Urethritis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Urethritis is due to inflammation of the urethra. Based on etiology it is classified into two main groups, infectious and non-infectious. Infectious causes are further classified into gonorrheal and non-gonorrheal. Urethritis is an inflammation of the genital tract that is mostly due to infectious causes. Its pathogenesis depends on the causative pathogen. Microscopic findings for gonococcal urethritis include, presence of gram-negative intracellular diplococci (GNID), invaded epithelial cells, vacuoles that contain multiple organisms, and >2 WBC per oil immersion field. Nongonococcal urethritis (NGU) is [[microscopically characterized by signs of inflammation with absence of gram-negative intracellular diplococci. If symptoms are present but no evidence of urethral inflammation is present, Nucleic Acid Amplification Tests (NAATs) for C. trachomatis and N. gonorrhoeae might identify infections.The most potent risk factor for urethritis is unprotected sex, especially among men who have sex with men. Other risk factors include low socioeconomic status, history of sexually transmitted diseases, and multiple sex partners. Urethritis is primarily diagnosed based on symptoms, signs of urethral inflammation and microscopic findings. Symptoms may comprise of dysuria, urethral pruritus, burning, Signs of urethral inflammation include urethral discharge, which can be mucoid, mucopurulent, or purulent. Microscopic findings in gonorrheal urethritis include, identification of gram-negative intracellular diplococci (GNID) or purple intracellular diplococci on methylene blue, or gentian violet stain. Presence of Invaded epithelial cells, vacuoles that contain multiple organisms and >2 WBC per oil immersion field. Nongonococcal urethritis (NGU) is microscopically characterized by signs of inflammation with absence of gram-negative intracellular diplococci. If symptoms are present but no evidence of urethral inflammation is present, Nucleic Acid Amplification Tests (NAATs) for C. trachomatis and N. gonorrhoeae might identify infections.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.

The first known case of urethritis was described by Albert Neisser, a German doctor, in 1879. In 1904, Ludwig Waelsch described mild non-gonococcal urethritis (NGU). In the 1930s and later, Philip Thygeson and others in the United States confirmed the vertical transmission of nongonococcal urethritis (NGU). 

Urethritis is classified into two main groups of infectious and non-infectious based on the etiology. Infectious causes are further classified into gonorrheal and non-gonorrheal.

Urethritis is an inflammation of the genital tract that is mostly due to infectious causes. Its pathogenesis depends on the causative pathogen. N. gonorrhea is usually transmitted via the genital tract to the human host. Following attachment to host cell, which is mediated by pili, gonococci become engulfed in a process known as parasite-directed endocytosis. This organism will survive inside the vacuoles and replicate. Among non-gonorrheal causes, Chlamydia trachomatis is the most common. The infectious process begins with cell surface attachment and phagocytosis by the host cell. The pathogen survives inside the cell by debilitating the cellular lysosomes and replicating as elementary bodies which is considered as the infective form of the pathogen. Microscopic findings for gonococcal urethritis include, presence of gram-negative intracellular diplococci (GNID), invaded epithelial cells, vacuoles that contain multiple organisms, and >2 WBC per oil immersion field. Nongonococcal urethritis (NGU) is microscopically characterized by signs of inflammation with absence of gram-negative intracellular diplococci.

Urethritis may be caused by either infectious or non-infectious causes. Infectious causes are divided into gonorrheal and non-gonorrheal. Non-gonorrheal pathogens are the most common cause of urethritis; Chlamydia trachomatis is the most common among them.

Urethritis must be differentiated from other causes of dysuria and urethral discharge, which include acute cystitis, epididymitis, prostatitis, cervicitis, and vulvovaginitis.

