UrethritisMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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594 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

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Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp37

Immediate priorities

›Disseminated gonococcal infection (DGI) recognition

›Fever with polyarthralgia and skin lesions

›Pustular or petechial acral skin lesions

›Asymmetric tenosynovitis especially wrists and hands

›Septic arthritis presentation

›Joint effusion with restricted range of motion

›Single large joint involvement

›Rare systemic complications

›Gonococcal endocarditis (new murmur, embolic phenomena)

›Gonococcal meningitis (meningismus, altered mental status)

›Escalation triggers

›Suspected DGI with fever and skin lesions

›Hospitalization and IV antibiotics indicated

›Ceftriaxone 1 g IV every 24 hours until clinical improvement

›Suspected gonococcal endocarditis or meningitis

›Immediate cardiology or neurology consult

›ID consultation required

›Inability to tolerate oral medications

›Parenteral therapy consideration

›Social admission for adherence concerns

Key concepts and pitfalls

›Empiric treatment pearls

›Treat empirically at point of contact — do not await NAAT results

›Clinical suspicion sufficient to initiate therapy

›ACEP Level B recommendation for empiric STI management

›Gram stain interpretation

›GNID on Gram stain = gonococcal urethritis

02History/hx63

Presenting symptoms

›Urethral discharge characteristics

›Color and quality

›Mucopurulent or frankly purulent (gonococcal)

›Scant mucoid or clear (chlamydial/nongonococcal)

›Timing

›Morning "glue" sign (dried secretions at meatus)

›Volume and duration

›Dysuria features

›Character of discomfort

›Internal versus meatal burning

›Onset and severity

›Urethral pruritus or irritation without visible discharge

Exposure history

›Incubation period and timing

›Gonococcal urethritis

›Onset typically 2 to 8 days after exposure

›Can be asymptomatic in 55 to 87% of urogenital gonorrhea in men

›Chlamydial or nongonococcal urethritis

›Onset typically 7 to 21 days after exposure

›Frequently asymptomatic or minimally symptomatic

›Sexual history

›Number and gender of partners and new partners

›Men who have sex with men (MSM) — higher gonorrhea and chlamydia prevalence

›Condom use consistency

›Routes of exposure

›Oral, anal, vaginal contact — relevant for extragenital site testing

›Transactional sex — elevated STI risk

03Physical Exam/exam44

Urethral assessment

›Urethral meatus inspection

›Spontaneous discharge visible

›Purulent (gonorrhea) versus mucoid (NGU)

›Meatitis or erythema at meatus

›Milking the urethra

›Express discharge if not spontaneously visible

›Technique: compress proximal urethra toward meatus

›Urethral swab or first-catch urine collection

›Swab for Gram stain and NAAT

›Gram stain: greater than or equal to 5 PMN per high power field is diagnostic of urethritis

›Gram-negative intracellular diplococci (GNID) = gonococcal

Genital examination

›Testicular and epididymal exam

›Testicular tenderness and swelling

›Epididymal induration suggests epididymitis

›Cremasteric reflex to exclude testicular torsion

›Prehn sign

›Scrotal elevation relieves pain in epididymitis

›Does not reliably distinguish torsion in clinical practice

›Skin and genital lesions

›Genital ulcers

›HSV: painful grouped vesicles or ulcers

›Syphilis: painless indurated chancre

›Condylomata or other lesions

›HPV-related changes

›Molluscum contagiosum

04Differential Diagnosis/ddx58

Infectious causes

›Gonococcal urethritis (ICD-10: A54.01)

›N. gonorrhoeae — gram-negative intracellular diplococci

›Profuse purulent discharge, acute onset 2 to 8 days post-exposure

›GNID on Gram stain is highly specific

›Increasing antibiotic resistance pattern

›Fluoroquinolone resistance widespread

›Cephalosporin resistance emerging

›Chlamydial urethritis (ICD-10: A56.01)

›Chlamydia trachomatis — obligate intracellular organism

›Scant mucoid discharge, milder dysuria, frequently asymptomatic

›Incubation 7 to 21 days

›Most common bacterial STI in the US

›Leading cause of nongonococcal urethritis (NGU)

›NAAT required for diagnosis (culture not routine)

›Mycoplasma genitalium urethritis (ICD-10: A56.01)

