Patient Story
A 24-year-old man presents to a skid row shelter clinic with 3 days of dysuria and penile discharge. A heavy purulent urethral discharge is seen (Figure 215-1). He admits to using crack cocaine and having multiple female sexual partners. He was diagnosed with gonococcal urethritis by clinical appearance and a urine specimen was sent for testing to confirm the gonorrhea and test for Chlamydia. He was treated with Ceftriaxone 250 mg IM for gonorrhea and 1 g of oral azithromycin for possible coexisting Chlamydia. He was offered and agreed to testing for other sexually transmitted diseases. He was told to inform his partners of the diagnosis. He was counseled about safe sex, and drug rehabilitation was recommended. On his 1-week follow-up visit, his symptoms were gone and he had no further discharge. His gonorrhea nucleic acid amplification test was positive and his Chlamydia, rapid plasma reagin (RPR), and HIV tests were negative. His case was reported to the Health Department for contact tracing.
Introduction
Urethritis is urethral inflammation caused by infectious (gonococcal or chlamydial) or noninfectious causes (trauma or foreign bodies). Gonococcal and chlamydial infections in men occur most commonly between the ages of 20 and 24 years, and the prevalence is highest in black men. Diagnosis is suspected clinically, reinforced by an office urine test positive for leukocyte esterase, and confirmed by a urine nucleic acid amplification test. Treat for both gonorrhea and Chlamydia until one or both are ruled out by laboratory testing.
Epidemiology
- Worldwide, 151 million cases of gonococcal and nongonococcal urethritis are reported annually (Figures 215-1 and 215-2).1
- Urethritis of all types occurs in 4 million Americans each year.1
- The prevalence of gonorrhea in men was 94.1 per 100,000 population among men in the US in 2010. The rate was highest among those men aged 20-24 years (421.0 per 100,000 population). In 2010, gonorrhea rates remained highest among black men and women (432.5), which was 18.7 times the rate among whites (23.1 per 100,000 population). The rates among Hispanics (49.9) was 2.2 times those of whites.2
- The prevalence of Chlamydia in men in the US in 2010 was 233.7 cases per 100,000 males. Age-specific rates among men were highest in those aged 20-24 years (1,187.0 cases per 100,000 males). The rate of chlamydia among black men and women was more than eight times the rate among whites (1,167.5 and 138.7 cases per 100,000 population, respectively). The rate among Hispanics was 2.7 times the rate among whites.2
Etiology and Pathophysiology
- Urethritis is urethral inflammation caused by infectious or noninfectious causes.
- Neisseria gonorrhoeae and Chlamydia trachomatis are the most important infectious causes. When transmitted, they can cause other illnesses and complications in men (epididymitis, prostatitis, and reactive arthritis) and women (pelvic inflammatory disease and infertility).
- Other infectious agents include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex viruses 1 and 2, adenovirus, and enteric bacteria.
- Noninfectious causes include trauma, foreign bodies, granulomas or unusual tumors, allergic reactions, or voiding dysfunction (any abnormal holding or voiding pattern not caused by an anatomical or a neurologic process).
Diagnosis
Male patients with urethritis can be asymptomatic or present with urethral discharge, dysuria, or urethral pruritus.
Urethritis is diagnosed when one of the following is present:3
- Mucopurulent or purulent urethral discharge (Figures 215-1 and 215-2
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