What is the Current Treatment for Uncomplicated Urethritis?

Patient Presentation
A 15-year-old previously healthy male comes to the clinic complaining of “somthing blocking my urine” occurring daily for the past two months. He describes it as more discomfort than pain. There is occasionally burning with urination. There is no other pain or discomfort.
On his review of systems he denies discharge, sores, lesion, fever, or hematuria. There is no history of conjunctivitis, joint pain or catheterization in the past.
His social history shows his last sexual activity was 4 months previous. He has had 2 lifetime partners and uses condoms sporatically.
His pertinent physical examination reveals he is afebrile with normal vital signs. His genitourinary examination reveals a circumcized male, Tanner stage 5. His testes are both in the scrotal sack without masses. His penis also has no masses. He states he has slight internal tenderness to palpation approximately 1 cm proximal to the corona. There is no deformity of the penis. He has no rashes, skin lesions or musculoskeletal abnormalities.
The laboratory evaluation shows a normal urinanalysis. Urethal cultures for Chlamydia trachomatis and Neisseria gonorrhoeae were sent. He was sent to the laboratory for Syphilis, HIV and Hepatitis B which were not completed because he left.
A presumed diagnosis of a sexually transmitted infection was made and he was treated with one dose of Azithromycin and Rocephin. His culture for chlamydia later was positive and he was followed-up by the public health department.

Discussion
Sexually transmitted infections (STIs) are the most frequent cause of genital related complaints in teenagers. Adolescents are at greater risk for STIs because they frequently have unprotected intercourse, are more susceptible to infection biologically, are engaged in more partnerships, and face multiple obstacles to utilization of health care. All adolescents in the United States can consent to the confidential diagnosis and treatment of STIs with few exceptions. Medical care for STIs can be provided to adolescents without parental consent or knowledge.

Urethritis is caused by an infection characterized by urethral discharge of mucopurulent or purulent material and sometimes by dysuria or urethral pruritis. Asymptomatic infections are common. The common pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis.

Urethritis should be documented on the basis of any of the following signs:

  • Mucopurulent or purulent discharge.

  • Gram stain of urethral secretions demonstrating >5 WBCs per oil immersion field. The gram stain is the preferred rapid diagnostic test.
  • Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating >10 WBCs per high power field.

Patients should be treated for both infections because of the high rate of co-infection if diagnostic tools (e.g., a gram stain and microscope) are unavailable or urethritis cannot be documented and the patient is at high risk of infection and unlikely to return for follow-up. Non-gonococcal urethritis is diagnosed if gram-negative intracellular diplococci cannot be identified on urethral smears.
If none of these criteria is present, then treatment should be deferred, and the patient should be tested for N. gonorrhoeae and C. trachomatis and followed closely if test results are negative. If the results demonstrate infection with either N. gonorrhoeae or C. trachomatis, the appropriate treatment should be given and sex partners referred for evaluation and treatment.
Common etiologies for non-gonococcal, non-chlamydial urethritis include Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis and Herpes simplex.

Chlamydia trachomatis is an obligate intracellular bacteria. It is one of the most common reportable sexually transmitted infections in the US, especially in teens and young adults. Genital infection in adolescents is sexually transitted but the possibility of sexual abuse should be considered in prepubertal children. The incubation period is variable but is usually at least 1 week. Testing for Chlamydia usually is done by tissue culture or detecting chlamydial antigen. Antigen testing of urethal, endocervical, or conjunctival swab specimens are common. Additionally, polymerase chain reaction and ligase chain reactions tests are useful for evaluating urine specimens. Positive antigen tests need to have a second test confirm the diagnosis because of the potential adverse implications of a false-positive test.
Patients do not need to be retested after completing treatment unless symptoms persist or reinfection is suspected.

Learning Point
Uncomplicated chlamydial genital tract infection in adolescents or young adults can be treated by:

Recommended Regimens:
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7 days.

Alternative Regimens:

Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Ofloxacin 300 mg twice a day for 7 days
OR
Levofloxacin 500 mg once daily for 7 days
Note: Doxycycline and ofloxacin are contrindicated during pregnancy.

Patients should be instructed to abstain from sexual intercourse until 7 days after therapy is initiated. Patients should refer for evaluation and treatment all sex partners within the preceding 60 days. Because a specific diagnosis may facilitate partner referral, testing for both gonorrhea and chlamydia is encouraged.

Uncomplicated gonococcal infections of the cervix, urethra and rectum may be treated by:

Recommended Regimens:

Cefixime 400 mg orally in a single dose
OR
Ceftriaxone 125 mg IM in a single dose
OR
Ciprofloxacin 500 mg orally in a single dose*
OR
Ofloxacin 400 mg orally in a single dose*
OR
Levofloxacin 250 mg orally in a single dose*

*These medications have specific uses. Additional information should be obtained from the Centers for Disease Control prior to using these regimens (see To Learn More below).

Questions for Further Discussion
1. What are the current options for male STI/birth control?
2. Potentially, how could a latex-allergic patient use a latex condom?
3. What STIs are considered reportable to public health officials?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Sexually Transmitted Diseases (STDs)

Centers for Disease Control. Morbity and Mortality Weekly Report. Sexually Transmitted Diseases Treatment Guidelines 2002. 2002;51:RR-6. Available from the Internet at: http://www.cdc.gov/STD/treatment/TOC2002TG.htm (rev. 5/10/02, cited 11/8/04)

American Academy of Pediatrics. Chlamydia trachomatis and Gonococcal Infections. In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;238-243, 285-291.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
November 29, 2004