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Introduction

Background
Urethritis is defined as infection-induced inflammation of the urethra. Although various clinical
conditions may result in irritation of the urethra, the term urethritis is typically reserved to describe
urethral inflammation caused by a sexually transmitted disease (STD). Urethritis is normally
categorized into one of two forms, based on etiology: gonococcal urethritis (GU) and
nongonococcal urethritis (NGU).

Pathophysiology
Urethritis is an inflammatory condition that can be infectious or posttraumatic in nature. Infectious
causes of urethritis are typically sexually transmitted and categorized as either gonococcal
urethritis (ie, due to infections with Neisseria gonorrhoeae) or NGU (ie, due to infections
with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma
genitalium, or Trichomonas vaginalis).

Rare infectious causes of urethritis include lymphogranuloma venereum, herpes


genitalis, syphilis, mycobacterial infection, and bacterial infections that are typically associated
with cystitis (usually gram-negative rods) in the presence of urethral stricture. Other rare but
reported causes of urethritis include viral, streptococcal, anaerobic, and meningococcal
infections.

Posttraumatic urethritis can occur in 2%-20% of patients practicing intermittent catheterization


and following instrumentation or foreign body insertion. Urethritis is 10 times more likely to occur
with latex catheters than with silicone catheters.

Urethritis may be associated with other infectious syndromes, such as epididymitis, orchitis,
prostatitis, proctitis,reactive arthritis, iritis, pneumonia, otitis media, and urinary tract infection.

Frequency
United States

Urethritis occurs in 4 million Americans each year. The incidence of gonococcal urethritis is
estimated at over 700,000 new cases annually, and the incidence of NGU is approximately 3
million new cases annually. Both infections are significantly underreported. The incidence of
gonococcal urethritis has declined steadily since 2000, and the incidence of NGU is increasing.
NGU incidence is highest in the summer months.

International

Worldwide, approximately 62 million new cases of gonococcal urethritis and 89 million new cases
of NGU are reported each year.

Mortality/Morbidity

• Approximately 10%-40% of women with urethritis eventually develop pelvic inflammatory


disease (PID), which may subsequently cause infertility and ectopic
pregnancy secondary to postinflammatory scar formation in the fallopian tubes. PID can
occur even in women with asymptomatic infections.
• Children born to mothers with Chlamydia infection may develop conjunctivitis, iritis, otitis
media, or pneumonia if exposed to the organism while passing through the birth canal.
Performing cesarean delivery in patients with known chlamydial infections and routine
treatment of all newborns with antichlamydial eyedrops has decreased the incidence of
this problem in developed countries.
• Disseminated gonococcal infection (DGI) and reactive arthritis develop in less than 1% of
female patients with urethritis.
• Morbidity due to urethritis in males is less common (1%-2%), typically taking the form of
urethral stricture or stenosis due to postinflammatory scar formation. Other potential
complications of urethritis in males include prostatitis, acute epididymitis, abscess
formation, proctitis, infertility, abnormal semen, DGI, and reactive arthritis.
• Reactive arthritis is characterized by NGU, anterior uveitis, and arthritis and is strongly
associated with the gene for HLA-B27. Rare but serious complications of DGI include
arthritis, meningitis, and endocarditis.
• Mortality rates are minimal in patients with gonococcal urethritis or NGU.

Race

• Urethritis has no racial predilection; however, persons of low socioeconomic class are
affected more often than persons of higher socioeconomic class.

Sex

• Urethritis has no sexual predilection; however, data may be skewed because urethritis is
underrecognized in women. Up to 75% of females with the condition can be
asymptomatic or may instead present with cystitis, vaginitis, or cervicitis. Homosexual
males are at a greater risk for urethritis than are (1) heterosexual males or (2) females in
general.

Age

• Urethritis may occur in any sexually active person, but incidence is highest among people
aged 20-24 years.

Clinical

History
Obtaining a careful patient history often helps differentiate between an STD and other causes of
urethritis. The questions can be quite personal, and the physician should take care to not appear
disgusted, amused, or judgmental regarding the patient's sexual history. If patients feel
uncomfortable, they may not be forthcoming with essential information that may be helpful in their
treatment or the treatment of any sexual partners, ie, including the chain of partners that may be
linked to the patient (eg, partners of partners and so on).

