Urethritis is inflammation of the urethra (the passage in the penis that urine and semen pass through). It can be caused by chlamydia or gonorrhoea, although frequently the cause is not identified. If neither gonorrhoea nor chlamydia can be isolated, the condition is known as non-specific urethritis.
In men, urethritis (inflammation of the urethra) which is not caused by gonorrhoea or chlamydial infection is called non-specific (meaning unknown cause) urethritis, or NSU.
Evidence of urethritis, i.e. 5 or more polymorphs (white blood cells involved in the inflammatory process) per high power field on microscopy, and the absence of gonorrhoea and chlamydia.
See Diagnosis and management guidelines entry for non specific urethritis
Non-Specific Urethritis (NSU) is diagnosed in males only, from microscopic examination of a smear made from a urethral swab. The diagnosis requires
and
Passage of urine may flush out urethral polymorphs, thus yielding a false negative result. Microscopy should preferably be performed at least 4 hours after the man last voided.
NSU may be diagnosed in the absence of symptoms such as urethral discharge or dysuria if there is no other obvious cause for inflammation such as herpes, balanitis or dermatitis.
In settings where microscopic examination of a urethral smear is unavailable on site, treatment of presumptive NSU is justified in symptomatic men.
Antibiotic treatment should never be commenced until after urethral swabs have been taken.
First line
doxycycline 200 mg orally daily for 10 days
or
azithromycin 1 g orally as a single dose
or
tetracycline HCl 500 mg orally 4 times daily for 10 days
Patients allergic to or intolerant of doxycycline
erythromycin 500 mg orally 4 times daily for 10 days
or
roxithromycin 150 mg orally twice daily for 10 days
Diagnosis of NSU cannot be confirmed until both chlamydia and gonorrhoea have been excluded, and therefore will not be known until several days after the patient¡¯s initial presentation. At the first consultation, the patient should be advised not to have further sex until there is proof that he does not have chlamydia or gonorrhoea.
Explain the nature of the infection. The condition is benign and there is no equivalent condition in females. Symptoms may be slow to resolve or may recur despite treatment.
The patient should be clinically reviewed 5 to 10 days after the completion of medication.
In some men, the symptoms of urethritis do not resolve despite compliance with antibiotic therapy and abstinence from sexual activity. In these men, where the urethral smear still shows >4 polymorphs/HPF the following treatment regimen is recommended:
If a tetracycline was the first line therapy
roxithromycin 150 mg orally twice daily for 10 days
plus
metronidazole 400 mg orally twice daily for 5 days
If a macrolide was first line therapy
doxycycline 200 mg orally for 10 days
plus
metronidazole 400 mg orally twice daily for 5 days
The diagnosis is made in men with dysuria and/or urethral discharge but no microscopic evidence of urethritis. (In settings where microscopy of a urethral smear is not available, this diagnosis cannot be reliably made.)
The patient should be reassured that the symptoms are due to a mild irritation and not infection. Possible causes may include trauma, eg vigorous sexual activity or masturbation, or irritants such as alcohol. No antibiotic treatment is required. The symptoms subside in one to two weeks.
The patient should be advised to avoid manipulation of the penis (no squeezing or milking of the urethra) and he should abstain from sexual activity and masturbation.
Ensure that tests for gonorrhoea and chlamydia (and urinary tract infection if clinically indicated) have been done to exclude these infections. The patient should return for these results in 1 week, and should not have sex until negative gonorrhoea and chlamydia are confirmed.
Non-specific Urethritis(Chinese Version)