Urethritis is the cause of several millions of healthcare visits in the United States. Chlamydia trachomatis is the most common reportable disease in the US. In 2014, a total of 350,062 gonorrhea cases were reported to the CDC in the US. Based on The National Health and Nutrition Examination Survey, the overall prevalence of chlamydia among persons aged 14–39 years was 1.7% during 2007-2012. Urethritis has a very good prognosis with proper treatment. Mortality is very uncommon in patients with gonococcal and non-gonococcal urethritis. Almost two-thirds of chlamydia infections occur among youths aged 15-24 years. The highest prevalence rates of gonococcal urethritis were found in ages 20 to 24 years both in men and women. In 2014, the overall rate of chlamydia infection in the United States among women was 627.2 cases per 100,000 females, over two times the rate among men (278.4 cases per 100,000 males). In 2014, the incidence of gonorrhea in the United States was reported as 120 cases per 100,000 males, while it was reported as 100 cases per 100,000 females.

The most potent risk factor for urethritis is unprotected sex, especially among men who have sex with men. Other risk factors include low socioeconomic status, history of sexually transmitted diseases, and multiple sex partners.

High-risk individuals should be screened for sexually transmitted diseases. The U.S. Preventive Service Task Force (USPSTF) developed recommendations for the screening of for Chlamydia trachomatis and N. gonorrhea.

Urethritis has a good prognosis and most patients are treated with appropriate antibiotics. If left untreated, it can resolve within 3 months in 95% of people with gonococcalurethritis. The symptoms of nongonococcal urethritis generally abate within 3 months in 30-70% of untreated people. Rarely, complications such as epididymitis, prostatitis, urethral stricture, chronic gonorrhea carrier state, may occur.

Urethritis is primarily diagnosed based on symptoms, signs of urethral inflammation and microscopic findings. Symptoms may comprise of dysuria, urethral pruritus, burning, Signs of urethral inflammation include urethral discharge, which can be mucoid, mucopurulent, or purulent. Microscopic findings in gonorrheal urethritis include, identification of gram-negative intracellular diplococci (GNID) or purple intracellular diplococci on methylene blue, or gentian violet stain. Presence of Invaded epithelial cells, vacuoles that contain multiple organisms and >2 WBC per oil immersion field. Nongonococcal urethritis (NGU) is microscopically characterized by signs of inflammation with absence of gram-negative intracellular diplococci. If symptoms are present but no evidence of urethral inflammation is present, Nucleic Acid Amplification Tests (NAATs) for C. trachomatis and N. gonorrhoeae might identify infections.

A detailed history, particularly with regard to sexual activity, must be taken. Symptoms suggestive for urethritis include dysuria and urethral discharge. History should specifically include, recent sexual activities, number of sex partners, or any new partner, use of condoms, history of prior STDs, and history of recent urethral instrumentation (e.g., urethral catheters).

Symptoms suggestive of urethritis include dysuria and urethral discharge.

The most common physical finding in urethritis is urethral discharge. The entire genital area must be examined in order to rule out other possibilities. Patients should be examined for inguinal lymphadenopathy, ulcers, and urethral discharge.

Urethritis may be considered on the basis of any of the following, mucoid, mucopurulent, or purulent discharge on examination, Gram stain of urethral secretions demonstrating ≥2 WBC per field, positive leukocyte esterase test on first-void urine or microscopic examination of sediment from a spun first-void urine demonstrating ≥10 WBC per high power field.

There are no ECG findings associated with urethritis.

There are no x-ray findings associated with urethritis.

There are no echocardiography/ultrasound findings associated with urethritis.

There are no CT scan findings associated with urethritis.

There are no MRI findings associated with urethritis.

There are no other imaging findings associated with urethritis.

There are no additional diagnostic findings for urethritis.

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.

There are no recommended therapeutic interventions for the management of urethritis.

Surgical intervention is not recommended for the management of urethritis.

Effective measures for the primary prevention of urethritis include limiting the number of sex partners and using condoms.

In order to prevent transmission to one’s partner and decrease the risk of antibiotic resistance, all patients must be instructed on safe sex practices and screening requirements after treatment.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

The first known case of urethritis was described by Albert Neisser, a German doctor, in 1879. In 1904, Ludwig Waelsch described mild non-gonococcal urethritis (NGU). In the 1930s and later, Philip Thygeson and others in the United States confirmed the vertical transmission of nongonococcal urethritis (NGU).

