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Urethritis (non-specific) and urethral irritation diagnosis and management

Last updated: June 2013

Diagnosis

Non-specific urethritis (NSU) is diagnosed in males only by the following:

  • absence of identifiable pathogens such as gonococci, chlamydia trachomatis, M.genitalium, herpes simplex virus (HSV), trichomonas, adenovirus on testing AND
  • gram stain evidence of urethritis (5 or more polymorphs per high power field) OR
  • mucopurulent or purulent urethral discharge or meatitis on examination.

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Treatment

Antibiotic treatment should not be commenced until urethral swabs have been taken.

Azithromycin 1 g orally as one dose (B1)

OR

Doxycycline 100 mg orally twice a day for 10 days (D).

In settings where microscopic examination of a urethral smear is unavailable on site, treatment of presumptive NSU is justified in symptomatic men.

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Patient education

The following points should be covered:

  • chlamydia, mycoplasma and gonorrhoea test results will be pending at the first visit
  • abstinence from sex for one week until results are given
  • the nature of the infection
  • the condition is benign and there is no equivalent in females
  • symptoms may be slow to resolve despite treatment.
  • sexual partners should be screened for sexually transmitted infection (STIs)/human immunodeficiency virus (HIV).

The significance of ureaplasma is uncertain and its detection does not alter management. Neisseria meningitidis is occasionally identified on urethral culture in symptomatic and asymptomatic men. Its finding is usually incidental and does not require treatment. However, in the presence of symptoms N. meningitidis is assumed to be the cause of urethritis and is treated with Ceftriaxone 500 mg IMI as a single dose (B1)

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Contact tracing

Contact tracing and empiric treatment of contacts is only required if chlamydia, M genitalium, gonorrhoea or trichomonas is isolated. However, sexual partners of men with NSU should be advised to have screening for STIs/HIV.

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Follow up

The patient should be clinically reviewed 5 to 10 days after the completion of medication for the following:

  • review results tests
  • check on medication compliance
  • evaluate symptoms and signs
  • check reaction to medication
  • enquire about sexual activity since treatment
  • if symptoms persist, repeat urethral smear for polymorphs, at least 2 hours after voiding

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Persistent Non-specific urethritis

In some men, the symptoms of urethritis do not resolve despite compliance with antibiotic therapy and abstinence from sexual activity.

These men should be retested for urethral pathogens and a repeat urethral smear for gram stain should be taken.

Where the urethral smear still shows 5 or more polymorphs per high power field the following treatment regimen is recommended:

Doxycycline 100 mg twice daily orally for 10 days (D)

OR

Azithromycin 1 g orally as one dose (B1) whichever was not used as therapy for the initial episode

PLUS

Metronidazole 400 mg orally 12 hourly for 5 days (B2).

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Urethral irritation

The diagnosis is made in men with dysuria and/or urethral discomfort but no microscopic evidence of urethritis, and negative tests for urethral pathogens. In settings where microscopy of a urethral smear is not available, this diagnosis cannot be reliably made. The urethral smear must be collected at the optimal time of more than 2 hours after micturition to confidently make this diagnosis.

Management

The patient should be reassured that the symptoms are due to a mild irritation and not infection. Possible causes may include trauma, for example vigorous sexual activity or masturbation, or irritants such as alcohol. No antibiotic treatment is required. The symptoms subside in one to two weeks.

The patient should be advised to avoid manipulation of the penis (no squeezing or milking of the urethra) and he should abstain from sexual activity and masturbation until symptoms resolve.

Ensure that tests for urethral pathogens (and urinary tract infection if clinically indicated) have been done to exclude these infections. The patient should return for these results in 1 week, and should not have sex until negative tests are confirmed.

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Further information

For further information on the diagnosis and management of urethritis (non-specific) or urethral irritation contact Clinic 275.

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Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations.

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