Rosen & Barkin's 5-Minute Emergency Medicine Consult (741 page)

• 665.50 Other injury to pelvic organs, unspecified as to episode of care or not applicable
  
• 867.0 Injury to bladder and urethra, without mention of open wound into cavity
  
• 867.1 Injury to bladder and urethra, with open wound into cavity
  

BASICS

• Urethritis is inflammation of the urethra from any cause (usually infection).
  
• Associated with urethral discharge and dysuria
  
• Urethritis may develop after exposure to a partner with an STD, bacterial vaginosis, or UTI.
  
• Urethritis may also develop after orogenital contact.
  

• STD; the most common causes are:
  
  • Neisseria gonorrhoeae
    (35%)
    
  • Chlamydia trachomatis
    (25–50%)
    
  • Mycoplasma genitalium
    and
    Ureaplasma urealyticum
    (30%)
    
• Rarer causes:
  
  • Trichomonas vaginalis
    
  • Candidal species
    
  • Herpes simplex virus
    
  • Adenovirus
    
  • Genital warts
    
  • Enteric bacteria (in the setting of insertive anal sex)
    
  • Alcohol
    
  • Systemic illnesses
    
  • Urethral foreign bodies
    

DIAGNOSIS

• Symptoms usually develop 1–2 wk after exposure but can take up to 4–6 wk.
  
• Initially minimal or absent in many patients
  

• Urethral discharge, dysuria
  
• Cloudy 1st portion of urine
  
• Pyuria
  
• Inguinal adenopathy may be present.
  

• Color, consistency, and quantity of urethral discharge.
  
• Associated symptoms of dysuria, urgency, frequency, hematuria, and hematospermia
  
• Risk factors for STDs:
  
  • Recent new partner or multiple sexual partners
    
  • Symptoms of partner
    
  • Anal/oral practices
    
  • Young age
    
  • Lower socioeconomic status
    

• Urethral discharge
  
• Staining on undergarments
  
• Meatal crusting
  
• Genital lesions
  
• Lymphadenopathy
  
• Palpate testes, epididymis, and spermatic cord:
  
  • Masses or tenderness
    

• Urethral swabs for
  N. gonorrhoeae
  and
  Chlamydia
  species will confirm the diagnosis.
  
• DNA amplification, DNA probe, and testing of urine specimens via polymerase chain reaction (PCR) have shown good sensitivity and are acceptable tests
  
• A rapid plasma regain (RPR) or Venereal Disease Research Laboratory (VDRL) should be drawn because STDs frequently occur together.
  
• An HIV test should also be offered to the patient.
  

• Gram stain and cultures from urethral swabs should be reviewed when the patient is re-evaluated by his or her physician after treatment.
  
• DNA amplification (ligase chain reaction [LCR] or PCR) can be used on 1st-void urine or urethral swab:
  
  • Equal efficacy for diagnosing
    N. gonorrhoeae
    and
    Chlamydia
    species
    
• UA should be performed after urethral swabs to identify UTIs.
  

• Chemical irritation from soaps or spermicides
  
• Epididymitis
  
• Orchitis
  
• Pelvic inflammatory disease
  
• Prostatitis
  
• Reactive arthritis (formerly Reiter syndrome)
  
• Urethral chancre (from syphilis)
  
• UTI
  

• Urethritis in children should arouse suspicion of child abuse.
  
• Because
  N. gonorrhoeae
  infects the entire vaginal vault in prepubescents, a speculum exam is not required:
  
  • External exam and cultures are sufficient.
    
• Potential complications:
  
  • Recurrent infections
    
  • Ascending UTIs, including pelvic inflammatory disease and epididymoorchitis
    
  • Fallopian tube damage and infertility
    
  • Arthritis
    
  • Conjunctivitis, uveitis, and blindness
    

TREATMENT

Most patients will not require significant stabilization.

• Treatment may be given empirically based on probable etiology.
  