• In 1879, Neisser discovered the gonococcus and, for the first time, the term “urethritis non‐gonorrhoica” was coined.
• In 1904, Ludwig Waelsch described mild non-gonococcal urethritis (NGU).
• After that Chlamydozoa, was described as infectious agent, that may cause NGU, which was, at that time, called Waelsch urethritis.
• In the 1930s and later, Philip Thygeson and others in the United States confirmed the vertical transmission of nongonococcal urethritis (NGU).^[1]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2] Zehra Malik, M.B.B.S[3]

Urethritis is an inflammation of the genital tract that is mostly due to infectious causes. Its pathogenesis depends on the causative pathogen. N. gonorrhea is usually transmitted via the genital tract to the human host. Following attachment to host cell, which is mediated by pili, gonococci become engulfed in a process known as parasite-directed endocytosis. This organism will survive inside the vacuoles and replicate. Among non-gonorrheal causes, Chlamydia trachomatis is the most common. The infectious process begins with cell surface attachment and phagocytosis by the host cell. The pathogen survives inside the cell by debilitating the cellular lysosomes and replicating as elementary bodies which is considered as the infective form of the pathogen.

Urethritis is divided into gonorrheal and non-gonorrheal causes. The pathophysiology of each one of them is different.

• N. gonorrhea is usually transmitted via the genital tract to the human host.
• Following attachment to host cell, which is mediated by pili, gonococci become engulfed in a process known as parasite-directed endocytosis. This organism will survive inside the vacuoles and replicate.^[1]
• Gonococcal virulence factors include:^[2][3][4]
  • Pili
  • The ability to attach to urethral epithelial cells
  • Production of extracellular proteases that cleave IgA

• Among non-gonorrheal causes, Chlamydia trachomatis is the most common.
• The infectious process begins with cell surface attachment and phagocytosis by the host cell. The pathogen survives inside the cell by debilitating the cellular lysosomes and replicating as elementary bodies which is considered as the infective form of the pathogen.^[5][6]

Urethritis does not follow any genetic pattern.

• Stevens-Johnson syndrome
• Nongonococcal urethritis (NGU) due to C. trachomatis may be associated with:
  • Epididymitis
  • Prostatitis
  • Reactive arthritis
• HIV transmission is facilitated by co-existing non-gonococcal urethritis, however treatment of NGU is the same in HIV negative or positive patients.

On gross pathology, mucoid, mucopurulent, or purulent discharge can be observed.

Characteristic findings include:^[7]

• Gram-negative intracellular diplococci (GNID) or purple intracellular diplococci on methylene blue, or gentian violet stain.
• Invaded epithelial cells
• Vacuoles that contain multiple organisms
• Polymorphic nuclear cellss

• Absence of gram-negative intracellular diplococci (GNID)
• Signs of inflammation present

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Urethritis may be caused by either infectious or non-infectious causes. Infectious causes are divided into gonorrheal and non-gonorrheal. Non-gonorrheal pathogens are the most common cause of urethritis; Chlamydia trachomatis is the most common among them.

Urethritis may be caused by either infectious or non-infectious causes. Infectious causes are divided into gonococcal and non-gonococcal. Non-gonorrheal pathogens are the most common cause of urethritis; Chlamydia trachomatis is the most common among them.^[1][2][3]

Causes

Non-infectious causes[4]

Infectious causes[3]

Heavy precipitation of urinary crystals, chemicals, bubble bath, Stevens-Johnson syndrome, spermicides

Gonococcal urethritis[1]

Non-gonococcal urethritis[5][6][7]

Chlamydia trachomatis Trichomonas vaginalis Mycoplasma genitalium Herpes simplex virus Adenovirus Ureaplasma urealyticum Neisseria meningitidis Haemophilus influenza Haemophilus parainfluenzae

