Urethritis - male

Overview

Urethral discharge and/or dysuria are typical symptoms of male urethritis.

Possible causes

  • Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causes of male urethritis.
  • Other organisms include:Mycoplasma genitalium, Herpes simplex virus (HSV), adenoviruses and Trichomonas vaginalisUreaplasma urealyticum exist as normal urethral flora.
  • Mycoplasma genitalium is developing resistance to single dose treatments used for Chlamydia trachomatis complicating the choice of first line treatment of urethritis for some men.
  • Chlamydia trachomatis infection at non-genital sites may not be treated adequately with single dose treatments.

Clinical presentation

SymptomsConsiderations
Urethral discharge

If copious and purulent, it is more indicative of gonorrhoea than other causes. However, any cause can produce scant and mucoid discharge.

Dysuria

In young men, indicates an STI until proven otherwise.

Urinary frequency

Suggestive of bladder infection.

Diagnosis

InfectionSite/SpecimenTest
Chlamydia* FPU NAAT
Gonorrhoea* FPU NAAT. If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment.
NGU Urethral swab Microscopy

FPU – First pass urine

NAAT – Nucleic acid amplification test

NGU – Non-gonococcal urethritis

* If test results are negative and symptoms persist, consider referral for testing of FPU for M. genitalium, herpes simplex virus (HSV) and adenovirus and microscopy for non-gonococcal urethritis (if not available through general practice).

Specimen collection

Clinician collected |
Self-collection

Special considerations

For men who have sex with men (MSM), undertake the following additional tests:

Management

Principle treatment options
InfectionRecommendedAlternative regimens
NGU Likely

Doxycycline 100mg PO, BD for 7 days

 

Azithromycin 1g PO, stat 

 

Gonorrhoea likely

Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat 

PLUS

Azithromycin 1g PO, stat

Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat

PLUS

Doxycycline 100mg PO, BD for 7 days

Mycoplasma genitalium

After completing doxycycline, use either azithromycin or moxifloxacin.

See Mycoplasma genitalium

Seek specialist advice

NGU – Non-gonococcal urethritis

Treatment advice

  • Ceftriaxone is the most effective treatment for gonorrhoea but azithromycin is usually added to reduce the chance of resistance emerging.
  • Azithromycin is effective for chlamydia but will fail and select resistance in at least 10% of M. genitalium, therefore doxycycline is preferred for NGU.
  • When NGU is considered likely but you would also prefer to treat a potential case of gonorrhoea, it is reasonable to add doxycycline instead of azithromycin to ceftriaxone.
  • If symptoms do not resolve, seek specialist advice for management of persistent NGU, including M. genitalium (often resistant), herpes simplex virus (HSV) and adenovirus.

Other immediate management

  • Advise no sexual contact for 7 days after treatment is administered
  • Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary.
  • Contact tracing
  • Provide patient with factsheet.

Contact Tracing

  • Contact tracing for gonorrhoea and chlamydia is a high priority and should be performed in all patients with confirmed infection
  • For non-gonococcal urethritis, male and female partners should be traced back for a minimum of 4 weeks.

See Australasian Contact Tracing website for more information.

Follow up

If STI confirmed, follow up provides an opportunity to:

  • Confirm patient adherence to treatment and assess for symptom resolution
  • Confirm contact tracing procedures have been undertaken or offer more contact tracing support
  • Provide further sexual health education and prevention counselling.

For test of cure (TOC) and retesting advice see:

Auditable outcomes

  • 100% of patients diagnosed with NGU are treated with an appropriate antibiotic regimen
  • 100% of patients are advised to avoid sexual contact for 7 days after treatment is prescribed.

References

Drugs, HIV and Viral Hepatitis Group, British Association for Sexual Health and HIV (BASHH) 2013. Available from: http://www.bashh.org/BASHH/Guidelines/Guidelines/BASHH/Guidelines/Guidelines.aspx

Last Updated: Thursday, 29 March 2018