›Second most common NGU pathogen after Chlamydia

›Emerging macrolide resistance problem

›Resistance-guided therapy preferred when NAAT available

›Associated with persistent and recurrent urethritis

›Particularly after azithromycin exposure

›Moxifloxacin 400 mg daily x 7 days used for macrolide-resistant cases

›Trichomonas vaginalis urethritis (ICD-10: A59.03)

›More common in heterosexual men, older age, incarcerated populations

›High-prevalence geographic areas

›Often asymptomatic in men

›Treatment: metronidazole 2 g PO single dose

05Laboratory Tests/lt43

Diagnostic microbiology

›Nucleic acid amplification testing (NAAT) — first-line diagnostic

›Specimen options

›First-catch urine (preferred non-invasive) or urethral swab

›Rectal and pharyngeal swabs if relevant exposure history

›Targets

›N. gonorrhoeae: sensitivity greater than 95%, specificity greater than 99%

›C. trachomatis: sensitivity greater than 95%, specificity greater than 99%

›M. genitalium NAAT

›Not widely available but recommended for recurrent/persistent NGU

›Resistance-guided testing (macrolide resistance mutation detection) when available

›T. vaginalis NAAT

›Higher sensitivity than wet prep (sensitivity 88 to 97%)

›Recommended in high-prevalence settings or recurrent NGU

›Gram stain of urethral discharge

›Diagnostic criteria for urethritis

›Greater than or equal to 5 PMN per high power field

›Greater than or equal to 2 PMN per oil immersion field on intraurethral swab

›Gram-negative intracellular diplococci (GNID)

›Sensitivity 95%, specificity 99% for gonococcal urethritis

›Allows same-visit empiric gonococcal therapy confirmation

Additional laboratory tests

›HIV testing

›Opt-out HIV testing at STI encounters

›All patients with STI risk factors

›4th generation Ag/Ab combination assay preferred

›Acute HIV can mimic STI syndrome with urethritis component

›Consider acute HIV in patients with non-specific systemic symptoms

06Diagnostic Tests/dt46

Scoring Systems

›Urethritis diagnostic criteria

›Clinical diagnosis of urethritis requires one of the following

›Mucopurulent or purulent urethral discharge on examination

›Gram stain: greater than or equal to 5 PMN per high power field on urethral smear

›Positive leukocyte esterase on first-catch urine or greater than or equal to 10 WBC per high power field on first-catch urine microscopy

›CDC 2021 treatment guideline criteria (MMWR)

›GNID on Gram stain = gonococcal urethritis — treat with ceftriaxone

›No GNID = NGU — treat with doxycycline

›Empiric dual therapy when Gram stain unavailable

MRI

›MRI applications in urethritis and complications

›Not indicated for uncomplicated urethritis

›Reserved for complications and sequelae

›Urethral stricture mapping if surgery planned

›Pelvic MRI for deep-seated complications

›Periurethral abscess delineation

›Prostate abscess in complicated gonococcal prostatitis

›Joint MRI for DGI complications

›Septic arthritis assessment when plain film inconclusive

›Early osteomyelitis detection

›CT applications in urethritis and complications

›Not indicated for uncomplicated urethritis

›Reservd for suspected complications

›Pelvic CT if abscess or deep pelvic infection suspected

›CT abdomen/pelvis for DGI with abdominal pain

›Perihepatitis (Fitz-Hugh-Curtis) in female partners

07Disposition/dispo29

Outpatient management

›Discharge criteria for uncomplicated urethritis

›Hemodynamically stable without systemic signs of infection

›No fever, no joint involvement, no skin lesions

›No evidence of epididymitis or DGI

›Able to tolerate oral medications

›Reliable access to pharmacy

›Adherence counseling provided

›Partner notification plan in place

›Expedited partner therapy (EPT) offered where permitted

›Partners within preceding 60 days should be evaluated and treated

Admission criteria

›Indications for hospitalization

›Suspected or confirmed DGI

›Fever, polyarthralgia, skin lesions, tenosynovitis

›IV ceftriaxone 1 g every 24 hours until 24 to 48 hours clinical improvement

›Gonococcal endocarditis or meningitis

›Ceftriaxone 1 to 2 g IV every 12 hours x 10 to 14 days (endocarditis 4 weeks)

›ID and relevant specialty consultation

›Inability to tolerate oral medications or severe nonadherence risk

›Consider observed therapy or social admission

Follow-up planning

›Return to care schedule

›Repeat NAAT testing (test of reinfection)

