Urethritis, Emergency Medicine

Basics

Description

Urethritis is inflammation of the urethra from any cause (usually infection).
Associated with urethral discharge and dysuria
Urethritis may develop after exposure to a partner with an STD, bacterial vaginosis, or UTI.
Urethritis may also develop after orogenital contact.

Etiology

STD; the most common causes are:
- Neisseria gonorrhoeae (35%)
- Chlamydia trachomatis (25 " 50%)
- Mycoplasma genitalium and Ureaplasma urealyticum (30%)
Rarer causes:
- Trichomonas vaginalis
- Candidal species
- Herpes simplex virus
- Adenovirus
- Genital warts
- Enteric bacteria (in the setting of insertive anal sex)
- Alcohol
- Systemic illnesses
- Urethral foreign bodies

Diagnosis

Symptoms usually develop 1 " 2 wk after exposure but can take up to 4 " 6 wk.
Initially minimal or absent in many patients

Signs and Symptoms

Urethral discharge, dysuria
Cloudy 1st portion of urine
Pyuria
Inguinal adenopathy may be present.

History

Color, consistency, and quantity of urethral discharge.
Associated symptoms of dysuria, urgency, frequency, hematuria, and hematospermia
Risk factors for STDs:
- Recent new partner or multiple sexual partners
- Symptoms of partner
- Anal/oral practices
- Young age
- Lower socioeconomic status

Physical Exam

Urethral discharge
Staining on undergarments
Meatal crusting
Genital lesions
Lymphadenopathy
Palpate testes, epididymis, and spermatic cord:
- Masses or tenderness

Essential Workup

Urethral swabs for N. gonorrhoeae and Chlamydia species will confirm the diagnosis.
DNA amplification, DNA probe, and testing of urine specimens via polymerase chain reaction (PCR) have shown good sensitivity and are acceptable tests
A rapid plasma regain (RPR) or Venereal Disease Research Laboratory (VDRL) should be drawn because STDs frequently occur together.
An HIV test should also be offered to the patient.

Diagnosis Tests & Interpretation

Lab

Gram stain and cultures from urethral swabs should be reviewed when the patient is re-evaluated by his or her physician after treatment.
DNA amplification (ligase chain reaction [LCR] or PCR) can be used on 1st-void urine or urethral swab:
- Equal efficacy for diagnosing N. gonorrhoeae and Chlamydia species
UA should be performed after urethral swabs to identify UTIs.

Differential Diagnosis

Chemical irritation from soaps or spermicides
Epididymitis
Orchitis
Pelvic inflammatory disease
Prostatitis
Reactive arthritis (formerly Reiter syndrome)
Urethral chancre (from syphilis)
UTI

Urethritis in children should arouse suspicion of child abuse.
Because N. gonorrhoeae infects the entire vaginal vault in prepubescents, a speculum exam is not required:
- External exam and cultures are sufficient.
Potential complications:
- Recurrent infections
- Ascending UTIs, including pelvic inflammatory disease and epididymoorchitis
- Fallopian tube damage and infertility
- Arthritis
- Conjunctivitis, uveitis, and blindness

Treatment

Initial Stabilization/Therapy

Most patients will not require significant stabilization.

Ed Treatment/Procedures

Treatment may be given empirically based on probable etiology.
Patients should be treated for both N. gonorrhoeae and C. trachomatis.

Medication

Gonorrhea:
- Azithromycin 2 g orally once
- Cefixime 400 mg PO once
- Cefotaxime 500 mg IM once (administered with probenicid 1 g orally once)
- Cefoxitin 2 g IM once (administered with probenicid 1 g orally once)
- Cefpodoxime 400 mg PO once
- Ceftizoxime 500 mg IM once
- Ceftriaxone 250 mg (peds: 25 " 50 mg/kg) IM/IV once
- Cefuroxime 1 g orally once
- Ciprofloxacin 500 mg PO once
- Gatifloxacin 400 mg PO once
- Levofloxacin 250 mg PO once
- Ofloxacin 400 mg PO once
- Spectinomycin 2 g IM once
Chlamydia:
- Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2 " 5) PO once
- Doxycycline 100 mg PO BID for 7 days
- Erythromycin base 500 mg (peds: 40 mg/kg/d div. QID) PO QID for 7 days
- Erythromycin ethyl succinate 800 mg (peds: 30 " 50 mg/kg/d div. QID) PO QID for 7 days
- Levofloxacin 500 mg PO QD for 7 days
- Ofloxacin: 300 mg PO BID for 7 days
M. genitalium:
- Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2 " 5) PO once

Fluoroquinolones and doxycycline are contraindicated in pregnancy
Azithromycin is safe and effective
Repeat testing 3 wk after treatment is recommended to ensure cure.

Increasing incidence of quinolone-resistant N. gonorrhoeae nationwide.

Follow-Up

Disposition

Admission Criteria
Patients should not require admission for urethritis unless there are other complaints or infections.
Discharge Criteria
All patients should be discharged with follow-up arranged at an outside clinic or with PCP.
Issues for Referral

If child abuse is suspected, child protective services must be involved; the child should be admitted if a safe home situation cannot be ensured.
Sexual partners should be evaluated.
In many states, STDs require reporting.

Follow-Up Recommendations

All patients should follow up with primary care to ensure adequate treatment of the infection.
All patients with suspected or confirmed urethritis should be referred for HIV testing.
Patients should be given information regarding safe sexual practices.

Pearls and Pitfalls

Always treat for both N. gonorrhoeae and C. trachomatis in suspected urethritis.
There is increasing evidence suggesting that patients with recurrent urethritis should be evaluated for infection with other atypical organisms (doxycycline-resistant U. urealyticum or M. genitalium; T. vaginalis)
Always consider other STDs in patients with urethritis.
Ensure that patients will inform their sexual partners so that they can be treated as well.

Additional Reading

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta: U.S. Department of Health and Human Services; 2007.
Mandell GL, Bennett JE, Dolin R (eds). Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Churchill Livingstone; 2004.
Merchant RC, Depalo DM, Stein MD, et al. Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible chlamydia and/or gonorrhea urethritis. Int J STD AIDS. 2009;20(8):534 " 539.
Takahashi S, Matsukawa M, Kurimura Y, et al. Clinical efficacy of azithromycin for male nongonococcal urethritis. J Infect Chemother. 2008;14(6):409 " 412.
Update to CDCs 2010 Sexually Transmitted Disease Treatment Guidelines: Oral Cephalosporins No Longer Recommended Treatment for Gonococcal Infections " MMWR. August 10, 2012.
Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1 " 110.

Codes

ICD9

098.0 Gonococcal infection (acute) of lower genitourinary tract
131.02 Trichomonal urethritis
597.80 Urethritis, unspecified
099.41 Other nongonococcal urethritis, chlamydia trachomatis
099.40 Unspecified other nongonococcal urethritis [NGU]
597.89 Other urethritis

ICD10

A54.01 Gonococcal cystitis and urethritis, unspecified
A59.03 Trichomonal cystitis and urethritis
N34.1 Nonspecific urethritis
A56.01 Chlamydial cystitis and urethritis
B37.41 Candidal cystitis and urethritis
N34.2 Other urethritis

SNOMED

31822004 Urethritis (disorder)
236682002 Gonococcal urethritis (disorder)
30116001 Trichomonal urethritis
236683007 Chlamydial urethritis (disorder)
266563005 Non-venereal urethritis (disorder)

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