Urethritis is inflammation of the urethra and is a lower urinary tract infection.
The urethra is a fibro-muscular tube that urine exits the body through, and semen in males.
Urethritis is characterized as gonococcal or nongonococcal.
Urethritis has a strong association with sexually transmitted infection (STI).
Neisseria gonorrhea and Chlamydia trachomatis are the most common causative organisms of STI.
Inflammation of the urethra is most frequently an infectious etiology, with STIs being the most common cause. Sexually transmitted urethritis has two classifications: gonococcal urethritis (GCU) following infection with Neisseria gonorrhea or nongonococcal urethritis (NGU).
Other etiologic agents associated with urethritis include:
Urethritis has an incidence of 4 million Americans each year. The incidence of Neisseria gonorrhea is estimated at over 600,000 new cases annually, and the incidence of nongonococcal urethritis is approximately 3 million new cases annually.
In one study of 424 men presenting with signs and symptoms of acute urethritis, 127 (30%) has infections of N. gonorrhea. In 297 males with nongonococcal urethritis, C. trachomatis was the infectious agent in 143 (48.1%). In 154 men presenting with non-chlamydial nongonococcal urethritis, The agents detected were: M. genitalium (22.7%), M. hominis (5.8%), U. urealyticum (19.5%), U. parvum (9.1%), H influenzae (14.3%), human adenovirus (16.2%), N meningitidis (3.9%), T vaginalis (1.3%), and various forms of herpes simplex virus 1 (7.1%) and 2 (2.6%).
Urethritis is more commonly diagnosed in males. Risk factors include young age, unprotected sexual intercourse, and multiple sexual partners.
Neisseria gonorrhea is one of the most common sexually transmitted diseases and the bacterial cause of gonococcal urethritis in males and cervicitis in females.
Chlamydia trachomatis is among the most common sexually transmitted diseases. It is the most common cause of nongonococcal urethritis in males and cervicitis in females.
Mycoplasma genitalium is the causative agent in 15-20% of nongonococcal urethritis in men.
Trichomonas vaginalis is a common cause of nongonococcal urethritis in Africa.
For cases of NGU, Chlamydia trachomatis continues to be a primary concern, although Trichomonas vaginalis and Mycoplasma genitalium are increasingly recognized as significant pathogens, and less commonly Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis, and Gardnerella vaginalis.
Urethritis is documented based on any of the following signs or laboratory tests:
Urethritis is commonly asymptomatic; if symptomatic the symptoms vary based on the causative organism.
Symptoms of urethritis may include dysuria, pruritus, burning and discharge at the urethral meatus. Frank purulent discharge suggests gonorrhea as the causative organism. Dysuria alone is common among chlamydia. If the patient has dysuria with painful genital ulcers, the causative organism is most likely herpes simplex virus.
Neisseria gonorrhea is often associated with copious purulent or mucopurulent urethral discharge in men and can be asymptomatic. In women, urethritis is often associated with cervicitis and can be asymptomatic. If symptoms are presents, dysuria is the most common. Other symptoms in women can include frequency and urgency.
Chlamydia trachomatis is most commonly asymptomatic. Symptomatic patients can have dysuria, urethral discharge. Females with urethritis usually have cervicitis as well and often are asymptomatic. Female patients may report dysuria, urgency or frequency. Symptoms of cervicitis include intermenstrual vaginal bleeding, post-coital bleeding, and changes in vaginal discharge, which can be the reported chief complaint of females with urethritis. Males that are symptomatic can complain of mucoid or watery discharge, dysuria. A small number of patients with chlamydia urethritis may develop reactive urethritis triad.
Mycoplasma genitalium infections are usually asymptomatic, however; symptoms may include dysuria, purulent or mucopurulent urethral discharge, urethral pruritus, balanitis, and posthitis. The urethral discharge is commonly associated with this organism but, is not always evident in contrast to the Neisseria gonorrhea infections. It can cause acute and persistent urethritis in men.
Herpes simplex virus usually presents with intense dysuria, and on physical examination, a limited amount of discharge can be present and commonly meatitis and balanitis. Majority of patients may not have herpetic lesions present on physical examination.
Adenovirus commonly presents with intense dysuria instead of urethral irritation than other causes of nongonococcal urethritis. Usually transmitted by oral sex with upper respiratory tract symptoms generally during fall and winter months. Patients usually do not report urethral discharge. Physical examination usually shows scant urethral serous discharge; meatitis and balanitis are often present and may demonstrate associated constitutional symptoms and conjunctivitis.
Some data indicate that enteric organisms are causative agents of urethritis from rectal exposure — gram-negative rods from urinary tract infections or insertive anal sex. Hemophilus species, Neisseria meningitides, Moraxella catarrhalis, and Streptococcus pneumonia are pathogens associated with insertive oral sex causes of NGU.