›3 months after treatment or first visit within 12 months

›Do NOT repeat NAAT less than 3 weeks after treatment (false positive from residual nucleic acid)

›Test-of-cure indications

›NOT needed for urogenital gonorrhea with ceftriaxone

08Treatment/t65

Empiric therapy

›First-line empiric treatment (etiology unknown at time of treatment)

›Ceftriaxone 500 mg IM single dose

›1000 mg IM if patient weight greater than 150 kg

›Covers N. gonorrhoeae (Class I recommendation, 2021 CDC STI guidelines)

›Doxycycline 100 mg PO BID x 7 days

›Co-administered with ceftriaxone for chlamydia coverage

›First dose directly observed when possible

›No longer recommended: azithromycin co-treatment for gonorrhea (2021 CDC guidelines)

Pathogen-directed therapy

›Confirmed gonococcal urethritis

›Ceftriaxone 500 mg IM single dose (preferred)

›Alternative if ceftriaxone unavailable: cefixime 800 mg PO single dose

›Fluoroquinolones not recommended due to widespread resistance

›Test for co-infection

›Always test for chlamydia co-infection

›Add doxycycline if chlamydia not excluded

›Confirmed chlamydial urethritis

›Doxycycline 100 mg PO BID x 7 days (preferred)

›Higher microbiologic cure rate than azithromycin (>95% vs ~80% rectal)

›Class I recommendation per 2021 CDC guidelines

›Alternative regimens

›Azithromycin 1 g PO single dose (inferior microbiologic cure, reserve for adherence concerns)

›Levofloxacin 500 mg PO daily x 7 days (alternative)

›Confirmed Mycoplasma genitalium urethritis

›Initial treatment

›Doxycycline 100 mg PO BID x 7 days

›Followed by moxifloxacin 400 mg PO daily x 7 days (sequential therapy)

›Resistance-guided therapy preferred when NAAT resistance testing available

›Macrolide-sensitive: azithromycin 1 g single dose then 500 mg daily x 3 days

›Macrolide-resistant: moxifloxacin 400 mg daily x 7 days

›Persistent NGU after M. genitalium treatment

›Refer to infectious disease or urology

›Confirmed Trichomonas vaginalis urethritis

›Metronidazole 2 g PO single dose

›Tinidazole 2 g PO single dose — equivalent efficacy, fewer GI side effects

›Avoid alcohol during and for 24 hours after metronidazole (disulfiram-like reaction)

›Treat partner simultaneously

›High reinfection rate without partner treatment

›Test of cure for T. vaginalis at 3 months

Persistent and recurrent urethritis

›Recurrent NGU management algorithm

›Step 1: Confirm adherence and exclude reinfection

›Re-exposure assessment

›NAAT for M. genitalium and T. vaginalis if not previously done

›Step 2: Target identified pathogen

›M. genitalium: resistance-guided therapy with moxifloxacin if macrolide-resistant

›T. vaginalis: metronidazole 500 mg PO BID x 7 days (multi-dose for recurrent)

›Step 3: No pathogen identified — consider empiric options

›Metronidazole 2 g PO single dose or tinidazole 2 g PO single dose

›Referral to ID or urology if no response

›Disseminated gonococcal infection treatment

›Bacteremic DGI (petechial skin lesions, tenosynovitis, polyarthralgia)

›Ceftriaxone 1 g IV every 24 hours

›Continue until 24 to 48 hours of clinical improvement

›Transition to cefixime 400 mg PO BID to complete 7 days total

›Gonococcal septic arthritis

›Ceftriaxone 1 g IV every 24 hours x 7 days minimum

›Joint drainage if large effusion

›Add chlamydia treatment

›Doxycycline 100 mg PO BID x 7 days concurrent therapy

Partner management

›Partner notification and treatment

›All partners within preceding 60 days

›Refer for evaluation, testing, and treatment

›Expedited partner therapy (EPT) in most US states

›Abstinence counseling

›Abstain from sexual intercourse for 7 days after single-dose treatment

›Or until 7-day course completed AND symptoms resolved AND partner treated

09Special Populations/sp65

Pregnancy

›Urethritis management in pregnancy

›Chlamydial urethritis/cervicitis in pregnancy

›Azithromycin 1 g PO single dose — preferred in pregnancy (class I)

