Urethritis Disease

DESCRIPTION

Syndrome of urethral inflammation marked by painful urination and discharge. Usually a sexually transmitted disease (STD); other causes not uncommon. Untreated cases may gradually resolve, but complications, such as urethral stricture in males or pelvic inflammatory disease (PID) in women, may then ensue.

System(s) affected: Renal/Urologic
Genetics: N/A
Incidence/Prevalence in USA: Very common - over 600,000 cases of Chlamydia and 350,000 cases of Gonorrhea reported in 1998. Highest incidence in urban, non-white populations.
Predominant age: Sexually active, postpubertal
Predominant sex: Classic symptoms more commonly reported by males; incidence in females probably equal

SIGNS AND SYMPTOMS

Both sexes may be asymptomatic carriers of the causative organisms
In males - abrupt onset of symptoms 3 to 5 days after exposure to an infected sexual partner
In females - classic urethral syndrome often not present. Infections which cause simple urethritis in males will often have symptoms besides dysuria, including vaginal discharge and cervicitis
Dysuria - pain throughout urination
Urethral discharge - may be profuse and purulent in acute GC, or scanty, evident only with milking of the urethra with other causes
Urethral itching or tenderness
Tenderness, edema and inflammation of the urethral meatus, especially in women
Dyspareunia
Vaginitis, cystitis, cervicitis in women
Proctitis, pharyngitis, conjunctivitis may also be present (sexual history is important)
Lymphadenopathy or fever are not part of the syndrome and suggest another diagnosis
Bloody discharge - rarely seen and suggests another diagnosis
Suprapubic or abdominal pain suggest another diagnosis or presence of complications, e.g. PID, prostatitis, or cystitis

CAUSES

Predominantly Neisseria gonorrhea and Chlamydia trachomatis infection, often together.
Less common infectious agents include:
- Ureaplasma urealyticum
- Trichomonas vaginalis
- Herpes virus
- Human papillomavirus
- Yeast
- Mycoplasma genitalium
Non-infectious causes – generally rare:
- Foreign bodies
- Soaps
- Shampoos
- Douches
- Spermicides
- Catheters
- Urethral instrumentation
- Manual stimulation

RISK FACTORS

Multiple sexual partners
History of other STD
Unprotected intercourse

LABORATORY

Gram stain of discharge: Polymorphic neutrophils with intracellular gram-negative diplococci strongly indicates GC; sheets of polymorphonuclear leukocytes without organisms suggest Chlamydia, while few to no polymorphonuclear leukocytes suggest other etiologies
Cultures or antigen detection for Chlamydia: Negative results may be false or may indicate another infecting organism
Urinalysis: If indicated, sample discharge before the patient voids; usually normal in cases of simple urethritis
Urine culture: Performed only if Gram stain of discharge is unremarkable or unobtainable
Wet prep of discharge: May reveal Trichomonas; usually reserved in males who fail adequate treatment for GC and Chlamydia
Syphilis, HIV, and Hepatitis B serology as indicated to rule out concomitant STDs

Drugs that may alter lab results: Previous recent treatment with antibiotics may lead to false negative results
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Urethral strictures (untreated GC), intraurethral lesions (venereal warts, congenital anomalies)

SPECIAL TESTS

Viral cultures if typical lesions are present or if symptoms persist despite adequate treatment

IMAGING

Urethrogram for persistent symptoms, rarely indicated

DIAGNOSTIC PROCEDURES

Urethrocystoscopy for persistent cases with suspected foreign body, intraurethral warts

APPROPRIATE HEALTH CARE

All cases can be treated in the outpatient setting
Single dose regimens can be directly observed in the office for noncompliant or high-risk patients
Antibiotics should not be withheld until culture (test) results are known; they should be initiated as soon as cultures (samples) have been collected
Treatment should cover both gonorrhea and chlamydia since they cause the majority of cases and often coexist
Patients with persistent symptoms and signs after adequate treatment should be:
- Evaluated and treated for Trichomonas if present
- Retreated with the original regimen if not compliant
- Treated with an alternative regimen for 14 days if Ureaplasma urealyticum is suspected (tetracycline resistance in ≤10% of isolates)

GENERAL MEASURES

Identification and treatment of sexual partners. For symptomatic individuals, all sexual partners within the previous 30 days should be investigated and treated. For asymptomatic persons the interval is lengthened to 60 days.

SURGICAL MEASURES

N/A

ACTIVITY

Full activity, no sexual intercourse until treatment is completed

DIET

Avoid alcohol with metronidazole

PATIENT EDUCATION

Handouts available online at www.familydoctor.org
Most important to emphasize need for compliance with therapy and treatment of sexual partners. Patients should be urged to undergo screening for other STDs.

PREVENTION/AVOIDANCE

Safer sex protection techniques, treatment of all sexual partners

POSSIBLE COMPLICATIONS

Stricture formation
Epididymitis
PID in women
Disseminated Gonococcal infection
Gonococcal meningitis
Gonococcal endocarditis
Perinatal transmission (Chlamydia conjunctivitis, Chlamydia pneumonia, ophthalmia neonatorum)

EXPECTED COURSE AND PROGNOSIS

If diagnosis is firmly established, appropriate medications prescribed and patient is compliant with treatment, there will be relief of symptoms within days and the problem will resolve without sequelae

ASSOCIATED CONDITIONS

Other STDs - patients should be strongly urged to undergo testing for syphilis Hepatitis B and HIV

AGE-RELATED FACTORS

Pediatric: Proven cases of GC or Chlamydia, Trichomonas should raise the question of sexual abuse
Geriatric: N/A
Others: None

PREGNANCY

Tetracyclines are contraindicated. Avoid Erythromycin estolate because of an increased risk of cholestatic jaundice. Otherwise use the standard treatment recommendations.

OTHER NOTES

For patients who present without symptoms stating that a sexual partner was treated for this problem: Obtain specimens for lab tests, but treat this patient before the results are available (due to the high prevalence of the illness and the possibility of false-negative test results). Use any of the regimens discussed in Medications section.

ABBREVIATIONS

STD = sexually transmitted disease
GC = gonococcus infection
PID = pelvic inflammatory disease

Clinical Investigations

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