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Sunday, August 10, 2025

Urethritis


Definition
Urethritis is inflammation of the urethra, most often caused by infection. It presents with urethral discomfort, discharge, and/or urinary symptoms, and can be sexually transmitted or non-sexually transmitted.

Causes

A. Infectious (most common)

  1. Sexually transmitted pathogens

    • Neisseria gonorrhoeae → Gonococcal urethritis (GU)

    • Chlamydia trachomatis → Nongonococcal urethritis (NGU)

    • Mycoplasma genitalium

    • Trichomonas vaginalis

    • Herpes simplex virus (HSV)

  2. Non-sexually transmitted bacteria

    • Escherichia coli (especially in catheterised patients)

    • Other coliforms and enterococci

B. Non-infectious

  • Mechanical injury (catheterisation, instrumentation)

  • Chemical irritation (soaps, spermicides)

Risk Factors

  • Unprotected sexual intercourse

  • Multiple sexual partners

  • Previous STI

  • New sexual partner

  • Urinary tract instrumentation

  • Poor genital hygiene

Clinical Features

  • Dysuria (burning sensation during urination)

  • Urethral discharge (purulent in gonorrhoea, mucoid or watery in chlamydia/NGU)

  • Urethral pruritus or discomfort

  • Erythema at urethral meatus

  • In some cases: asymptomatic (especially in chlamydia)

  • In women: symptoms may be less specific and overlap with cystitis

Complications

  • Men: epididymitis, prostatitis, infertility

  • Women: pelvic inflammatory disease (PID), infertility, ectopic pregnancy

  • Disseminated gonococcal infection

  • Chronic urethritis

Diagnosis

  • Urethral swab or first-void urine for nucleic acid amplification tests (NAAT) for N. gonorrhoeae and C. trachomatis (gold standard)

  • Gram stain of urethral smear:

    • GU – Gram-negative diplococci inside polymorphonuclear leukocytes

    • NGU – increased WBCs without Gram-negative diplococci

  • Urinalysis to detect pyuria

  • Culture for antibiotic susceptibility in gonorrhoea

  • Consider testing for HIV, syphilis, and other STIs

Treatment

Empirical therapy (covering both gonorrhoea and chlamydia) – recommended while awaiting results in sexually active patients:

  • Ceftriaxone 500 mg intramuscularly single dose (gonorrhoea cover)

  • PLUS Doxycycline 100 mg orally twice daily for 7 days (chlamydia cover)

Alternative for doxycycline: Azithromycin 1 g orally single dose (less preferred due to resistance in M. genitalium)

For specific pathogens:

  • Trichomonas vaginalis: Metronidazole 2 g orally single dose

  • Mycoplasma genitalium: Moxifloxacin 400 mg orally daily for 7–14 days if resistant to first-line agents

Supportive:

  • Abstain from sexual activity until treatment complete and symptoms resolve

  • Test and treat sexual partners from the last 60 days

Prevention

  • Safe sex practices (consistent condom use)

  • Routine STI screening for at-risk populations

  • Prompt treatment of partners to prevent reinfection




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