What are the likely causes of urethral pain in a 72‑year‑old man after sexually transmitted infections have been excluded?

Likely Causes of Urethral Pain in a 72-Year-Old Male After Excluding STDs

In a 72-year-old man with urethral pain after sexually transmitted diseases have been ruled out, the most likely cause is chronic prostatitis/chronic pelvic pain syndrome, which accounts for approximately 50% of men with persistent urethral symptoms and inflammation without identifiable microbial pathogens. 1

Primary Diagnostic Considerations

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• This is the leading diagnosis when urethral pain, discomfort, and irritative voiding symptoms persist beyond 3 months in men. 1
• Approximately 50% of men with chronic nonbacterial prostatitis/chronic pelvic pain syndrome demonstrate evidence of urethral inflammation without any identifiable microbial pathogens 1
• This condition represents a common pathway of dysfunctional urethral epithelium that becomes "leaky," leading to bacterial and abacterial inflammation, ultimately resulting in fibrosis from chronic impairment 2

Non-Sexually Transmitted Bacterial Urethritis

• In men over 35 years of age (particularly those over 72), urinary tract infections caused by Gram-negative enteric organisms (particularly Escherichia coli) become more common 1
• This is especially relevant in patients with recent urinary tract instrumentation, surgery, or anatomical abnormalities 1, 3
• Classical urinary tract pathogens rather than sexually transmitted pathogens are the predominant causes in older men 3

Urethral Pain Syndrome

• This encompasses dysuria, urinary urgency and frequency, nocturia, and persistent or intermittent urethral and/or pelvic pain in the absence of proven infection 2
• While more frequent in women, it does occur in men 2
• The etiology is multifactorial and may include urethral spasms, early interstitial cystitis, and chronic epithelial dysfunction 2

Secondary Considerations

Epididymitis (Non-STD Related)

• In men over 35 years, nonsexually transmitted epididymitis associated with urinary tract infections from Gram-negative enteric organisms is more common 1
• This typically presents with unilateral testicular pain and tenderness, with palpable epididymal swelling 1

Less Common Infectious Causes

• Trichomonas vaginalis can cause urethritis even when initial STD testing is negative, as it requires specific culture techniques using intraurethral swab or first-void urine specimen 1
• Novel pathogens such as Streptococcus urinalis have recently been implicated in male urethritis, though this remains rare 4
• Herpes simplex virus occasionally causes urethritis 1, 5

Non-Infectious Causes

• Trauma or injection of irritating compounds into the urethra 6
• Urethral stricture or anatomical abnormalities, particularly relevant in elderly patients 1, 3

Critical Diagnostic Approach

Key investigations should include:

• Urinalysis and urine culture for Gram-negative bacteria to identify non-STD bacterial causes 1
• Intraurethral swab or first-void urine specimen for T. vaginalis culture if not previously performed 1
• Evaluation for objective signs of urethritis (>5 WBCs per oil immersion field on urethral smear or >10 WBCs per high-power field in urine) 1, 5
• Assessment for prostatitis through examination of prostatic secretions if chronic symptoms are present 3

Important Clinical Pitfalls

• Do not initiate antimicrobial therapy without objective signs of urethritis (documented inflammation or positive cultures), as symptoms alone are insufficient basis for treatment 1
• Urologic examinations usually do not reveal a specific etiology in chronic cases 1
• The majority of men with "prostatitis" symptoms do not have documentable infection and respond poorly to medications 3
• In over 50% of non-gonococcal urethritis cases, no causative agent is identified even with thorough investigation 4, 6