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Definition, Etiology, pathogenesisTop
Urethritis is usually a sexually transmitted disease (STD). Gonococcal urethritis is caused by Neisseria gonorrhoeae, while the more common nongonococcal urethritis is predominantly due to infection with Chlamydia trachomatis but also secondary to infections by Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, or less frequently other microorganisms. Rarely urethritis may be caused by repeated trauma, for example, with bladder catheterization.
Clinical Features Top
Signs and symptoms usually develop within a few days for gonococcal urethritis, and between 1 and 3 to a maximum of 5 weeks for nongonococcal urethritis. Symptoms include pain in the distal urethra at voiding (intensity is highest in the morning); occasional itching around the external opening of the urethra between mictions; frequency and urgency in patients with concomitant cystitis or prostatitis; purulent, occasionally blood-stained urethral discharge, which is sometimes observed only after massaging the urethra; and vaginal discharge in women. Systemic signs and symptoms of infection are absent. Note that the majority of chlamydial infection are asymptomatic, in particular in female patients, potentially leading to pelvic inflammatory disease and its sequelae.
Microscopic examination of a Gram-stained urethral smear or first-void urine combined with nucleic acid amplification test (NAAT) (tests for gonorrhea and chlamydia) are the diagnostic tests of choice. In the microscopic examination, the presence of neutrophils confirms the diagnosis of urethritis, while intracellular gram-negative diplococci within neutrophils are the evidence of gonococcal etiology.
Infection with C trachomatis can be asymptomatic in up to 50% of women and over time may lead to pelvic inflammatory disease and its consequences. In men it can cause urethritis, prostatitis, epididymitis, and infertility.
Due to the limited availability of diagnostic tests for microorganisms typically causing urethritis, empiric treatment for gonococcal and nongonococcal urethritis is usually started as soon as possible and involves a single dose of IM ceftriaxone 500 mg to 1 g (alternatively, a single dose of oral cefixime 400 mg) plus either doxycycline 100 mg bid for 7 days or a single dose of oral azithromycin 1 g. All sexual partners at risk of potential infection should also undergo testing and treatment.