Urethritis Flashcards
What is urethritis?
Urethritis is the inflammation of the urethra, most often due to infection.
What are the different classifications of urethritis?
The infection can be classified by its aetiology, either as gonococcal urethritis and non-gonococcal urethritis.
What are the causes of gonococcal and non-gonococcal urethritis?
Gonococcal urethritis is caused by N. gonorrhoeae, whereas non-gonococcal urethritis is caused most commonly by C. trachomatis, followed by M. genitalium and T. vagninalis.
What are the risk factors for urethritis?
The main risk factors for the condition are age <25yrs, men who have sex with men, previous STI, recent new sexual partner or more than one partner in the last year.
What are the clinical features of urethritis?
The typical presenting symptoms of urethritis are dysuria, penile irritation and discharge from the urethral meatus.
Eliciting a thorough sexual history can help narrow down the likely pathogens and risk stratify the burden of disease, as well as inform necessary additional sexual health screens and partner notification.
Patients can also present with features from the complications of urethritis, such as epididymitis or reactive arthritis.
Briefly describe reactive arthritis
Reactive Arthritis is a sterile inflammatory arthritis caused by a distant infection producing an autoimmune response to certain joints. Commonly caused by Chlamydia trachomatis, Chlamydia pneumoniae, Campylobacter spp., Shigella spp. or Salmonella spp..
It normally presents as an oligoarthritis, typically in the lower limb joints, alongside potential other extra-articular manifestations including conjunctivitis or uveitis, urethritis, cervicitis, or prostatitis, keratoderma blenorrhagicum or painless oral ulcers, or malaise or fatigue.
Around 80% of reactive arthritides resolve within 6 months. Treatment involves rest and treating the affected joint(s) with NSAIDs or local steroid injections; treatment of underlying condition often has limited impact on overall disease progression.
What investigations should be ordered for urethritis?
Urethral gram stain under microscopy should be performed on urethral swabs if available (available in the GUM setting); pus cells suggest urethritis, and any presence of Gram negative diplococci are highly sensitive for a gonococcal infection.
Gold standard diagnosis is from a first-void urine being sent for Nucleic Acid Amplification Test (NAAT), for N. gonorrhoeae, C. trachomatis and M. genitalium.
All suspected cases should also have a mid-stream urine dipstick performed, with a low threshold for sending for culture (MC&S). Triple site testing for culture should also be done in the case of gonococcal infection.
Consider further STI screening, such as HIV and syphilis serology, as appropriate. Semen culture can also be appropriate where prostatitis is a suspected.
Briefly describe the initial management of urethritis
Antibiotic management is the mainstay of initial management, with the specific regime dependent on the underlying or suspected causative organism.
Current BASHH guidelines recommend:
- Gonococcal = Ceftriaxone 1g IM single dose + Azithromycin 1g PO single dose
- Non-gonococcal = Doxycycline 100mg PO BD for 7 days OR Azithromycin 1g PO single dose
Briefly describe the long-term management of urethritis
Patients should abstain from sexual activity for 7 days after antibiotic course is finished, symptoms have resolved, and their sexual partners have been treated. In cases of gonorrhoea, a test of cure is required.
Counsel patients on condom use and advise the patient to notify their sexual partners to attend the GUM clinic for testing and treatment.
Briefly describe the Guidelines from the Royal College of General Practitioners and RCGP and the British Association for Sexual Health and HIV (BASHH)
What differentials should be considered for urethritis?
Balanitis, acute prostatitis and cystitis.
How does urethritis and balanitis differ?
Balanitis, inflammation of the glans penis, presents with pruritis, erythema and discharge between the foreskin and the glans, contrasting with the urethral discharge and dysuria of urethritis. Balanitis is more common in older patients and can be secondary to bacterial or fungal infection.
How does urethritis and acute prostatitis differ?
Acute prostatitis may present with LUTS, ejaculatory pain, and pain in the penis, perineum, or rectum. Any urethral discharge present is often blood-tinged.
How does urethritis and cystitis differ?
Cystitis presents with dysuria and frequency, however rarely is associated with urethral discharge.