Cardiovascular	No underlying causes
Chemical/Poisoning	Bath salts, bubble bath, spermicides, talcum powder
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	Urethral catheterization, instrumentation
Infectious Disease	Adenovirus, Candida albicans, Chlamydia trachomatis, Group D streptococcus, Herpes simplex virus, Lymphogranuloma venereum, Mycoplasma genitalium, Mycoplasma hominis, Neisseria gonorrheae, Pelvic inflammatory disease, protozoa, Treponema pallidum, Trichomonas vaginalis, Ureaplasma parvum, Ureaplasma urealyticum
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Balanitis xerotica obliterans, Reiter syndrome, Stevens-Johnson syndrome
Sexual	No underlying causes
Trauma	Urethral trauma
Urologic	No underlying causes
Miscellaneous	Bicycle riding, diaphragm use (contraception), foreign body insertion, heavy precipitation of urinary crystals, physical irritation of the urethra

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Urethritis presents with urinary irritative symptoms and urethral discharge. Differential diagnosis is based on gender and chronicity of symptoms.

Urethritis must be differentiated from other diseases that cause lower urinary tract irritation symptoms (e.g., dysuria, urgency and frequency in addition to urethral discharge); these include cystitis, cervicitis, vulvovaginitis, epididymitis, prostatitis, and syphilis.^{[1][2][3][4][5][6][7][8][9]}

• The following table summarizes the differential diagnosis for urethritis.

Diseases	Symptoms					Physical Examination				Diagnostic tests			Past medical history	Other Findings
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Urethritis	–	+	–	–	+	+	–	Urethral discharge	+	Positive leukocyte esterase test or >10 WBCs Mucous threads in the morning urine	–	Gram stain & mucoid or purulent discharge	Prior STDs Urinary tract infections New sexual partner Recent intercourse Recent catheterization	Purulent discharge may suggest gonorrhoea Exclusive dysuria suggest Chlamydia Painful genital ulcers with dysuria suggest HSV
Pyelonephritis	+	+	–	–	+	+	Flank or costovertebral angle	+	+	Leukocytes Nitrite +ve	Identifies causative bacteria	Urine culture	History of pyelonephritis Recent history of hospitalisation Nephrolithiasis Immunosupression	Costovertebral angle tenderness Patient is in acute distress Look for obstructive causes
Cystitis	+	+	+	+	+	+	Suprapubic	–	+	Nitrite +ve Leukocyte esterase +ve WBCs RBCs	>100,000CFU/mL	Urine culture	Recent catheterisation Pregnancy Recent intercourse Diabetes Personal or family history of UTI Known abnormality of the urinary tract BPH HIV	Imaging studies help differentiate the various types May accompany back pain, nausea, vomiting, and chills
Prostatitis	–	+	+	+	+	+	–	–	–	10–20 leukocytes for acute and chronic bacterial subtypes	Identifies causative bacteria (in bacterial subtypes)	Urine culture	Urogenital disorders Recent catheterization or other genitourinary instrumentation History of UTIs	Tender and enlarged prostate in acute prostatitis[1][3] Tender and soft (boggy) prostate in chronic prostatitis[1] A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis.
Diseases	Symptoms					Physical Examination				Diagnostic tests			Past medical history	Other Findings
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Vulvovagintis	–	–	–	–	+	+	–	Vaginal discharge	+	–	–	Gram stain & culture of discharge	Number and type of sexual partners (new, casual, or regular) Prior STDs Previous history of symptomatic BV in female partner (in homosexual women)	Fishy odor from the vagina (Whiff test) Thin, white/gray homogeneous vaginal discharge Microscopy (wet prep) and vaginal pH  Clue cells
Cervicitis	–	+	–	–	+	+	Cervical	Endocervical exudate	–	–	–	Culture for gonococcal cervicitis	Abnormal vaginal bleeding after intercourse or after menopause Abnormal vaginal discharge Painful sexual intercourse Pressure or heaviness in the pelvis	Purulent or mucopurulent endocervical exudate Sustained endocervical bleeding easily induced by a cotton swab >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea
Epididymitis	+	–	+	+	+	+	Testicular & suprapubic	+/– urethral discharge	+	Hematuria may be seen	+	Culture	Unilateral, gradual, and localized scrotal pain posterior to the testis Scrotal swelling Scrotal wall erythema Constitutional symptoms: feeling warm, chills, nausea and vomiting	Ultrasound in patients with acute testicular pain to assess for testicular torsion If equivocal do surgical exploration
Syphilis (STD)	–	–	–	–	–	+/–	–	–	+	–	–	Darkfield microscopy	History of STD HIV Immunosupression Previous history of chancre	May be asymptomatic Painless chancre in primary syphilis Secondary syphilis may have generalised features and condylomata lata Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Urethritis is the cause of several millions of healthcare visits in the United States. Chlamydia trachomatis is the most common reportable disease in the US. In 2014, a total of 350,062 gonorrhea cases were reported to the CDC in the US. Based on The National Health and Nutrition Examination Survey, the overall prevalence of chlamydia among persons aged 14–39 years was 1.7% during 2007-2012. Urethritis has a very good prognosis with proper treatment. Mortality is very uncommon in patients with gonococcal and non-gonococcal urethritis. Almost two-thirds of chlamydia infections occur among youths aged 15-24 years. The highest prevalence rates of gonococcal urethritis were found in ages 20 to 24 years both in men and women. In 2014, the overall rate of chlamydia infection in the United States among women was 627.2 cases per 100,000 females, over two times the rate among men (278.4 cases per 100,000 males). In 2014, the incidence of gonorrhea in the United States was reported as 120 cases per 100,000 males, while it was reported as 100 cases per 100,000 females.