Urethritis is clinically suspected when any sexually active man who presents with symptoms consistent with urethritis including pruritus, discharge or dysuria. Urethritis is mostly a clinical diagnosis based on history and physical examination, however; there are some specific diagnostic laboratory tests utilized. Diagnosis is made based on examination showing evidence of mucopurulent or purulent discharge, >2 WBC per oil immersion field from gram stain of a urethral swab, positive leukocyte esterase and/or presence of >10 WBCs per high-power field of the first-void urine. Diagnosis depends on the availability of point-of-care testing. The gram stain test has been traditionally the gold standard for diagnosis of urethritis. A new technique (methylene blue/gentian violet [MB/GV] smear) has had reports as an alternative to Gram staining. MB/GV does not require heat fixation and has very similar performance characteristics to Gram stain. Taylor et al.  found the sensitivity of both Gram stain and MB/GV to be 97.3% for the detection of gonococcal infection compared with culture. The specificity of Gram stain and MB/GV was 99.6%, and investigation showed 100% correlation between Gram stain and MB/GV for the detection of GC.
Neisseria gonorrhea is diagnosed initially with nucleic acid amplification testing with first-catch urine or urethral swab. A urethral culture provides essential information regarding antibiotic resistance. Other diagnostic testing includes microscopy for males, culture, urethral culture, antigen detection, and endocervical or urethral swabs used with genetic probe methods.
Chlamydia trachomatis is diagnosable in females based on urinalysis revealing pyuria with no organisms reported on Gram stain or culture. In sexually active young female patients with pyuria and no bacteriuria, there should be a strong suspicion of urethritis caused by chlamydia. The laboratory test of choice is Nucleic acid amplification test with first-void urine. Other available tests are urethral culture, vaginal culture, antigen detection, genetic probes.
Mycoplasma genitalium diagnosis can be difficult, however; the only FDA approved test is nucleic acid amplification tests which in most clinical settings are widely unavailable.
Gonococcal urethritis: the recommended treatment of choice is a single dose of ceftriaxone 250mg intramuscular injection and a single dose of oral 1 gram of azithromycin to cover for coinfection with chlamydia. Neisseria meningitides urethritis is treated the same.
Nongonococcal urethritis: the recommended treatment:
Chlamydia trachomatis: The treatment of choice is a single dose of 1 gram of oral azithromycin or 100mg doxycycline twice a day for seven days. Alternative treatment options are ofloxacin 300mg orally twice daily for seven days or levofloxacin 500mg orally once a day for seven days. If coinfected with gonorrhea treatment with one dose of 250mg ceftriaxone intramuscular injection in addition to 1 gram oral single dose azithromycin. In pregnant females, 1 gram orally of azithromycin is the recommended treatment. If pregnant females are unable to tolerate recommended treatment, these patients should have treatment with one of the following regimens:
In females who are pregnant or lactating the following medication treatments options are contraindicated- levofloxacin, ofloxacin, erythromycin estolate, and doxycycline.
All patients should undergo repeat testing three months after treatment and reinfection should receive therapy with of azithromycin.
Mycoplasma genitalium: the recommended antibiotic of choice is azithromycin 1 gram orally as a single dose. For those patients resistant to treatment with azithromycin, moxifloxacin is a treatment alternative.
Other causes of similar symptoms in males include prostatitis, epididymitis, cystitis, proctitis and chemical irritation.
Differential diagnosis in female patients include cervicitis, cystitis, vaginitis.
Neisseria gonorrhea shows associations with some rare complications including penile edema, periurethral abscesses, post-inflammatory urethral strictures, and penile lymphangitis.
Conditions associated with Chlamydia trachomatis include pelvic inflammatory disease, infertility, ectopic pregnancy, Fitz-Hugh-Curtis syndrome, proctitis, and reactive arthritis.
Complete reactive arthritis triad also known as Reiter syndrome includes urethritis, uveitis and arthritis is a rare disease most commonly caused by Chlamydia trachomatis, acute epididymitis, orchitis, and prostatitis.
Diagnosing urethritis can be a challenge if patients do not feel comfortable discussing their sexual practices. For the patients to feel at ease to disclose important history, a robust doctor-patient relationship must exist. Doctors should work closely with other staff to ensure patient comfort and patient care. Pertinent history can lead to different suspected organisms, and since treatment is organism-specific, it is imperative to maintain and establish this relationship early on.
Clinicians should work closely with a pharmacist to ensure the best antibiotic choices for treatment, with the pharmacist verifying appropriate coverage, dosing, and duration. Patient and community safety are affected by ensuring the prescribing of the best antibiotic and medication compliance. Nursing can chart progress and counsel the patient on compliance, as well as answering any patient questions, and reporting concerns or results to the clinical team. The patient's confidentiality is a priority as well as reporting diseases.
By having an interprofessional team approach to testing and treating patients, it will maximize patient care benefit and medication compliance while eradicating the disease. [Level 5]
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