›Doxycycline contraindicated in pregnancy (fetal bone and tooth development)

›Amoxicillin 500 mg PO TID x 7 days — alternative if azithromycin not available

›Gonococcal urethritis/cervicitis in pregnancy

›Ceftriaxone 500 mg IM single dose (1 g if weight > 150 kg)

›Fluoroquinolones and tetracyclines contraindicated in pregnancy

›Pregnancy complications from untreated infection

›Chlamydia: preterm labor, PROM, neonatal conjunctivitis, neonatal pneumonia

›Gonorrhea: preterm birth, chorioamnionitis, neonatal ophthalmia neonatorum

›Neonatal prophylaxis

›Erythromycin 0.5% ophthalmic ointment at birth for gonococcal ophthalmia prophylaxis

›Universal newborn eye prophylaxis (most US states)

›Screening recommendations in pregnancy

›Universal chlamydia and gonorrhea screening at first prenatal visit

›Repeat in third trimester for high-risk patients

›HIV, syphilis, hepatitis B co-screening

›T. vaginalis screening

›Routine screening not universally recommended

›Screen if symptomatic or high-risk

Geriatric

›Urethritis in older adults

›Atypical presentations more common

›Absent or minimal discharge

›Dysuria may be attributed to prostatitis or BPH

›Lower index of suspicion leads to underdiagnosis

10Background/b76

Epidemiology

›Incidence and prevalence

›Gonorrhea — USA statistics

›Over 677,000 cases reported annually in the US (2020 CDC data)

›Second most commonly reported notifiable disease

›Incidence highest in 20 to 24 year age group

›Chlamydia — USA statistics

›Over 1.6 million cases reported annually in the US — most common reportable STI

›Estimated 2.86 million infections annually including undiagnosed

›Women and adolescents disproportionately affected

›M. genitalium prevalence

›Found in 15 to 25% of NGU cases not due to chlamydia

›Macrolide resistance increasing — up to 40% of circulating strains in some regions

›T. vaginalis prevalence

›Estimated 2 to 3 million infections annually in the US

›More common in Black Americans, older adults, incarcerated populations

›Global and demographic patterns

›WHO estimates over 374 million new STI cases globally per year (gonorrhea, chlamydia, syphilis, trichomoniasis combined)

›Sub-Saharan Africa and Southeast Asia highest burden

›MSM account for disproportionate gonorrhea burden in US

Pathophysiology

›Gonococcal urethritis mechanism

›N. gonorrhoeae adhesion and invasion

›Pili and outer membrane proteins mediate adhesion to urethral epithelium

›IgA protease enables mucosal immune evasion

›Inflammatory cascade

›Intense PMN infiltration produces purulent discharge

›TNF-alpha and IL-8 drive local inflammation

›Ascending infection risk

›Untreated urethritis can ascend to epididymis, prostate, and bloodstream

›DGI occurs in 0.5 to 3% of gonorrhea cases

›Nongonococcal urethritis mechanism

›Chlamydia trachomatis biology

›Obligate intracellular organism with biphasic lifecycle

›Elementary body (EB): infectious, metabolically inactive form

›Reticulate body (RB): replicative intracellular form

›M. genitalium characteristics

›Smallest self-replicating organism

›Lacks cell wall — intrinsically resistant to beta-lactam antibiotics

›Tip organelle mediates cytoadherence to urethral epithelium

›T. vaginalis mechanism

›Flagellated protozoan — direct cytotoxicity to urethral epithelium

›Stimulates cytokine release and inflammatory response

›Often asymptomatic in men despite causing inflammation

›Antibiotic resistance mechanisms

›Gonorrhea resistance

›Plasmid-mediated penicillinase (PPNG) — penicillin resistance

›Chromosomal mosaic penA mutations — reduced cephalosporin susceptibility

›Efflux pumps (mtrCDE) and porB mutations — multiple resistance mechanisms

›M. genitalium macrolide resistance

›23S rRNA mutations A2058G/A2059G confer high-level macrolide resistance

›Prevalence of macrolide resistance increasing globally (up to 50% in some regions)

Therapeutic Considerations

›2021 CDC STI treatment guideline key changes

›Chlamydia treatment preference shift

›Doxycycline now preferred over azithromycin (higher microbiologic cure rates)

›Azithromycin microbiologic cure for rectal chlamydia approximately 80% vs doxycycline 99%

