Urethritis

Urethritis is the swelling/ inflammation of the urethra, which is the tube

that carries pee from the kidneys to the bladder. It is mostly common in
men. (Patients Info 2018).

Image 1 taken from Patient’s info 2018

Causes
It can be caused by different sexually transmitted organisms for
example: chlamydia (chlamydia trachomatis), gonorrhoea and
sometimes the organisms cannot be identified. (Patient’s info 2018).
Few of the possible causes include:
 Gonococcal urethritis which is caused by a bacterium called
Neisseria Gonorrhoea.
 Non-gonococcal urethritis (NGU) or non-specific urethritis (NSU)
which is due to causes other then gonorrhoea. For example,
chlamydia, syphilis (Treponema pallidum), M.gen (Mycoplasma
genitalium), trichomoniases (Trichomonas vaginalis), genital warts
(Human papillomavirus (HPV) 6 and 11), herpes simplex virus
HSV (HSV-1 and HSV-2) which are caught by sexual contact with
an infected person during vaginal, anal, or oral sex.
 It is also seen that men can have both gonococcal and non-
gonococcal urethritis. (Geeky medics)
 Other causes may include injury from a catheter, surgery of the
urethra, stenosis of the urethra, stones in urethra, any
reaction/irritation from the soaps, lotions, and spermicide creams.
 Urethritis can occur without any cause at all as well. (Patient’s info
2018).
 Risk factors
 15–24-year-olds
 Anyone can develop urethritis, but it is seen to be more common
amongst men aged 25 who has recently changed sexual partners.
 Having sex without a condom or any protective measures can
cause urethritis and any other STIs. (Patient’s info 2018).
 Multiple sexual partners
 Illicit drug use and alcohol use
 Men who have sex with men (MSM)
 Sex workers
 Urban areas (Geeky medics)

Signs and symptoms

 A white discharge from the end of the penis (not always)
 Up to quarter of the men do not have symptoms
 An urge to pass urine frequently
 Soreness, irritation, or itchiness inside the penis
 pain and burning while passing urine
 pain and swelling in one or both testicles

Diagnosis
 urine sample to detect suspected infections- Nucleic Acid
Amplification Test (NAAT)- First pass urine in males and
vulvovaginal swabs in females are used for testing. (Geeky
medics)
 a swab from urethra


Image 2 taken from (Patient’s info 2018).
It can take up to 14 days from exposure for infection with Chlamydia or
Gonorrhoea to show up on a NAAT test, therefore screening should be
repeated after this window. (Geeky medics)
 blood tests
 men who have sex with men are also required to take a swab from
the pharynx (back of the throat) and rectum.

Treatment and Management

 a course of antibiotics depending on the germ bacterium present

shown in the results.
 For bacterium chlamydia trachomatous, Azithromycin 1g oral
flowed by 500mg daily for two days. Doxycycline 100mg is taken
twice daily for seven days. A full STI screen including blood tests
should be performed if not already done. Contact tracing and
partner notification need to be offered. Advise that all forms of
sexual intercourse need to be avoided until all parties are tested
and treated. A test of cure at around 5 weeks should be offered in
cases of rectal infection or pregnancy. For individuals under 25
years of age, repeat testing should be offered at 3 months. (Geeky
medics)

 For bacterium Neisseria gonorrhoeae Ceftriaxone 1g

intramuscular injection as a single dose or Ciprofloxacin 500mg
orally as a single dose (only where antimicrobial sensitivities are
known prior to treatment) or Cefixime 400mg orally as a single
dose with Azithromycin 2g orally as a single dose (if IM injection
is contraindicated). (Geeky medics)
 For bacterium Treponema pallidum. Treatment is with Benzathene
benzylpenicillin IM injection, however, the dose depends on the
nature of the infection, whether the infection is congenitally
acquired, and whether the individual is pregnant. Prednisolone is
given alongside antibiotics in cases of neurosyphilis. Primary,
secondary and early latent syphilis: Benzathine
benzylpenicillin 2.4 million units IM injection as a single dose. Late
latent, cardiovascular and gummatous syphilis: Benzathine
benzylpenicillin 2.4 million units IM injection weekly for three
weeks (three doses) Patients should be followed up with a clinical
review and repeat serology testing at 3, 6 and 12 months.

