
• Treat empirically before culture results available 2

Alternative for enteric organisms or cephalosporin allergy:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 2, 3

For Epididymitis in Men >35 Years (Enteric Bacteria)

Fluoroquinolone monotherapy: Levofloxacin 500 mg orally once daily for 10 days 4, 3

Adjunctive Measures

• Bed rest and scrotal elevation until fever and inflammation subside 2, 4
• NSAIDs for pain control 4
• Avoid sexual intercourse until patient and partners complete treatment and are asymptomatic 2

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Partner Management

All sex partners within 60 days preceding symptom onset must be evaluated and treated: 2

• For symptomatic men, 30-day exposure period is sufficient 2
• For asymptomatic infections, 60-day period recommended 2
• Female partners require examination for PID, which needs more intensive therapy 2
• Male partners can be treated presumptively even without examination if they have no symptoms of other STDs and no drug allergies 2

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Common Pitfalls

Failure to improve within 3 days requires re-evaluation for:

• Testicular torsion, tumor, abscess, testicular cancer, or tuberculous/fungal epididymitis 2, 4
• Wrong diagnosis or inadequate antimicrobial coverage 2

Relying solely on urinalysis misses the majority of STI-related cases in younger men because infections originate from urethral pathogens, not urinary tract bacteria 3

Testing only urethral sites in MSM misses 53% of chlamydia and 64% of gonorrhea infections located at pharyngeal or rectal sites 5

Most STIs in men are asymptomatic - screening based on sexual behavior and risk factors is more effective than symptom-based testing 1, 6