• Sexual history: Certain sexual practices may increase or decrease the likelihood of
contracting urethritis secondary to an STD.
o Contraceptive use: Using condoms helps substantially decrease the chance of
STD transmission. Other types of birth control either do not improve or worsen
the chance of transmitting urethritis. The use of spermicides may cause a
chemical urethritis, with associated dysuria findings that mimic those of infectious
urethritis.
o Age at first intercourse: With the exception of some religious groups who
encourage marriage and monogamy at an early age, a younger age at first
intercourse is correlated with increased risk of contracting STDs.
o Number of sexual partners: Individuals with multiple partners are more likely to
have contracted an STD. Long-term monogamous couples are extremely unlikely
to contract an STD. A married patient should not be informed of the diagnosis (or
possible diagnosis) in the presence of his or her spouse, but the spouse should
be treated once the patient has had the opportunity to explain the situation.
o Sexual preference: Homosexual men have the highest rate of STDs. They are
followed, in order of occurrence rates, by heterosexual men, heterosexual
women, and homosexual women.
o Previous STDs: Patients with a prior history of STDs are at an increased risk of
contracting another STD. Concurrent STDs may also occur. A high level of
suspicion for other more sinister STDs, such as syphilis and HIV infection, should
be maintained. In addition, urethritis can increase viral shedding of HIV and can
increase the likelihood of transmission.
• Symptoms: Many patients, including approximately 25% of those with NGU, are
asymptomatic and present following partner screening. Up to 75% of women with C
trachomatis infection are asymptomatic.
o Timing: Symptoms generally begin 4 days to 2 weeks after contact with an
infected partner, or the patient may be asymptomatic.
o Urethral discharge: Fluid may be yellow, green, brown, or tinged with blood, and
production is unrelated to sexual activity.
o Dysuria: Dysuria is usually localized to the meatus or distal penis, worst during
the first morning void, and made worse by alcohol consumption. Urinary
frequency and urgency are typically absent. If present, either should suggest
prostatitis or cystitis.
o Itching: A sensation of urethral itching or irritation may persist between voids, and
some patients have itching instead of pain or burning.
o Orchalgia: Men sometimes complain of heaviness in the genitals. Associated
pain in the testicles should suggest epididymitis, orchitis, or both.
o Menstrual cycle: Women occasionally complain of worsening symptoms during
menses.
o Foreign body or instrumentation: The patient should be questioned about recent
urethral catheterization or instrumentation, either medical or self-induced (eg,
foreign body). These procedures may cause traumatic urethritis.
• Systemic symptoms: Systemic symptoms (eg, fever, chills, sweats, nausea) are typically
absent but, if present, may suggest disseminated gonococcemia, pyelonephritis, arthritis,
conjunctivitis, proctitis, prostatitis, epididymitis or orchitis, pneumonia, otitis media, low
back pain (ie, reactive arthritis), iritis, or rash (characteristically involving the palms of
hands and soles of feet).
Physical
Most patients with urethritis do not appear ill and do not present with signs of sepsis, such as
fever, tachycardia, tachypnea, or hypotension. The primary focus of the examination is on the
genitalia.

• Men
o The best plan is to avoid examining the patient immediately after micturition
because urination temporarily washes away discharge and potentially culturable
organisms. Because urine culture is an important component of the evaluation,
advise the patient to urinate approximately 2 hours before the examination so
that culture and examination results are optimal and the patient can comfortably
provide a urine specimen after the examination.
o Ensure that the patient is standing, is completely undressed, and that the room is
warm and has good lighting. When the patient is undressed, inspecting the
underwear for secretions may yield additional information.
o Examine the patient for skin lesions that may indicate other STDs, such
as condyloma acuminatum,herpes simplex, or syphilis. The examiner must
retract the foreskin of uncircumcised men. Lesions and exudate may be hiding
beneath.
o Examine the lumen of the distal urethral meatus for lesions, stricture, or obvious
urethral discharge.
o Strip the urethra by gently milking from the base of the penis to the glans. Any
discharge may then be seen exuding from the urethral meatus. Palpate along the
urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or
for firmness suggestive of foreign body.
o Examine the testes for evidence of mass or inflammation. Palpate the spermatic
cord, looking for swelling, tenderness, or warmth suggestive of orchitis or
epididymitis.
o Check for inguinal adenopathy.
o Palpate the prostate for tenderness or bogginess suggestive of prostatitis. During
the digital rectal examination, note any lesions around the anus.
• Women
o The best plan is to avoid examining the patient immediately after micturition
because urination temporarily washes away discharge and potentially culturable
organisms. Because urine culture is an important component of the evaluation,
advise the patient to urinate approximately 2 hours before the examination so
that culture and examination results are optimal and the patient can comfortably
provide a urine specimen after the examination.
o The patient should be in the lithotomy position.
o Inspect the skin for any lesions that may indicate the presence of other STDs.
o Strip the urethra by inserting a finger into the anterior vagina and stroking forward
along the urethra. Any discharge should be sampled for examination.
o Follow the urethral examination with a complete pelvic examination, including
cervical cultures.
• General: Fever, palmar rash, joint tenderness, and conjunctivitis are indications of
systemic disease.
Causes