 For bacterium HSV-1 and HSV-2 , Primary episode: Aciclovir

400mg oral three times a day for 5 days (commenced within 5
 days of symptom onset). Recurrent episodes: Aciclovir 800mg
oral three times a day for 2 days. Prophylaxis in patients with >5
episodes per year: Aciclovir 400mg twice daily. Saltwater baths,
topical petroleum jelly, oral analgesia and topical lidocaine gel can
be used for pain control. Again, a full STI screen should be offered
to individuals. There is no requirement for contact tracing,
however, patients should be advised to refrain from intercourse
when they have lesions and disclosure in relationships should be
advised. Condoms can reduce the rate of spread and should be
encouraged. (Geeky medics)
 For bacterium Human papillomavirus (HPV) 6 and 11, Topical:
Topical podophyllotoxin (Warticon® and Condyline®) Topical
imiquimod (patients should be made aware that this damages
condoms). Physical ablation: Cryotherapy and Surgical excision.
A full STI screen including blood tests should be offered. Contact
tracing is not required. The use of condoms should be
encouraged. Note that the HPV vaccine has not been shown to be
effective in treating existing anogenital warts. (Geeky medics)
 For bacterium Trichomonas vaginalis, Metronidazole 2g oral as a
single dose or 400-500mg twice daily for 5-7 days (note alcohol
should be avoided during treatment and for 72 hours afterwards).
A full STI screen including blood tests should be performed.
Contact tracing and partner notification need to be offered. Advise
that all forms of sexual intercourse need to be avoided until both
parties are tested and treated. Test of cure is not routinely
required. (Geeky Medics).
 For bacterium Mycoplasma genitalium, in cervicitis/urethritis:
Doxycycline 100mg twice daily for 7 days followed
by Azithromycin 1g as a single dose then 500mg daily for 2 days
(total 10 days of antibiotic treatment). In PID/epididymo-orchitis:
Moxifloxacin 400mg daily for 14 days. Different regimens apply in
pregnancy. A full STI screen including blood tests should be
performed. Current partners should be informed and treated.
Advise that all forms of sexual intercourse need to be avoided until
for at least 14 days after initiation of treatment and until symptoms
have resolved. Test of cure should be performed 5 weeks post-
initiation of treatment. (Geeky medics)
 Even If no bacterium is found in the results, it is still advisable to
complete the course of antibiotics. (Patient’s info 2018).

 Any person you have had sex with in the previous four weeks
should be tested for infection, even if they do not have any
 symptoms. A course of medicines called antibiotics is usually
advised for sexual partners, even if the tests are negative
(Patient’s info 2018)

Complication
 A very rare complication if NGU is not treated can cause arthritis
because without treatment the bacteria may stay inside the
urethra. The symptoms subside with time but there is still a chance
of passing the infection on. (Patient’s info 2018). Or sexually
acquired reactive arthritis (SARA). (Geeky medics)
 Pelvic inflammatory disease (PID)- increases the risk of ectopic
pregnancy and infertility
 Fitz-Hugh-Curtis syndrome- secondary to PID there is
inflammation of the hepatic capsule leading to perihepatic
adhesions
 Chronic pelvic pain in females
 Infertility in male secondary to epididymitis
 Prostatitis
 Bartholinitis
 Epididymitis
 Reactive arthritis
 Lymphogranuloma venereum (LGV) is caused by a more
invasive serotype of chlamydia trachomatis which presents as a
triad of inguinal lymphadenopathy, proctocolitis and fever. Patients
with proctitis should have NAAT swabs sent to test for this.
Patients with LGV, and HIV-positive individuals with proctitis,
should be treated with 3 weeks of Doxycycline and be offered a
test of cure at least 3 weeks after completion of treatment. (Geeky
medics).
 Urinary retention
 HSV keratitis- dendritic lesion on the cornea
 Aseptic meningitis
 Herpes proctitis
 Neonatal HSV- an increased risk if the mother becomes infected in
the third trimester
 Herpetic whitlow (Geeky medics)
 Jarisch-Herxheimer reaction- antibiotic treatment of syphilis
causes a sepsis-like picture due to the release of toxins from
treponemal bacterium breakdown, therefore steroids are
administered beforehand to prevent this.
 HIV co-infection
 Ano -genital cancer
  Scarring following treatment

References

Geeky medics. Sexually transmitted infections. Available on

[https://geekymedics.com/sexually-transmitted-infections-stis/].
Accessed on 30/11/2021

Patients’ info (2018). Non-gonococcal urethritis by Dr Mary Harding.

Available on [https://patient.info/sexual-health/sexually-transmitted-
infections-leaflet/non-gonococcal-urethritis]. Accessed on 30/11/2021.

Patients’ info (2018). Non-gonococcal urethritis by Dr Mary Harding.

Image 1 and 2. Available on [https://patient.info/sexual-health/sexually-
transmitted-infections-leaflet/non-gonococcal-urethritis]. Accessed on
30/11/2021