What is the recommended management for a sexually active man presenting with urethral discharge and abdominal pain?

Management of Sexually Active Man with Urethral Discharge and Abdominal Pain

Treat immediately with dual therapy: ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days, and urgently evaluate for epididymitis or pelvic complications given the presence of abdominal pain. 1

Immediate Clinical Assessment

The combination of penile discharge and abdominal pain in a sexually active man requires urgent evaluation because abdominal pain suggests possible ascending infection—specifically epididymitis or, less commonly, peritonitis from disseminated gonococcal infection. 2

Key examination findings to document:

• Urethral discharge characteristics: Mucopurulent or purulent discharge indicates urethritis caused by Neisseria gonorrhoeae or Chlamydia trachomatis 1
• Testicular examination: Unilateral testicular pain, tenderness, and palpable epididymal swelling (starting at the lower pole) indicate epididymitis 2
• Prehn sign: Pain relief with scrotal elevation suggests epididymitis rather than testicular torsion 2
• Abdominal examination: Lower abdominal tenderness may represent extension of epididymal inflammation or referred pain 2

Diagnostic Testing (Do Not Delay Treatment)

Obtain these tests before initiating antibiotics, but do not wait for results to treat:

• Urethral Gram stain: ≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis; intracellular gram-negative diplococci indicate gonorrhea 1
• Nucleic acid amplification testing (NAAT): First-void urine or urethral swab for N. gonorrhoeae and C. trachomatis 1
• First-void urinalysis: ≥10 white blood cells per high-power field or positive leukocyte esterase supports urethritis 1
• HIV and syphilis serology: All patients with sexually transmitted urethritis require screening 1

First-Line Empiric Treatment

The standard regimen covers both gonorrhea and chlamydia because:

• C. trachomatis causes 23-55% of nongonococcal urethritis cases 3
• Co-infection rates are high, and clinical presentation cannot reliably distinguish pathogens 1
• Single-pathogen treatment leads to treatment failure and ongoing transmission 1

Recommended dual therapy:

• Ceftriaxone 500 mg intramuscularly as a single dose 1
• PLUS doxycycline 100 mg orally twice daily for 7 days 1

If epididymitis is confirmed (based on testicular tenderness and swelling), extend doxycycline to 10 days. 2

Alternative Regimens (Only if Doxycycline Contraindicated)

• Erythromycin base 500 mg orally four times daily for 7 days PLUS ceftriaxone 500 mg IM 3
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days PLUS ceftriaxone 500 mg IM 3

Important caveat: Azithromycin 1 g single dose is FDA-approved for chlamydial urethritis 4, but doxycycline is now preferred first-line because it provides better coverage for Mycoplasma genitalium and Ureaplasma species, which cause 20-40% of nongonococcal urethritis 3

Critical Management of Abdominal Pain

The presence of abdominal pain requires specific evaluation for:

• Epididymitis: Most likely cause in men under 35 with sexually transmitted pathogens 2
• Testicular torsion: Surgical emergency—must be excluded if pain onset was sudden or severe 2
• Disseminated gonococcal infection: Rare but can cause perihepatitis (Fitz-Hugh-Curtis syndrome) 2

If epididymitis is diagnosed:

• Prescribe bed rest, scrotal elevation, and NSAIDs until fever and inflammation resolve 2
• Mandatory reassessment at 72 hours: Lack of improvement requires ultrasound and consideration of abscess, tumor, or alternative diagnosis 2

Red flags requiring immediate surgical consultation:

• Sudden onset of severe pain (suggests torsion) 2
• Negative Prehn sign (pain worsens with scrotal elevation) 2
• Fever with systemic symptoms (suggests abscess or necrotizing infection) 2

Patient Instructions

Sexual activity restrictions:

• Abstain from all sexual intercourse for 7 days after starting treatment AND until symptoms completely resolve 1
• Do not resume sexual activity until all partners have been treated 1

Expected clinical response:

• Urethral discharge and dysuria should improve within 3 days 1
• If epididymitis is present, testicular pain should begin improving within 3 days of antibiotics 2
• Return immediately if no improvement by day 3—this indicates treatment failure or wrong diagnosis 1, 2

Partner Management (Mandatory)

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

• Partners receive ceftriaxone 500 mg IM single dose PLUS doxycycline 100 mg twice daily for 7 days 1
• Expedited partner therapy (providing prescriptions directly to the patient for their partners) is an acceptable alternative when partner evaluation is not feasible 3

Rationale: Female partners of men with nongonococcal urethritis have high rates of chlamydial infection and risk pelvic inflammatory disease; male partners are often asymptomatic carriers 3

Follow-Up Strategy

Routine test-of-cure at 3-4 weeks is NOT recommended unless:

• Symptoms persist or recur after completing therapy 3
• Therapeutic noncompliance is suspected 3
• Reinfection from untreated partner is likely 3

Mandatory repeat STI screening at 3-6 months because reinfection rates exceed 20% in this population 3

Common Pitfalls to Avoid

Do not treat with fluoroquinolones (ciprofloxacin, levofloxacin) for suspected gonorrhea—resistance rates exceed 70% in many regions, making these agents ineffective 5

Do not use azithromycin monotherapy—single-dose azithromycin alone is no longer recommended as first-line because it misses M. genitalium cases that require longer courses 3

Do not attribute abdominal pain to "referred pain" without excluding epididymitis—failure to diagnose and treat epididymitis can lead to abscess, testicular infarction, or chronic pain 2

Do not delay treatment waiting for test results—empiric dual therapy must be initiated immediately based on clinical diagnosis 1

Do not assume negative urinalysis rules out sexually transmitted urethritis in men under 35—urethral pathogens (C. trachomatis, N. gonorrhoeae) often do not cause significant pyuria, and urethral swab testing is required 2