Urethritis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2], Cafer Zorkun, M.D., Ph.D. [3], Sujit Routray, M.D. [4]

Treatment is based on the causative pathogen. Presumptive treatment should be initiated while waiting for the diagnostic confirmation. Once the diagnosis is confirmed, the appropriate antibiotic regimen should be initiated to reduce the risk of complications. Doxycycline 100 mg PO bid for 7 days is administered to treat Non-gonococcal Urethritis, as an alternative therapy azithromycin 1 g PO in a single dose or azithromycin 500 mg orally in a single dose; then 250 mg orally daily for 4 days is recommended. For gonococcal urethritis, ceftriaxone 500 mg IM in a single dose (for patients weighing ≥150 kg (300 lbs) ceftriaxone 1 g IM in a single dose), for alternate therapy gentamicin 240 mg PO in a single dose plus azithromycin 2 g PO in a single dose, or cefixime 800 mg PO in a single dose is recommended. Metronidazole 2 g PO in a single dose is used for patients with recurrent and persistent urethritis. Following treatment, patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy. Providers should be alert to the possibility of chronic prostatitis/chronic pelvic pain syndrome in male patients experiencing persistent pain (perineal, penile, or pelvic), discomfort, irritating voiding symptoms, pain during or after ejaculation, or new onset premature ejaculation lasting for >3 months. All sex partners within the preceding 60 days should be referred for evaluation, testing, and empiric treatment with a drug regimen effective against Chlamydia. Clinicians must report both chlamydia and gonorrhea to health departments.

• Presumptive treatment should be initiated while waiting for the diagnostic confirmation.
• Once the diagnosis is confirmed, the appropriate antibiotic regimen should be initiated to reduce the risk of complications.^[1]
• Erythromycin is no longer considered as an alternative choice for non-gonococcal urethritis due to its gastrointestinal side effect and number of doses required.
• Due to its lower efficacy levofloxacin is no longer alternatively used for non-gonococcal urethritis.
• The standard of choice is described below.^[2][3][4]

• HIV and syphilis should be tested in men with non-gonococcal urethritis. HIV transmission is facilitated by co-existing non-gonococcal urethritis, however treatment of NGU is the same in HIV negative or positive patients.
• Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy. these patients should also be tested for Mycoplasma genitalium and Trichomonas vaginalis. ^[3]
• It is recommended for male patients to return after three months for re-testing to rule out re-infection especially if urethritis was due to chlamydia, gonorrhea, or trichomoniasis.
• Symptoms without signs or laboratory evidence of urethral inflammation are not sufficient for re-treatment.
• Possibilities of chronic prostatitis/chronic pelvic pain syndrome in male patients demonstrating persistent pain (perineal, penile, or pelvic), discomfort, irritating voiding symptoms, pain during or after ejaculation, or new onset premature ejaculation lasting for >3 months should be evaluated and if present, a [[[urology]] consult should be made.^[3][4]
• Clinicians must report both chlamydia and gonorrhea to health departments.

• If expedited treatment is required and permissible by state law for the partner then, in chlamydia negative partners single 800 mg oral dose of cefixime is recommended. In patients where chlamydia is not excluded recommended therapy is single 800 mg oral dose of cefixime plus oral doxycycline 100 mg twice daily for 7 days.
• All sex partners within the preceding 60 days should be referred for evaluation, testing, and empiric treatment with a drug regimen effective against Chlamydia.
• A specific diagnosis might facilitate partner referral. Therefore, testing for gonorrhea and chlamydia infection is encouraged. A substantial proportion of female partners of males with non-chlamydial, non-gonococcal urethritis are infected with chlamydia.
• Partner treatment is recommended for males with non-gonococcal urethritis regardless of whether a specific etiology is identified.^[3][4]