• Chlamydia trachomatis is the most common reportable disease in the US. In 2014, a total of 1,441,789 chlamydial infections were reported to the CDC.
• In 2014, the incidence of urethritis due to Chlamydia trachomatis infection was estimated to be 456 cases per 100,000 individuals in the US.
• In 2014, a total of 350,062 gonorrhea cases were reported to the CDC in the US.^[1]
• In 2014, the incidence of urethritis due to N. gonorrhea infection was estimated to be 110.7 cases per 100,000 individuals in the US.
• Worldwide, there are an estimated 78 million gonorrhea cases, and 131 million cases of chlamydia yearly.^[2][3]

• Based on The National Health and Nutrition Examination Survey, the overall prevalence of chlamydia among persons aged 14–39 years was 1.7% during 2007-2012.^[4]

• Urethritis has a very good prognosis with proper treatment. Mortality is very uncommon in patients with gonococcal and non-gonococcal urethritis.

• Chlamydia trachomatis
  • Almost two-thirds of chlamydia infections occur among youths aged 15-24 years.^[5]
• Gonorrhea
  • The highest prevalence rates were found in ages 20 to 24 years both in men and women.

• Chlamydia trachomatis^[4]
  • In 2014, the chlamydia rate in African-Americans was 6 times the rate in Caucasians.
  • The rate among American Indians/Alaska Natives was almost 4 times the rate among Caucasians.
• Gonorrhea^[4]
  • In 2014, the rate of reported gonorrhea cases remained highest among African-Americans (405.4 cases per 100,000 individuals).
  • The rate among African-Americans was 10.6 times the rate among Caucasians (38.3 cases per 100,000 population).
  • The gonorrhea rate among American Indians/Alaska natives was 159.4 cases per 100,000 individuals, 4.2 times that of Caucasians.

• 
  Rate of Chlamydia reported cases by gender
• 
  Chlamydia Prevalence by race and age
• 
  Rate of Gonorrhea reported cases by sex
• 
  Gonorrhea Prevalence by race

Graphs adapted from https://www.cdc.gov/

• Chlamydia trachomatis
  • In 2014, the overall rate of chlamydia infection in the United States among women was 627.2 cases per 100,000 females, over two times the rate among men (278.4 cases per 100,000 males).^[1]
• Gonorrhea
  • In 2014, incidence of gonorrhea in the United States was reported as 120 cases per 100,000 males, while it was reported as 100 cases per 100,000 female.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

The most potent risk factor for urethritis is unprotected sex, especially among men who have sex with men. Other risk factors include low socioeconomic status, history of sexually transmitted diseases, and multiple sex partners.