• Patients should be treated for both
  N. gonorrhoeae
  and
  C. trachomatis
  .
  

• Gonorrhea:
  
  • Azithromycin 2 g orally once
    
  • Cefixime 400 mg PO once
    
  • Cefotaxime 500 mg IM once (administered with probenicid 1 g orally once)
    
  • Cefoxitin 2 g IM once (administered with probenicid 1 g orally once)
    
  • Cefpodoxime 400 mg PO once
    
  • Ceftizoxime 500 mg IM once
    
  • Ceftriaxone 250 mg (peds: 25–50 mg/kg) IM/IV once
    
  • Cefuroxime 1 g orally once
    
  • Ciprofloxacin 500 mg PO once
    
  • Gatifloxacin 400 mg PO once
    
  • Levofloxacin 250 mg PO once
    
  • Ofloxacin 400 mg PO once
    
  • Spectinomycin 2 g IM once
    
• Chlamydia
  :
  
  • Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2–5) PO once
    
  • Doxycycline 100 mg PO BID for 7 days
    
  • Erythromycin base 500 mg (peds: 40 mg/kg/d div. QID) PO QID for 7 days
    
  • Erythromycin ethyl succinate 800 mg (peds: 30–50 mg/kg/d div. QID) PO QID for 7 days
    
  • Levofloxacin 500 mg PO QD for 7 days
    
  • Ofloxacin: 300 mg PO BID for 7 days
    
• M. genitalium:
  
  • Azithromycin 1 g (peds: 10 mg/kg day 1, 5 mg/kg days 2–5) PO once
    

• Fluoroquinolones and doxycycline are contraindicated in pregnancy
  
• Azithromycin is safe and effective
  
• Repeat testing 3 wk after treatment is recommended to ensure cure.
  

FOLLOW-UP

Patients should not require admission for urethritis unless there are other complaints or infections.

All patients should be discharged with follow-up arranged at an outside clinic or with PCP.

• If child abuse is suspected, child protective services must be involved; the child should be admitted if a safe home situation cannot be ensured.
  
• Sexual partners should be evaluated.
  
• In many states, STDs require reporting.
  

• All patients should follow up with primary care to ensure adequate treatment of the infection.
  
• All patients with suspected or confirmed urethritis should be referred for HIV testing.
  
• Patients should be given information regarding safe sexual practices.
  

• Always treat for both
  N. gonorrhoeae
  and
  C. trachomatis
  in suspected urethritis.
  
• There is increasing evidence suggesting that patients with recurrent urethritis should be evaluated for infection with other atypical organisms (doxycycline-resistant
  U. urealyticum
  or
  M. genitalium; T. vaginalis)
  
• Always consider other STDs in patients with urethritis.
  
• Ensure that patients will inform their sexual partners so that they can be treated as well.
  

• Centers for Disease Control and Prevention.
  Sexually Transmitted Disease Surveillance, 2006
  . Atlanta: U.S. Department of Health and Human Services; 2007.
  
• Mandell GL, Bennett JE, Dolin R (eds).
  Principles and Practice of Infectious Diseases.
  6th ed. Philadelphia, PA: Churchill Livingstone; 2004.
  
• Merchant RC, Depalo DM, Stein MD, et al. Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible chlamydia and/or gonorrhea urethritis.
  Int J STD AIDS
  . 2009;20(8):534–539.
  
• Takahashi S, Matsukawa M, Kurimura Y, et al. Clinical efficacy of azithromycin for male nongonococcal urethritis.
  J Infect Chemother
  . 2008;14(6):409–412.
  
• Update to CDC’s 2010 Sexually Transmitted Disease Treatment Guidelines: Oral Cephalosporins No Longer Recommended Treatment for Gonococcal Infections –
  MMWR
  . August 10, 2012.
  
• Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2010.
  MMWR Recomm Rep
  . 2010;59(RR-12):1–110.