How should an adult male with urethral pain during ejaculation and mild dysuria be evaluated and managed?

Management of Urethral Pain During Ejaculation and Dysuria

This patient most likely has urethritis and should be treated empirically with doxycycline 100 mg orally twice daily for 7 days PLUS ceftriaxone 500 mg IM as a single dose to cover both chlamydia and gonorrhea, without waiting for test results. 1, 2

Diagnostic Evaluation

Confirm urethritis before initiating treatment by documenting at least one of the following objective findings: 1, 2

• Visible mucopurulent or purulent urethral discharge on examination
• ≥10 white blood cells per high-power field in first-void urine sediment
• Positive leukocyte esterase test on first-void urine

Obtain diagnostic testing immediately but do not delay treatment: 1, 2

• Nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis from first-void urine or urethral swab
• Urethral Gram stain if available (≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis) 1
• Syphilis serology and HIV testing should be offered to all patients 1, 2

First-Line Treatment Regimen

The CDC recommends immediate empiric dual therapy: 1, 2

• Doxycycline 100 mg orally twice daily for 7 days (covers C. trachomatis, Mycoplasma genitalium, and Ureaplasma urealyticum)
• PLUS ceftriaxone 500 mg IM single dose (covers N. gonorrhoeae)

This dual regimen is critical because: 1, 2

• C. trachomatis causes only 23-55% of nongonococcal urethritis cases
• M. genitalium responds better to azithromycin but doxycycline remains first-line
• Gonorrhea must be covered empirically if testing is unavailable or results are pending

Alternative regimens if doxycycline is contraindicated: 1

• Erythromycin base 500 mg orally four times daily for 7 days
• OR erythromycin ethylsuccinate 800 mg orally four times daily for 7 days
• Still combine with ceftriaxone 500 mg IM single dose

Critical Behavioral Instructions

Instruct the patient to: 1, 2

• Abstain from all sexual intercourse for 7 days after starting single-dose therapy or until completing the full 7-day doxycycline course AND until symptoms completely resolve
• Abstain from sexual intercourse until all sex partners have been treated
• Return for evaluation only if symptoms persist or recur after completing therapy

Partner Management

All sexual partners within the preceding 60 days require evaluation and empiric treatment: 1, 2

• Partners should receive the same chlamydia-effective regimen (doxycycline or azithromycin) even if the patient's specific etiology is unknown
• Expedited partner treatment (giving the patient prescriptions for partners) is an acceptable alternative approach 1
• Partners should be treated empirically without waiting for test results

Follow-Up Strategy

Patients should return for re-evaluation only if: 1, 2

• Symptoms persist or recur after completing therapy
• No improvement is seen within 3 days of starting treatment (requires diagnostic re-evaluation)

Do not perform test-of-cure at 3-4 weeks unless: 1

• Therapeutic noncompliance is suspected
• Reinfection is suspected
• Symptoms persist

However, repeat testing at 3-6 months is strongly recommended because men with documented chlamydial or gonococcal infections have high reinfection rates. 1

Important Differential Diagnosis Consideration

Be alert to chronic prostatitis/chronic pelvic pain syndrome if: 1, 2

• Pain during or after ejaculation persists for >3 months despite appropriate treatment
• Patient experiences persistent perineal, penile, or pelvic pain
• Irritative voiding symptoms continue beyond 3 months
• New-onset premature ejaculation develops

This condition requires referral to urology for further evaluation and does not respond to standard urethritis treatment. 1, 2

Common Pitfalls to Avoid

Do not treat based on symptoms alone without objective evidence of urethritis - symptoms without documentation of urethral inflammation are not sufficient basis for treatment. 1

Do not use azithromycin 1 g single dose as first-line therapy - while previously recommended, doxycycline 7-day course is now preferred because it provides better coverage for multiple pathogens including M. genitalium. 1, 2

Do not assume all urethritis is sexually transmitted - in men >35 years with risk factors (recent instrumentation, bladder outlet obstruction), enteric gram-negative organisms may be the cause and require different antibiotic coverage. 3, 4

Do not forget to test for other STIs - patients diagnosed with one STI should receive testing for syphilis and HIV. 1, 2