Urethritis

para>Annual chlamydia and gonorrhea screening is recommended for all sexually active women <25 years, women >25 years with risk factors, and all men who have sex with men (3).

DIAGNOSIS

Chief complaint
- Urethral discharge (mucopurulent suggestive of N. gonorrhoeae)
- Dysuria
- Erythema of the urethral meatus
- Symptom onset 2 to 8 days following exposure
History
- Sexual history, including condom use, number of partners, sexual behaviors
- Previous STIs
- Substance abuse
- Recent travel
- Symptoms indicative of complications or additional sites of infection (i.e., men: testicular pain and swelling, anal itching, rectal pain or bleeding; women: lower abdominal pain, dyspareunia, irregular vaginal bleeding)
Male GU exam (possible findings)
- Urethral discharge
- Meatal erythema
- Testicular tenderness
- Palpate scrotum to check for epididymitis or orchitis.
- Check for ulcers.
- Check for inguinal lymphadenopathy.
Female GU exam (possible findings)
- Vaginal discharge
- Endocervical discharge, hyperemia, and/or friability

Pediatric Considerations

Pediatric infections with gonorrhea and chlamydia after the neonatal period strongly suggest sexual contact. If indicated, investigations should be initiated promptly (3).

DIFFERENTIAL DIAGNOSIS

Other genitourinary tract diseases
- Cystitis/urinary tract infection
- Epididymitis
- Prostatitis
- PID
- Pyelonephritis
Vaginal atrophy, especially in postmenopausal women
Stevens-Johnson syndrome
Reiter syndrome: uveitis, urethritis, arthritis
Wegener granulomatosis

DIAGNOSTIC TESTS & INTERPRETATION

ALERT

Health care providers are required to report all gonorrhea and chlamydia infections in accordance with local and state requirements.

Initial Tests (lab, imaging)

Gram-stain diagnosis of urethritis if: urethral secretions with ≥2 WBC per oil immersion field, mucopurulent or purulent discharge, or first void urine sediment with ≥10 WBC per high-power field (hpf) (3)
Gonorrhea
- Nucleic acid amplification test (NAAT): in men: first void urine preferred (90 " 100% sensitivity, 97 " 100% specificity for gonorrhea); in women: vaginal swab preferred (patient or clinician collected), end cervical swab acceptable, first void urine may detect 10% fewer infections (3)[A]
- Culture: traditional gold standard " most commonly used in cases of suspected treatment resistance (3)
Chlamydia
- NAAT: in men: first catch urine equal to urethral swab (85 " 95% sensitivity, 93 " 99% specificity); in women: vaginal swab preferred (patient or clinician collected), end cervical swab acceptable, first void urine may detect 10% fewer infections (3)[A]
- Tissue cultures: traditional gold standard, but currently NOT recommended (3)
- If concern for trichomonas: NAAT (urine, urethral, vaginal, or endocervical swab), wet mount, or culture
- There is no FDA-approved diagnostic test available for M. genitalium.

ALERT

Due to the similarity in clinical symptoms and high rates of coinfection, cotesting for gonorrhea and chlamydia infection is recommended. In addition, given that risk factors for gonorrhea and chlamydia indicate risks for other STIs, screening for HIV, RPR, Hepatitis C, and Hepatitis B may also be indicated.

Follow-Up Tests & Special Considerations

Test of cure for chlamydia and gonorrhea is recommended in pregnant women or when treatment noncompliance is suspected (3).
Repeat testing in 3 months recommended due to rates of reinfection (3)
HIV infection: Persons with HIV infection should receive the same treatment as patients without HIV infection (3).

Diagnostic Procedures/Other
Urethrocystoscopy for cases with suspected foreign body, intraurethral warts, urethral stricture
Test Interpretation
Urethral strictures (untreated gonorrhea), intraurethral lesions (venereal warts, congenital anomalies), PID, or tubo-ovarian abscesses are possible.

TREATMENT

GENERAL MEASURES

Most cases can be treated in the outpatient setting.
Single-dose regimens with direct observation preferred (3)

MEDICATION

First Line

Gonorrhea
- Ceftriaxone 250 mg IM plus either: azithromycin 1 g PO 1 dose (preferred) OR doxycycline 100 mg PO BID for 7 days (if azithromycin allergy) (3)[A]
- For children ≤45 kg: ceftriaxone 25 to 50 mg/kg (max 125 mg) IM 1 dose. For children >45 kg: use adult dosing.
Chlamydia
- Azithromycin: 1 g PO 1 dose OR
- Doxycycline: 100 mg PO BID for 7 days (3)[A]
- Alternative regimens (all for 7 days): erythromycin base 500 mg PO QID, erythromycin ethylsuccinate 800 mg PO QID, levofloxacin 500 mg daily, OR ofloxacin 300 mg PO BID
Trichomonas
- Metronidazole: 2 g PO 1 dose
Recurrent and resistant urethritis
- Metronidazole: 2 mg PO single dose OR tinidazole 2 g PO single dose plus azithromycin 1 g PO 1 dose
Contraindications: sensitivity to any of the indicated medications
Precautions: Patients taking tetracyclines may have increased photosensitivity.
Significant possible interactions
- Tetracyclines should not be taken with milk products or antacids.
- Oral contraceptives may be rendered less effective by oral antibiotics. Patients and partners should use a back-up method of birth control for the remainder of the cycle.