The most important risk factors for urethritis is unprotected sex, especially among men who have sex with men. The following are other risk factors:^[1][2]

• Low socioeconomic status
• Prior or current STD
• New or multiple sex partners
• Circumcision

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

High-risk individuals should be screened for sexually transmitted diseases. The U.S. Preventive Service Task Force (USPSTF) developed recommendations for the screening of for Chlamydia trachomatis and N. gonorrhea.

According to the U.S. Preventive Service Task Force (USPSTF), screening for sexually transmitted disease is recommended as outlined below for Chlamydia trachomatis and N. gonorrhea.^[1][2]

Chlamydia trachomatis
Population	Recommendations
Women	Sexually active women under 25 years of age Sexually active women aged 25 years and older if at increased risk Prior history of sexually transmitted infection A new sex partner More than one sex partner A sex partner with concurrent partners A sex partner who has a sexually transmitted infection Retest 3 months after treatment.
Men	Consider screening young men in high-prevalence clinical settings or in populations with a high burden of infection (e.g., men who have sex with men)
Pregnant women	All pregnant women under 25 years of age Pregnant women aged 25 years and older if at increased risk Retest during the third trimester for women under 25 years of age or at risk Pregnant women with chlamydial infection should have a test-of-cure 3-4 weeks after treatment and be retested within 3 months
Men Who have Sex With Men (MSM)	At least annually for sexually active MSM at sites of contact (urethra, rectum) regardless of condom use Every 3 to 6 months if at increased risk
HIV positive patients	For sexually active individuals, screen at first HIV evaluation and at least annually More frequent screening may be indicated depending on individual risk behaviors and local epidemiology

Neisseria Gonorrhea
Population	Recommendations
Women	Sexually active women under 25 years of age Sexually active women age 25 years and older if at increased risk Prior history of sexually transmitted infection A new sex partner More than one sex partner A sex partner with concurrent partners A sex partner who has a sexually transmitted infection Retest 3 months after treatment.
Men Who have Sex With Men (MSM)	At least annually for sexually active MSM at sites of contact (urethra, rectum, pharynx) regardless of condom use Every 3 to 6 months if at increased risk
Pregnant women	All pregnant women under 25 years of age and older women if at increased risk Retest 3 months after treatment
HIV positive patients	For sexually active individuals, screen at first HIV evaluation and at least annually More frequent screening may be indicated depending on individual risk behaviors and the local epidemiology

• Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Urethritis has a good prognosis and most patients are treated with appropriate antibiotics. If left untreated, it can resolve within 3 months in 95% of people with gonococcal urethritis. The symptoms of nongonococcal urethritis generally abate within 3 months in 30-70% of untreated people. Rarely, complications such as epididymitis, prostatitis, urethral stricture, chronic gonorrhea carrier state, may occur.

• If left untreated, it can resolve within 3 months in 95% of people with gonococcal urethritis. The symptoms of nongonococcal urethritis generally abate within 3 months in 30-70% of untreated people.^[1]
• Prolonged asymptomatic urethral carriage of gonococci occurs in 2% to 3% of newly infected men if left untreated.^[2]

Common complications of urethritis include:

• Acute epididymitis
• Prostatitis

• It occurs in 20% to 30% of men with non-gonorrheal urethritis (NGU); however, it is usually asymptomatic and responds to standard treatment.^[3]

• Urethral stricture

• Gonorrhea may cause urethral stricture.

• Oculogenital syndrome

• Consisting of conjunctivitis and non-gonorrheal urethritis (NGU) may be seen in approximately 4% of patients with urethritis.^[4]

• Reactive arthritis

• Associated with nongonococcal urethritis in 1% to 2% of cases, primarily in men and is strongly associated with HLA-27.^[5]

• Rare complications include:^[6]
  • Salpingitis
  • Cervicitis
  • Seminal vesiculitis
  • Penile edema
  • Periurethral abscess
  • Regional lymphadenitis
  • Infertility

• The prognosis is generally good following standard therapy.