Urethritis – penile
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Urethral discharge and dysuria are typical symptoms of penile urethritis.
Make a clinical diagnosis of gonorrhoea or non-gonococcal urethritis (NGU) and treat accordingly (see clinical presentation).
- 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.
|
Symptoms |
Considerations |
|---|---|
|
Urethral discharge |
Gonorrhoea – usually copious and purulent. More common in men who have sex with men and Aboriginal and Torres Strait Islander people |
|
Dysuria |
In a penis, indicates a sexually transmitted infection (STI) rather than a urinary tract infection (UTI) until proven otherwise |
|
Urinary frequency |
Suggestive of bladder infection |
Test for the following infections
|
Site/specimen |
Test |
Consideration |
|---|---|---|
|
NAAT: Chlamydia trachomatis, Mycoplasma genitalium and Neisseria gonorrhoeae |
All patients who have suspected or confirmed NGU should be tested for chlamydia, gonorrhoea and M. genitalium by using NAATs. A specific diagnosis can potentially reduce complications, re-infection and transmission. If omitted initially, test for M. genitalium in patients with persistent or recurrent symptoms after initial empirical treatment | |
|
Urethral swab |
Gonorrhoea culture and antibiotic sensitivity |
In patients with urethral discharge |
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.
|
Principal treatment options | ||
|---|---|---|
|
Infection |
Recommended |
Alternative regimens |
|
NGU likely |
Doxycycline 100 mg PO, BD for 7 days | |
|
Gonorrhoea likely |
Ceftriaxone 500 mg in 2 mL of 1% lignocaine IMI, stat |
Ceftriaxone 500 mg in 2 mL of 1% lignocaine IMI, stat |
|
Seek specialist advice | ||
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:
- 100% of patients diagnosed with urethritis are treated with an appropriate antibiotic regimen.
