Urethritis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Sujit Routray, M.D. [3]

Overview

Non-gonococcal urethritis is generally treated with either azithromycin or doxycyline. For patients with gonococcal urethritis, the preferred regimen is either combination of ceftriaxone and azithromycin.

Medical Therapy

Antibiotic Therapy

Disease	Treatment
Nongonococcal Urethritis	Preferred: Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days Alternatives: Erythromycin base 500 mg PO qid for 7 days Erythromycin ethylsuccinate 800 mg PO qid for 7 days Levofloxacin 500 mg PO qd for 7 days Ofloxacin 300 mg PO bid for 7 days
Gonococcal Urethritis	Preferred: Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g PO in a single dose Alternative: Cefixime 400 mg PO in a single dose PLUS Azithromycin 1 g PO in a single dose
Recurrent and Persistent Urethritis	Preferred: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose PLUS Azithromycin 1 g PO in a single dose for 7 days
Gastroesophageal Reflux Disease	May present with chronic dry cough but the typical symptom is heart burn.
Congestive heart failure	Features with orthopnea, paroxysmal nocturnal dyspnea, fine crackles on auscultation and chest x-ray findings of cardiac enlargement and pulmonary congestion (Kerley B lines, and pleural effusion).

Follow-Up

• Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy.
• Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not a sufficient basis for re-treatment.
• Providers should be alert to the possibility of chronic prostatitis/chronic pelvic pain syndrome in male patients experiencing persistent pain (perineal, penile, or pelvic), discomfort, irritative voiding symptoms, pain during or after ejaculation, or new-onset premature ejaculation lasting for > 3 months.
• Unless a patient’s symptoms persist or therapeutic noncompliance or reinfection is suspected, a test-of-cure (i.e., repeat testing 3–4 weeks after completing therapy) is not recommended for persons with documented Chlamydia or gonococcal infections who have received treatment with recommended or alternative regimens. However, because men with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months after treatment, repeat testing for all men diagnosed with Chlamydia or Gonorrhea is recommended 3–6 months after treatment, regardless of whether patients believe that their sex partners were treated.
• In individuals who have persistent symptoms after treatment without signs and symptoms of urethritis, the efficacy of extended-duration antimicrobials has not been demonstrated. Individuals who have persistent or recurrent urethritis can be retreated with the initial regimen if they did not comply with the treatment regimen or if they were re-exposed to an untreated sex partner. Persistent urethritis after doxycycline treatment might be caused by doxycycline-resistant U. urealyticum, M. genitalium, or T. vaginalis.

Treatment of Sexual Partners

• All sex partners within the preceding 60 days should be referred for evaluation, testing, and empiric treatment with a drug regimen effective against Chlamydia.
• A specific diagnosis might facilitate partner referral. Therefore, testing for gonorrhea and chlamydia is encouraged. Because a substantial proportion of female partners of males with non-chlamydial, non-gonococcal urethritis are infected with Chlamydia, partner treatment is recommended for males with non-gonococcal urethritis regardless of whether a specific etiology is identified.