• Gonococcal urethritis
o Gonococcal urethritis (80% of cases) is caused by N gonorrhoeae, which is a
gram-negative intracellular diplococcus.
o Patients with gonococcal urethritis have a shorter incubation period than those
with NGU, and the onset of dysuria and purulent discharge is abrupt.
• Nongonococcal urethritis
o Patients with NGU (50% of cases) have a longer incubation period than those
with gonococcal urethritis, and the onset of either dysuria or, less commonly, a
mucopurulent discharge, is subacute. Patients with NGU are much more likely to
be asymptomatic than patients with gonococcal urethritis.
o NGU is caused by C trachomatis (15-55% of cases), U urealyticum (40-60% of
cases), M hominis (5-10% of cases), and T vaginalis (<5% of cases). The
number of fastidious organisms implicated in NGU is increasing and includes
several Ureaplasma and Mycoplasma species. The causative organism cannot
be identified in most patients with NGU.
o Rare cases may be related to lymphogranuloma venereum, herpes simplex,
syphilis, mycobacteria, or urinary tract infection with urethral stricture. Other rare
but reported causes of NGU include anaerobes, adenovirus, cytomegalovirus,
and streptococcus.
o Urethritis following catheterization occurs in 2-20% of patients practicing
intermittent catheterization and is 10 times more likely to occur with latex
catheters than with silicone catheters.
• Urethritis of mixed etiology: Polymicrobial NGU and cases of urethritis due to both
gonococcal infection and nongonococcal factors are possible and can explain some
treatment failures. This should also be considered in patients with HIV infection.

Differential Diagnoses
Acute Bacterial Prostatitis and Prostatic Abscess Mycoplasma Infections
Arthritis as a Manifestation of Systemic Disease Oophoritis
Bacterial Cystitis Papillomavirus
Chancroid Pelvic Inflammatory Disease
Chlamydial Genitourinary Infections Proctitis and Anusitis
Chlamydial Pneumonias Prostatitis, Bacterial
Condyloma Acuminatum Salpingitis
Dermatologic Diseases of the Male Genitalia: Malignant Syphilis
Dermatologic Diseases of the Male Genitalia: Nonmalignant Trichomoniasis
Epididymitis Ureaplasma Infection
Gardnerella Urethral Cancer
Gonococcal Arthritis Urethral Caruncle
Gonococcal Infections Urethral Diverticula
Herpes Simplex Urethral Diverticulum
Human Papillomavirus Urethral Strictures
Infertility Urethral Syndrome
Molluscum Contagiosum Urethral Trauma
Mycobacterium Gordonae Urethral Warts
Mycobacterium Haemophilum Vaginitis
Mycobacterium Kansasii Vulvovaginitis
Other Problems to Be Considered
Trichomonal vaginitis
Candidal vaginitis
Alcohol ingestion
Contact dermatitis secondary to spermicides
Guilt over sexual behavior likely to be perceived as deviant
Guilt over infidelity
Dried semen mistaken for discharge
Stevens-Johnson syndrome
Foreign body
Fungal infections of the genitourinary tract

Workup

Laboratory Studies
Urethritis can be diagnosed based on the presence of one or more of the following: (1) a
mucopurulent or purulent urethral discharge, (2) urethral smear that demonstrates at least 5
leukocytes per oil immersion field on microscopy, and (3) first-voided urine specimen that
demonstrates leukocyte esterase on dipstick test or at least 10 white blood cells (WBCs) per
high-power field on microscopy.

All patients with urethritis should be tested for N gonorrhoeae and C trachomatis.

