Male dysuria and discharge

Question 1

Symptoms of urethritis

Answer 1

Dysuria, Urethral pain or Discharge
Genital rash/ulceration or Testicular pain
Rarely->frequency or strangury (urge to urinate w\ empty bladder) –> upper genital tract pathology

Question 2

Important points in a sexual History

Answer 2

Sexuality and sites of genital contact
Recent change of or multiple sexual partners
Recent change from barrier to non-barrier methods
Sex outside UK or with someone from outside UK

Question 3

Differential Diagnosis of Urethritis

Answer 3

Gonococcal Urethritis, Non-specific urethritis (NSU)
Trauma or UTI
Physiological –> sexual stimulation, spermatorrhoea or prostatorrhoea

Question 4

Causes of Urethritis

Answer 4

Gonorrhea –> 2-5% Chlamydia –> 15-50%
Mycoplasmas genitalium –> 9-25%
Trichomonas vaginalis (TV) –> 10-20% UTI –>1-5%
No cause found –> 30-80%

Question 5

Urethral Discharge

Answer 5

Gonorrhoea ->Profuse & purulent, incubation ~5 days, 5% asymptomatic
Chlamydia -Mucoid or mucopurulent, incubation ~2-3 weeks, 30% asymptomatic

Question 6

Possible findings on examination of urethritis

Answer 6

Rash –> candidal or circinate balanitis, genital warts, disseminated gonorrhoea, secondary syphilis, drug related reactions
Herpetic ulceration, Epididymo-orchitis

Question 7

Diagnosing urethritis

Answer 7

Urethral swab –> gram stain (gram -ve intracellular diplocci) and microscopy or directly plating
Urine for PCR
Dark ground microscopy

Question 8

Direct Plating (in GUM clinics)

Answer 8

10% of gonorrhoea is missed on microscopy
Using Thayer-martin medium allows for selective growth of gonorrhoea
Allows for antibiotic sensitivity testing

Question 9

Transported samples

Answer 9

Must be placed in Amie’s or Stuart’s transport medium
Must reach the lab within 8-12 hours
Allows for antibiotic sensitivity testing
Useful in community setting

Question 10

Urine PCR

Answer 10

Must be first void urine
Can test for chlamydia and gonorrhoea
Samples retain viability for several days but cannot be used for antibiotic sensitivity testing

Question 11

Treatment of gonorrhoea urethritis

Answer 11

Gonorrhoea –> Ceftriaxone 500mg IM stat + 1g Azithromycin oral stat

Question 12

Management of urethritis

Answer 12

Full SHx –> partner notification (within 6 months)
no sex for 7 days after treatment of partners
Review antibiotic sensitivity if needed
Routine HIV and syphilis at 6 or 12 weeks

Question 13

Treatment Failure

Answer 13

Re-infection
Gonorrhoea may be resistance, less likely with Ceftraixone, but more likely with overseas contacts
–> must be guided by antibiotic sensitivity

Question 14

Treatment of chlamydial or non-specific urethritis

Answer 14

Doxycycline 100mg PO BD for 1wk (>95% effective) OR Azithromycin 1g oral stat (Metronidazole 400 oral BD for 5 days or 2g stat)

Question 15

Treatment of persistent urethritis

Answer 15

Azithromycin 500mg stat then 250mg for 4 days + metronidazole 400mg twice daily for 5 days
OR Erythromcin 500mg QDS for 3 weeks + metronidazole 400mg BD for five days