• Chlamydia trachomatis, Mycoplasma genitalium and Neisseria gonorrhoeae are the most common causes of penile urethritis.
• Other organisms include:  herpes simplex virus (HSV), adenoviruses and Trichomonas vaginalis. Ureaplasma urealyticum is considered normal urethral flora.
• M. genitalium is often resistant to azithromycin or doxycycline. Azithromycin fails to eradicate about 10% of susceptible infections, leading to the selection of resistance, whereas doxycycline does not select resistance and is therefore preferred for the treatment of NGU.
• Up to 50% of cases may have no microbiological cause identified.

Test for the following infections

NAAT – Nucleic acid amplification test

*If test results are negative and symptoms persist, consider testing of FPU for herpes simplex virus (HSV), adenovirus and trichomoniasis (NAAT).

Specimen collection guidance

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:

• Anorectal swabs and pharyngeal swabs for chlamydia(NAAT) and gonorrhoea (NAAT)
• Blood test for syphilis, human immunodeficiency virus  (HIV),  hepatitis A  and  hepatitis B. Consider testing for hepatitis C, if there is a history of injecting drug use or patient is HIV positive.

NGU – Non-gonococcal urethritis

Treatment advice

• Ceftriaxone is the most effective treatment for gonorrhoea but azithromycin is added to reduce the chance of resistance emerging.
• Doxycycline is preferred for NGU and chlamydia and also initiates treatment for M. genitalium.
• 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 commenced, or until the course is completed and symptoms resolved, whichever is later.
• Contact tracing according to identified pathogen.
• Provide patient with factsheet.

• Contact tracing for gonorrhoea,  chlamydia and Mycoplasma genitalium is a high priority and should be performed in all patients with confirmed infection
• For urethritis not caused by these specific infections, all partners should be traced back for a minimum of 4 weeks and offered asymptomatic screening tests.

See Australasian Contact Tracing website for more information.

If STI confirmed, follow-up provides an opportunity to:

• Confirm patient adherence to treatment and assess for symptom resolution
• Confirm contact tracing has been undertaken or offer more contact tracing support
• Educate about condom use, contraception, HIV PrEP/PEP, safe injecting practices, consent, CST and vaccinations for HAV, HBV and HPV as indicated. 

For test of cure  and retesting advice see:

• Gonorrhoea
• Chlamydia
• M. genitalium.

• 100% of patients diagnosed with urethritis are treated with an appropriate antibiotic regimen.