Urethritis - male

Overview

Urethral discharge and/or dysuria are typical symptoms of male urethritis.

Make a clinical diagnosis of gonorrhoea or non-gonococcal urethritis (NGU) and treat accordingly.

 

Possible causes

Clinical presentation

SymptomsConsiderations
Urethral discharge

Gonorrhoea - usually copious and purulent. More common in MSM and Indigenous populations.

Non-gonococcal urethritis - usually less discharge.

Dysuria

In young men, indicates an STI until proven otherwise.

Urinary frequency

Suggestive of bladder infection.

Diagnosis

InfectionSite/SpecimenTest
Chlamydia* FPU NAAT
Gonorrhoea* FPU

NAAT.

If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment.

If any discharge Urethral swab Microscopy and culture

FPU – First pass urine

NAAT – Nucleic acid amplification test

* If test results are negative and symptoms persist, consider testing of FPU for M. genitalium (if not already done), herpes simplex virus (HSV) and adenovirus.

Specimen collection

Clinician collected |
Self-collection

A urethral swab can be collected for NAAT if urine cannot be obtained.

Special considerations

For men who have sex with men (MSM), undertake the following additional tests:

Management

Principle treatment options
InfectionRecommendedAlternative regimens
NGU Likely

Doxycycline 100mg PO, BD for 7 days

 

Azithromycin 1g PO, stat 

 

Gonorrhoea likely

Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat 

PLUS

Azithromycin 1g PO, stat

Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat

PLUS

Doxycycline 100mg PO, BD for 7 days

Mycoplasma genitalium

After completing doxycycline, use either azithromycin or moxifloxacin.

See Mycoplasma genitalium

Seek specialist advice

NGU – Non-gonococcal urethritis

Treatment advice

  • Ceftriaxone is the most effective treatment for gonorrhoea  but azithromycin is usually added to reduce the chance of resistance emerging.
  • Azithromycin is effective for chlamydia  but will fail and select resistance in at least 10% of M. genitalium, therefore doxycycline is preferred for NGU.
  • When NGU is considered likely but you would also prefer to treat a potential case of gonorrhoea, it is reasonable to add doxycycline instead of azithromycin to ceftriaxone.
  • If symptoms do not resolve, seek specialist advice for management of persistent NGU, including M. genitalium  (often resistant), herpes  simplex virus (HSV) and adenovirus.

Other immediate management

  • Advise no sexual contact for 7 days after treatment is administered
  • Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary.
  • Contact tracing
  • Provide patient with factsheet.

Contact Tracing

  • Contact tracing for gonorrhoea and chlamydia is a high priority and should be performed in all patients with confirmed infection
  • For non-gonococcal urethritis, male and female partners should be traced back for a minimum of 4 weeks.

See Australasian Contact Tracing website for more information.

Follow up

If STI confirmed, follow up provides an opportunity to:

  • Confirm patient adherence to treatment and assess for symptom resolution
  • Confirm contact tracing procedures have been undertaken or offer more contact tracing support
  • Provide further sexual health education and prevention counselling.

For test of cure (TOC) and retesting advice see:

Auditable outcomes

  • 100% of patients diagnosed with NGU are treated with an appropriate antibiotic regimen
  • 100% of patients are advised to avoid sexual contact for 7 days after treatment is prescribed.

References

Drugs, HIV and Viral Hepatitis Group, British Association for Sexual Health and HIV (BASHH) 2013. Available from: http://www.bashh.org/BASHH/Guidelines/Guidelines/BASHH/Guidelines/Guidelines.aspx

Last Updated: Thursday, 04 October 2018