›Gonorrhea treatment update

›Azithromycin combination no longer recommended (rising azithromycin resistance)

›Ceftriaxone monotherapy is standard of care

›Pharyngeal gonorrhea management

›More difficult to eradicate than urogenital gonorrhea

›Test-of-cure recommended 14 days post-treatment

›Antimicrobial stewardship

›Resistance-guided therapy for M. genitalium

›Empiric macrolide avoidance reduces resistance amplification

›Moxifloxacin remains effective for macrolide-resistant M. genitalium

›Zoliflodacin (novel antibiotic) in clinical trials for gonorrhea

›Public health implications

›Ceftriaxone is last reliable single-agent gonorrhea therapy

›Surveillance for cephalosporin-resistant N. gonorrhoeae ongoing (CDC GISP program)

›Point-of-care and expedited care strategies

›Empiric treatment at first visit

›Reduces transmission during results pending period

›Does not require culture for initial management decision

›Expedited partner therapy (EPT)

›Prescribing or dispensing medication for partner without clinical evaluation

›Permitted in most US states with variable legal frameworks

›Reduces reinfection rates and community transmission

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Urethritis Discharge Instructions

›Your diagnosis and treatment

›You were diagnosed with urethritis (inflammation of the urethra), likely caused by a sexually transmitted infection

›You received antibiotic treatment today — complete the full course even if symptoms improve

›Your medications

›Take all prescribed antibiotics as directed — do not skip doses

›Doxycycline: take with a full glass of water and remain upright for 30 minutes to prevent esophageal irritation

›Avoid alcohol while taking metronidazole (tinidazole) — can cause severe nausea and flushing

›Sexual activity restrictions

›Abstain from all sexual intercourse for 7 days after single-dose treatment OR until you have finished a 7-day course AND symptoms have resolved AND your partner has been treated

›Using condoms consistently reduces risk of reinfection

›Partner notification

›Your sexual partners from the last 60 days need to be tested and treated

›Your doctor may be able to provide medication for your partner (expedited partner therapy) without them needing to come in

›Follow-up testing

›Return for repeat STI testing in 3 months (this is to check for reinfection, not treatment failure)

›Do not get retested sooner than 3 weeks after treatment — early testing may give a false-positive result

›Public health reporting

›Gonorrhea and chlamydia are reportable conditions — your healthcare provider is required by law to notify public health authorities (your name is kept confidential)

›Return to the emergency department immediately for

›Testicular pain or swelling

›Fever, joint pain, or joint swelling

›Skin rash or unusual skin spots

›Eye redness or discharge

›Symptoms not improving after 48 to 72 hours of treatment

›Inability to take your medications

›Expected recovery

12References/r39

Guidelines and key sources

›CDC 2021 STI Treatment Guidelines

›Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021

›Primary reference for all treatment regimens and diagnostic criteria

›Covers gonorrhea, chlamydia, M. genitalium, T. vaginalis, and partner management

›Key guideline changes: doxycycline preferred for chlamydia; azithromycin combination removed for gonorrhea

›PMID: 34292926

›Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344968/

›Urethritis Rapid Evidence Review

›Sell J, Nasir M, Courchesne C. Urethritis: Rapid Evidence Review. American Family Physician. 2021

›Comprehensive clinical summary for outpatient and ED management

›PMID: 33929174

›JAMA Review: Diagnosis and Treatment of STIs

›Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and Treatment of Sexually Transmitted Infections: A Review. JAMA. 2022

›Covers epidemiology, diagnosis, and treatment of major STIs

›Incubation periods, symptom prevalence, NAAT performance

›AFP Chlamydial and Gonococcal Infections

›Yonke N, Aragón M, Phillips JK. Chlamydial and Gonococcal Infections: Screening, Diagnosis, and Treatment. American Family Physician. 2022

›Screening recommendations and treatment algorithms

›PMID: 35426632

›Emerging and Reemerging STIs

›Williamson DA, Chen MY. Emerging and Reemerging Sexually Transmitted Infections. NEJM. 2020

›M. genitalium resistance patterns and emerging management strategies

›PMID: 32187466

›IDSA/ASM Microbiology Laboratory Guidance 2024

›Miller JM, Binnicker MJ, Campbell S, et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update. CID. 2024

›NAAT performance characteristics and specimen collection guidance

›DOI: 10.1093/cid/ciae104

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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