7.04 Urethritis (Drip)

agk’s Library of Common Simple Emergencies

Presentation

A male complains of dysuria, a burning discomfort along the urethra, or a urethral discharge. A copious, thick, yellow- green discharge which stains underwear is characteristic of gonorrhea, whereas a thin, white, scant discharge with milder symptoms is characteristic of chlamydia. Urethritis in a female may be asymptomatic or indistinguishable from cystitis or vaginitis, or may be manifest as UTI symptoms with a low concentration of bacteria on urine culture, or tenderness localized to the anterior vaginal wall. In addition to increased vaginal discharge, women may have intermenstrual bleeding, especially postcoital spotting and cervical friability.

What to do:

• Gram stain any urethral discharge, looking for gram- negative diplococci inside white cells, which imply gonococcal infection.
• Order a serologic test for established syphilis. Further antibiotic treatment is required if the RPR or VDRL is positive .
• Examine the urine sediment for swimming protozoa, implying infection with Trichomonas vaginalis, best treated with metronidazole (Flagyl) 250mg qid x 7d, or 2gm po once.
• If there is no sign of gonorrhea or trichomonas causing the urethritis, assume the infection is caused by chlamydia or ureaplasma, best treated with doxycycline 100mg bid for 7 days, or azithromycin 1000mg po once. (If the patient is pregnant, use erythromycin ethyl succinate (EES) 800mg qid x7d or erythromycin base, not estolate, 500mg qid x7d).
• Ask about sexual partners who should also be treated.
• Instruct the patient on the correct use of the condom to prevent reinfection.

What not to do:

• Do not send off a serologic test for syphilis without following up on the results

Discussion

Cultures and fluorescent antibody tests to diagnose chlamydia are expensive and insensitive, so presumptive treatment remains the best strategy. Many gonorrhea victirns develop a rebound urethritis, probably with chlamydia, following single dose antibiotic treatment.

Non-gonococcal urethritis is the most common sexually treated disease in US men. Complications include acute epididymitis, Reiter's syndrome and persistent or recurrent urethritis. More important, failure to identify and treat non-gonococcal urethritis places female sexual partners at risk for mucopurulent cervicitis, pelvic inflammatory disease, ectopic pregnancy and tubal infertility. Sexually-transmitted infections that produce cervical inflammation in women and urethritis in men man facilitate transmission of human immunodeficiency virus (HIV).

References:

• Stamm WE, Hicks CB, Martin DH et al: Azithromycin for empirical treatment of the nongonococcal urethritis syndrome in men. J Am Med Assoc 1995;274:545-549.

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