Urethritis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Urethritis presents with urinary irritative symptoms and urethral discharge. Differential diagnosis is based on gender and chronicity of symptoms.

Differential Diagnosis

Urethritis must be differentiated from other diseases that cause lower urinary tract irritation symptoms (e.g., dysuria, urgency and frequency in addition to urethral discharge); these include cystitis, cervicitis, vulvovaginitis, epididymitis, prostatitis, and syphilis.

• The following table summarizes the differential diagnosis for urethritis.

Diseases	Symptoms					Physical Examination				Diagnostic tests			Past medical history	Other Findings
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Urethritis	–	+	–	–	+	+	–	Urethral discharge	+	Positive leukocyte esterase test or >10 WBCs Mucous threads in the morning urine	–	Gram stain & mucoid or purulent discharge	Prior STDs Urinary tract infections New sexual partner Recent intercourse Recent catheterization	Purulent discharge may suggest gonorrhoea Exclusive dysuria suggest Chlamydia Painful genital ulcers with dysuria suggest HSV
Pyelonephritis	+	+	–	–	+	+	Flank or costovertebral angle	+	+	Leukocytes Nitrite +ve	Identifies causative bacteria	Urine culture	History of pyelonephritis Recent history of hospitalisation Nephrolithiasis Immunosupression	Costovertebral angle tenderness Patient is in acute distress Look for obstructive causes
Cystitis	+	+	+	+	+	+	Suprapubic	–	+	Nitrite +ve Leukocyte esterase +ve WBCs RBCs	>100,000CFU/mL	Urine culture	Recent catheterisation Pregnancy Recent intercourse Diabetes Personal or family history of UTI Known abnormality of the urinary tract BPH HIV	Imaging studies help differentiate the various types May accompany back pain, nausea, vomiting, and chills
Prostatitis	–	+	+	+	+	+	–	–	–	10–20 leukocytes for acute and chronic bacterial subtypes	Identifies causative bacteria (in bacterial subtypes)	Urine culture	Urogenital disorders Recent catheterization or other genitourinary instrumentation History of UTIs	Tender and enlarged prostate in acute prostatitis[1][3] Tender and soft (boggy) prostate in chronic prostatitis[1] A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis.
Diseases	Symptoms					Physical Examination				Diagnostic tests			Past medical history	Other Findings
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Vulvovagintis	–	–	–	–	+	+	–	Vaginal discharge	+	–	–	Gram stain & culture of discharge	Number and type of sexual partners (new, casual, or regular) Prior STDs Previous history of symptomatic BV in female partner (in homosexual women)	Fishy odor from the vagina (Whiff test) Thin, white/gray homogeneous vaginal discharge Microscopy (wet prep) and vaginal pH  Clue cells
Cervicitis	–	+	–	–	+	+	Cervical	Endocervical exudate	–	–	–	Culture for gonococcal cervicitis	Abnormal vaginal bleeding after intercourse or after menopause Abnormal vaginal discharge Painful sexual intercourse Pressure or heaviness in the pelvis	Purulent or mucopurulent endocervical exudate Sustained endocervical bleeding easily induced by a cotton swab >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea
Epididymitis	+	–	+	+	+	+	Testicular & suprapubic	+/– urethral discharge	+	Hematuria may be seen	+	Culture	Unilateral, gradual, and localized scrotal pain posterior to the testis Scrotal swelling Scrotal wall erythema Constitutional symptoms: feeling warm, chills, nausea and vomiting	Ultrasound in patients with acute testicular pain to assess for testicular torsion If equivocal do surgical exploration
Syphilis (STD)	–	–	–	–	–	+/–	–	–	+	–	–	Darkfield microscopy	History of STD HIV Immunosupression Previous history of chancre	May be asymptomatic Painless chancre in primary syphilis Secondary syphilis may have generalised features and condylomata lata Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas