What is the recommended management, including antimicrobial therapy, counseling, partner notification, and follow‑up, for an adult male with suspected or confirmed sexually transmitted infections?

Management of Sexually Transmitted Infections in Adult Males

Immediate Empiric Treatment Based on Clinical Presentation

For urethritis (purulent or mucopurulent discharge, dysuria), treat immediately with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 7-10 days to cover both gonorrhea and chlamydia. 1, 2, 3, 4

Urethritis Management Algorithm

Diagnostic confirmation:

• Obtain urethral Gram stain showing ≥5 polymorphonuclear leukocytes per oil immersion field to confirm urethritis 1, 3, 5
• Gram-negative intracellular diplococci on Gram stain confirms gonococcal infection 1, 5
• Perform nucleic acid amplification tests (NAATs) on first-void urine or urethral swab for N. gonorrhoeae and C. trachomatis 1, 3, 5, 4
• If Gram stain is negative, examine first-void urine for leukocytes (≥10 WBC per high-power field) or positive leukocyte esterase 1, 3

Treatment regimens:

• Recommended: Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 1, 6
• Doxycycline is now preferred over azithromycin for chlamydia due to superior efficacy 6
• Alternative regimens: Levofloxacin 500 mg orally once daily for 7 days OR ofloxacin 300 mg orally twice daily for 7 days 1
• Azithromycin shows better response for Mycoplasma genitalium infections 1

Epididymitis Management Algorithm

Age-based treatment approach is critical:

For men <35 years (sexually transmitted etiology):

• Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
• This targets N. gonorrhoeae and C. trachomatis, the predominant pathogens in this age group 2, 3

For men ≥35 years (enteric organism etiology):

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 3
• This covers E. coli and other enteric Gram-negative organisms associated with urinary tract abnormalities 2, 3

Adjunctive therapy for all ages:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1, 2, 3

Critical follow-up:

• Reassess within 3 days; failure to improve requires reevaluation of diagnosis and consideration of alternative diagnoses including testicular torsion, tumor, abscess, testicular cancer, tuberculosis, or fungal infection 1, 2, 3

Syphilis Management

For primary, secondary, or early latent syphilis (<1 year duration):

• Penicillin G benzathine 2.4 million units IM single dose 6

For late latent or unknown duration syphilis:

• Penicillin G benzathine 2.4 million units IM weekly for 3 consecutive weeks 6

For neurosyphilis, ocular, or otic syphilis:

• Aqueous crystalline penicillin G IV for 10-14 days 6
• Thorough evaluation for neurologic, ophthalmic, and otic symptoms is essential at any stage 6

Partner Notification and Management

All sexual partners from the preceding 60 days must be evaluated and treated empirically even if asymptomatic. 1, 2, 3

• Partners should receive treatment before laboratory results are available when STI diagnosis is likely 1
• Utilize both patient referral and provider referral strategies 1
• Local health departments can assist with confidential partner notification for HIV, syphilis, gonorrhea, and chlamydia 1
• Patients must abstain from sexual intercourse until both patient and all partners complete therapy and are symptom-free 1, 2, 3

Counseling and Prevention

HIV testing and counseling should be offered to all patients with suspected STIs. 3, 7

• Conduct personalized risk assessment during pretest counseling 1
• Explain meaning of positive and negative test results 1
• Develop realistic, personalized risk reduction plan 1
• Consider doxycycline post-exposure prophylaxis (doxy PEP) for certain high-risk groups 7
• Promote effective barrier contraception 4

Follow-Up Testing

Test-of-cure is required for:

• All cases of pharyngeal gonorrhea 6
• Rectal chlamydia if treated with azithromycin 6

Routine test-of-cure is not required for uncomplicated urogenital gonorrhea or chlamydia if treated with recommended regimens. 6

Critical Pitfalls to Avoid

Always exclude testicular torsion in any patient with acute testicular pain, especially adolescents and when pain onset is sudden and severe. 2, 3, 5

• Torsion is a surgical emergency requiring immediate specialist consultation 3
• Torsion occurs more frequently without clinical evidence of inflammation or infection 3

Do not use ciprofloxacin as first-line therapy for urethritis in men <35 years:

• Ciprofloxacin is not optimal for chlamydial infection 3
• Recommended fluoroquinolones are levofloxacin or ofloxacin, not ciprofloxacin 3

Do not delay treatment while awaiting laboratory results:

• Empiric therapy should be initiated immediately based on clinical presentation 1
• Approximately 70% of HSV and trichomoniasis infections and 53-100% of extragenital gonorrhea and chlamydia are asymptomatic 4

Ensure proper dosing for gonorrhea treatment:

• Current CDC guidelines recommend ceftriaxone monotherapy with weight-based dosing 6
• Standard dose is 250 mg IM for most patients 1, 2, 3

Special Populations

HIV-infected patients:

• Use the same treatment regimens as HIV-negative patients for uncomplicated infections 1, 2, 3
• Maintain higher suspicion for fungal and mycobacterial causes in immunosuppressed patients 1, 2, 3

Patients with penicillin allergy:

• For epididymitis: Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 3

Reporting Requirements

Report all confirmed cases of gonorrhea, chlamydia, syphilis, and HIV to local health departments. 1

• Accurate identification and timely reporting are integral to disease control 1
• Specific diagnosis improves partner notification and treatment 1