Urethritis in men

Background

Urethral anatomy

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

• Renal/perirenal
  • Pyelonephritis
    • Emphysematous pyelonephritis
  • Renal abscess
  • Perinephric abscess
• Ureteral
  • Infected urolithiasis
• Bladder
  • Acute cystitis ("UTI")
  • Chronic cystitis
• Urethra/periurethra
  • Urethritis
  • Prostatitis

Clinical Features

Chlamydia trachomatis on male GU exam consistent with urethritis.

• Dysuria
• Urethral discharge

Differential Diagnosis

Dysuria

• Genitourinary infection
  • Acute cystitis ("UTI")
  • Pyelonephritis
  • Urethritis
  • Chronic cystitis
  • Infected nephrolithiasis
  • Prostatitis
  • Epididymitis
  • Renal abscess/perinephric abscess
  • Emphysematous pyelonephritis
• Nephrolithiasis
• Urethral issue
  • Urethritis
  • Urolithiasis
  • Urethral foreign body
  • Urethral diverticulum
  • Allergic reaction (contact dermatitis)
  • Chemical irritation
  • Urethral stricture or obstruction
  • Trauma to vagina, urethra, or bladder
• Gynecologic
  • Vaginitis/cervicitis
  • PID
  • Genital herpes
  • Pelvic organ prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • Interstitial cystitis
  • Behavioral symptom without detectable pathology

Evaluation

Workup

• Urinalysis
• Urine GC/chlamydia
• Consider M. genitalium and trichomonas testing

Diagnosis

• Typically initially a clinical diagnosis with empiric treatment

Management

Uncomplicated Infection

Treatment to cover both gonorrhea and chlamydia Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

• Gonorrhea
  • Ceftriaxone IM x 1 (500mg if <150kg, 1g if ≥150kg)
• Chlamydia
  • Doxycycline 100 mg PO BID x 7 days

Ceftriaxone contraindicated

• Gonorrhea
  • Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
  • Cefixime 800 mg PO x 1
• Chlamydia^
  • Doxycycline 100 mg PO BID x 7 days

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

• Gonorrhea
  • Cefixime 800mg PO x 1
• Chlamydia
  • Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
  • Pregnant: azithromycin 1g PO x 1

Recurrent or Persistent

Target M. genitalium

• Moxifloxacin 400 mg daily x 7 days

Consider coverage of trichomonas, among men who have sex with women

• Metronidazole 2 g PO in a single dose
• Azithromycin 1 g PO x1

Disposition

• Outpatient

See Also

• STIs
• Urinary tract infections