• Gram stain
o Traditionally, treatment was based on Gram stain results. Patients with gram-
negative intracellular diplococci on urethral smear received treatment for
gonococcal urethritis, and those without gram-negative intracellular diplococci
received treatment for nongonococcal urethritis (NGU).
o Because current recommendations suggest patients receive concomitant
treatment for both, and with the success of nucleic acid amplification tests
(NAATs), a Gram stain may be unnecessary.
• Urethral culture for N gonorrhoeae and C trachomatis
o Endourethral culture (obtained by gently inserting a malleable cotton-tipped swab
1-2 cm into the urethra), rather than culture of the expressible discharge, is
necessary to test for C trachomatisinfection. Endocervical cultures should also be
obtained in women.
o This culture may be a useful screening tool for penicillinase-producing N
gonorrhoeae or chromosomally mediated resistance to multiple antibiotics;
however, the results do not influence the initial antibiotic therapy, and performing
this screening may not be cost-effective.
• Urine
o Urinalysis is not a useful test in patients with urethritis, except for helping exclude
cystitis or pyelonephritis, which may be necessary in cases of dysuria without
discharge. Patients with gonococcal urethritis may have leukocytes in a first-void
urine specimen and fewer or none in a midstream specimen. More than 30% of
patients with NGU do not have leukocytes in urine specimens.
o Many nucleic acid–based tests for C trachomatis and N gonorrhoeae can be
performed on urine specimens (see below). These require a first-voided
specimen. For Chlamydia species, endourethral samples are more accurate.
• Nucleic acid amplification tests
o Polymerase chain reaction assays are available for gonococcal urethritis
and Chlamydia infection. NAATs are also available
for Mycoplasma species, Ureaplasma species, and T vaginalis, but these are not
recommended, as they are expensive and do not alter the choice of treatment.
o NAATs are the preferred test for Chlamydia and are more sensitive than
traditional culture methods.Chlamydia DNA probe results are 60%-70% sensitive
and nearly 100% specific. Obtain samples on swabs at least 2 hours after
micturition, using a calcium-alginate swab on a nonwooden stick inserted at least
1 cm in depth to help prevent false-negative findings. Chlamydia ligase chain
reaction is 90%-95% sensitive and nearly 100% specific. Obtain samples on
swabs at least 2 hours after micturition, using a calcium-alginate swab on a
nonwooden stick inserted at least 1 cm in depth to help prevent false-negative
results.
o DNA-based tests, unlike culture, do not allow for antibiotic susceptibility testing,
but this is unnecessary in most patients.
• Potassium hydroxide preparation: This is used to evaluate for fungal organisms.
• Wet preparation: Secretions reveal the movement of trichomonal organisms, if present.
• STD testing: Patients with urethritis should be counseled about the risk for more serious
STDs. They should be offered syphilis serology (Venereal Disease Research Laboratory
test or Rapid Plasma Reagin test) and HIV serology.
• Nasopharyngeal and/or rectal swabs: Men who have sex with men (and perhaps other
patients) should undergo gonorrhea screening with nasopharyngeal and/or rectal swabs.
Validation of NAATs for these specimens is still in progress.1
• Pregnancy testing: Women who have had unprotected intercourse should be offered
pregnancy testing.
• Other tests: Patients with reactive arthritis are diagnosed based on the presence of NGU
and clinical findings of uveitis and arthritis. HLA-B27 testing is of limited value. More
readily available laboratory findings, such as elevated erythrocyte sedimentation rate
(ESR) in the absence of rheumatoid factor, may be helpful.

Imaging Studies

• Imaging studies, specifically retrograde urethrography, are unnecessary in patients with


urethritis, except in cases of trauma or possible foreign body insertion.

Procedures

• Catheterization
o In cases of urethral trauma, urethral catheter placement can hold the urethra
open to avoid urinary retention caused by edema or a flap of elevated mucosa.
o The catheter also serves to tamponade urethral bleeding.
• Cystoscopy
o When urethral catheter placement is not possible after urethral trauma, careful
negotiation of the urethra with a flexible cystocope can allow passage of a
guidewire, over which the Council tip urethral catheter can be placed. This can
generally be performed in the emergency department or outpatient clinic with
local anesthesia (lidocaine jelly). However, if not easily accomplished on the
initial attempt, this procedure should be aborted to avoid further urethral trauma,
and a suprapubic tube should be placed.
o A foreign body or stone in the urethra, which may mimic urethritis, can be
removed cystoscopically. Unless the object is very small and very distal, this
procedure probably should be undertaken in the operating suite while the patient
is under anesthesia. A rigid cystoscope with a larger lumen sheath and working
port allows utilization of more secure endoscopic graspers. The object can often
be removed through the large lumen of the cystoscope sheath, rather than
pulling it through the distal urethra (which may cause further trauma).
• Filiforms and followers: Filiforms and followers can also be used by experienced
urologists but are being used less frequently in cases of urethral trauma because of the
wide availability of flexible cystoscopes. In addition, this technique can lead to more
severe urethral trauma if not used correctly.
• Suprapubic tube placement: With more severe urethral trauma preventing urethral
catheter placement or inadequate facilities for emergent cystoscopy in patients with
urethral obstruction due to trauma or foreign bodies, a suprapubic catheter is an excellent
temporizing measure to divert urine and relieve patient discomfort until definitive therapy
can be undertaken.

http://emedicine.medscape.com/article/438091-overview

Urethritis is inflammation of the urethra from any cause.

