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Urethritis, Emergency Medicine

Basics

Description

- Potential complications: - Recurrent infections - Ascending UTIs, including pelvic inflammatory disease and epididymoorchitis - Fallopian tube damage and infertility - Arthritis - Conjunctivitis, uveitis, and blindness

- 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

  • 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 vaginalisCandidal speciesHerpes simplex virusAdenovirusGenital wartsEnteric bacteria (in the setting of insertive anal sex)AlcoholSystemic illnessesUrethral 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 partnersSymptoms of partnerAnal/oral practicesYoung ageLower socioeconomic status

Physical Exam

  • Urethral discharge
  • Staining on undergarments
  • Meatal crusting
  • Genital lesions
  • Lymphadenopathy
  • Palpate testes, epididymis, and spermatic cord:

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 infectionsAscending UTIs, including pelvic inflammatory disease and epididymoorchitisFallopian tube damage and infertilityArthritisConjunctivitis, 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 onceCefixime 400 mg PO onceCefotaxime 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 onceCeftizoxime 500 mg IM onceCeftriaxone 250 mg (peds: 25 " 50 mg/kg) IM/IV onceCefuroxime 1 g orally onceCiprofloxacin 500 mg PO onceGatifloxacin 400 mg PO onceLevofloxacin 250 mg PO onceOfloxacin 400 mg PO onceSpectinomycin 2 g IM once
  • Chlamydia:Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2 " 5) PO onceDoxycycline 100 mg PO BID for 7 daysErythromycin base 500 mg (peds: 40 mg/kg/d div. QID) PO QID for 7 daysErythromycin ethyl succinate 800 mg (peds: 30 " 50 mg/kg/d div. QID) PO QID for 7 daysLevofloxacin 500 mg PO QD for 7 daysOfloxacin: 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Chancroid
  • Epididymitis/Orchitis
  • Gonococcal Disease
  • Herpes, Genital
  • Lymphogranuloma Venereum
  • Pelvic Inflammatory Disease
  • Prostatitis
  • Syphilis
  • UTIs, Adult
  • UTIs, Pediatric
  • Vaginal Discharge/Vaginitis

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)