Pregnancy Considerations

Chlamydia: All pregnant women <25 years and older women at increased risk should be screened for chlamydia at their first prenatal visit and again in the 3rd trimester. Women with chlamydia infections should be treated, have a documented TOC 3 to 4 weeks after treatment, and retested in 3 months (3).
Gonorrhea: All pregnant women <25 years and older women at increased risk should be screened for gonorrhea at their first prenatal visit and again in the third trimester. Women with gonorrhea infections should be treated and be retested in 3 months (3).
Tetracyclines and quinolones are contraindicated.
Avoid erythromycin estolate because of an increased risk of cholestatic jaundice.
Single-dose therapy is recommended.

Second Line

Gonorrhea: If ceftriaxone is not an option, cefixime 400 mg PO 1 dose plus either: azithromycin 1 g PO 1 dose OR doxycycline 100 mg PO BID for 7 days (if azithromycin allergy); followed by a TOC in 1 week (3).
Chlamydia alternative regimens (all for 7 days): erythromycin base 500 mg PO QID, erythromycin ethylsuccinate 800 mg PO QID, levofloxacin 500 mg daily, OR ofloxacin 300 mg PO BID (3)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Sexual activity should be avoided for 7 days following administration of single-dose therapy or until completion of multiday regimen.
All sexual partners who came in contact with the patient within 60 days should be referred for evaluation, testing, and presumptive treatment (3).
Expedited partner therapy (EPT) is an acceptable alternative. EPT " the practice of treating the diagnosed patient 's sex partner(s) for chlamydia or gonorrhea by providing medications or prescriptions to the patient to provide to the partner(s) without clinical evaluation (3).

Patient Monitoring

Instruct patients to return if symptoms persist or recur after completing treatment.
Test of cure in 3 to 4 weeks in pregnant women suspected of nonadherence, reinfection, persistent symptoms
Screen for reinfection in all patients at 3 months.

DIET

Avoid alcohol when taking metronidazole.

PATIENT EDUCATION

Behavioral counseling interventions are recommended. Evidence of benefit increase with intensity of intervention (4).
Successful approaches include basic information about STIs and transmission, assess risk for transmission, include training skills (i.e., condom use, communication about safe sex, problem solving, goal setting) (4).

PROGNOSIS

If the diagnosis is firmly established, appropriate medications are prescribed and the patient is compliant with treatment; relief of symptoms occurs within days and the problem will resolve without squeal.

COMPLICATIONS

Stricture formation
Epididymitis
Prostatitis
PID in women
Disseminated gonococcal infection
Gonococcal meningitis
Gonococcal endocarditis
Perinatal transmission (chlamydial conjunctivitis, chlamydial pneumonia, ophthalmia neonatorum)
Reiter syndrome

REFERENCES

11 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2013. Atlanta, GA: U.S. Department of Health and Human Services; 2014.22 LeFevre ML. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):902 " 910.33 Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1 " 137.44 O 'Connor EA, Lin JS, Burda BU, et al. Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;161(12):874 " 883.

ADDITIONAL READING

U.S. Preventive Services Task Force. Final Recommendation Statement. Gonorrhea and Chlamydia: Screening 2014. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/chlamydia-and-gonorrhea-screening. Accessed 2015.

CODES

ICD10

N34.2 Other urethritis
A56.01 Chlamydial cystitis and urethritis
A54.01 Gonococcal cystitis and urethritis, unspecified
N34.1 Nonspecific urethritis
M02.30 Reiter 's disease, unspecified site

ICD9

597.80 Urethritis, unspecified
597.89 Other urethritis
099.41 Other nongonococcal urethritis, chlamydia trachomatis
098.0 Gonococcal infection (acute) of lower genitourinary tract
099.3 Reiter 's disease
597.81 Urethral syndrome NOS

SNOMED

31822004 Urethritis (disorder)
429728004 Bacterial urethritis
236683007 Chlamydial urethritis (disorder)
236682002 Gonococcal urethritis (disorder)
236690002 Reiter 's urethritis (disorder)
84619001 Nongonococcal urethritis (disorder)

CLINICAL PEARLS

Inflammation of the urethra, frequently associated with dysuria, pruritus, and/or urethral discharge
Common manifestation of STI
Classified as gonococcal (caused by N. gonorrhoeae) and nongonococcal
Nucleic acid amplification test (NAAT) preferred method of diagnosis for men and women
Single-dose regimens with direct observation preferred
In cases of gonorrhea or chlamydia infection, in person or expedited partner therapy (EPT) recommended for all partners of patients within the last 60 days
Given that risk factors for gonorrhea and chlamydia indicate risk for other STIs, screening for HIV, RPR, Hepatitis C, and Hepatitis B may also be indicated.
Repeat testing for gonorrhea and chlamydia in 3 months recommended due to rates of reinfection.
Special considerations in pediatric and pregnant populations
Treatment in persons with HIV infection is the same as in patients without HIV infection.
Health care providers are required to report all gonorrhea and chlamydia infections in accordance with local and state requirements.

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