Causes

Urethritis may be caused by bacteria or a virus. The same bacteria that cause urinary
tract infections (E. coli) and some sexually transmitted diseases
(chlamydia, gonorrhea) can lead to urethritis. Viral causes of urethritis include herpes
simplex virus and cytomegalovirus.

Other causes include:

• Sensitivity to the chemicals used in spermicides or contraceptive jellies,


creams, or foams
• Injury

Risks for urethritis include:


• High-risk sexual behavior (such as anal sex without a condom)
• History of sexually transmitted diseases
• Male, ages 20 - 35
• Many sexual partners
• Young women in their reproductive years

Symptoms

In men:

• Blood in the urine or semen


• Burning pain while urinating (dysuria)
• Discharge from penis
• Fever (rare)
• Frequent or urgent urination
• Itching, tenderness, or swelling in penis or groin area
• Pain with intercourse or ejaculation

In women:

• Abdominal pain
• Burning pain while urinating
• Fever and chills
• Frequent or urgent urination
• Pelvic pain
• Vaginal discharge

Exams and Tests

The health care provider will perform a physical examination. In men, the exam will
include the abdomen, bladder area, penis, and scrotum. The physical exam may
show:

• Discharge from the penis


• Tender and enlarged lymph nodes in the groin area
• Tender and swollen penis

A digital rectal exam will also be performed.

Women will have abdominal and pelvic exams. The health care provider will check
for:

• Discharge from the urethra


• Tenderness of the lower abdomen
• Tenderness of the uterus

The following tests may be done:

• Complete blood count (CBC)


• C-reactive protein test
• Pelvic ultrasound (women only)
• Pregnancy test (women only)
• Urinalysis and urine cultures
• Tests for gonorrhea, chlamydia, and other sexually-transmitted diseases

Treatment

The goals of therapy are to:

• Improve symptoms
• Prevent the spread of infection
• Eliminate the cause of infection

Antibiotic therapy should target the bacteria causing the infection. In some cases,
antibiotics may need to be given through a vein (by IV). You may take pain relievers
(including pyridium, which works on the urinary tract) along with antibiotics.

People with urethritis who are being treated should avoid sex or use condoms during
sex. If an infection is the cause of the inflammation, your sexual partner must also be
treated.

Urethritis caused by trauma or chemical irritants is treated by avoiding the source of


injury or irritation.

Outlook (Prognosis)

With the correct diagnosis and treatment, urethritis usually clears up without any
complications. However, urethritis can lead to permanent damage to the urethra
(scar tissue called urethral stricture) and other urinary organs in both men and
women.

Possible Complications

Men with urethritis are at risk for the following complications:

• Cystitis
• Epididymitis
• Orchitis
• Pyelonephritis
• Prostatitis
• Urethral stricture

Women with urethritis are at risk for the following complications:

• Cervicitis
• Cystitis
• Ectopic pregnancy
• Fertility problems
• Miscarriage
• Pelvic inflammatory disease (PID)
• Pregnancy complications
• Pyelonephritis
• Salpingitis (infection of the ovaries)

When to Contact a Medical Professional

Call your health care provider if you have symptoms of urethritis.

Prevention

Some causes of urethritis may be avoided with good personal hygiene and by
practicing safer sexual behaviors such as monogamy (one sexual partner only) and
using condoms.

References

Gerber GS, Brendler CB. Evaluation of the urologic patient: history, physical
examination, and urinalysis. In: Wein AJ, ed.Campbell-Walsh Urology. 9th ed.
Philadelphia, Pa: Saunders Elsevier; 2007: chap 3.

Frenkl T, Potts J. Sexually transmitted diseases. In: Wein AJ, ed. Campbell-Walsh
Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 11.

Lentz GM. Urogynecology: physiology of micturition, diagnosis of voiding dysfunction,


and incontinence: surgical and nonsurgical treatment. In: Katz VL, Lentz GM, Lobo
RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa:
Mosby Elsevier; 2007: chap 21.

Eckert LO, Lentz GM. Infections of the lower genital tract: vulva, vagina, cervix, toxic
shock syndrome, HIV infections. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM,
eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:
chap 22.

http://www.nlm.nih.gov/medlineplus/ency/article/000439.htm

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