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]

Medical Therapy

Treatment should be initiated as soon as possible after diagnosis.

Pharmacotherapy

A variety of drugs may be prescribed based on the cause of the patient's urethritis. Some examples of medications based on causes include:

• Clotrimazole (Mycelex) - Trichomonas
• Doxycycline (Vibramycin) - Chlamydia
• Fluconazole (Diflucan) - Monilial
• Metronidazole (Flagyl) - Trichomonas
• Nitrofurantoin - Bacterial Infection
• Nystatin (Mycostatin) - Monilial
• Co-trimoxazole, which is a combination of Sulfamethoxazole and Trimethoprim in a ratio of 5 to 1 (Septrin, Bactrim) - Bacterial Infection

Nongonococcal Urethritis Treatment

Azithromycin and doxycycline are highly effective for chlamydial urethritis; however, infections with M. genitalium respond better to azithromycin (249,250). Single-dose regimens have the advantage of improved compliance and directly observed treatment. To maximize compliance with recommended therapies, medications should be dispensed on-site in the clinic, and the first dose should be directly observed.

Nongonococcal Urethritis Treatment Preferred Regimen ▸ Doxycycline 100 mg bid po x 7 days OR ▸Azithromycin 1 gm po as single dose Pregnancy ▸ Erythromycin 500 mg po qid x 7 days OR ▸Amoxicillin 500 mg po tid x 7 days Alternative Regimen ▸ Erythromycin 500 mg qid po x 7 days OR ▸Ofloxacin 300 mg q12h po x 7 days OR ▸Levofloxacin 500 mg q24h x 7 days Pregnancy ▸ Azithromycin 1 gm po single dose

Gonococcal Urethritis Treatment

Gonococcal Urethritis Treatment Preferred Regimen‡ ▸ Ceftriaxone 250 mg IM x 1 dose PLUS ▸ Azithromycin 1 gm PO x 1 dose for 7 days OR Doxycycline 100 mg po q12h for 7 days Alternative Regimen ▸ Azithromycin 2 gm po x 1 dose OR Cephalosporins single dose ▸ Ceftizoxime 500 mg IM OR ▸ Cefotaxime 500 mg IM OR ▸ Cefoxitin 2 gm IM + Probenecid 1 gm po OR ▸ Cefixime 400 mg po¶ PLUS ▸ Azithromycin 1 gm PO x 1 doseORDoxycycline 100 mg po q12h x 7 days OR ▸ SpectinomycinNUS 2 gm IM x 1 dose Failure of treatment† ▸ Ceftriaxone 500 mg IM x 1 dose PLUS ▸ Azithromycin 2 gm po x 1dose

‡Use combination therapy even if NAAT test is negative for Chlamydiae.
†Treat sex partner, repeat NAAT test after 1 week of cure.
¶If IM cephalisporins are not available.

Proper perineal hygiene should be stressed. This includes avoiding use of vaginal deodarant sprays and proper wiping after urination and bowel movements. Intercourse should be avoided until symptoms subside.

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 retreatment. 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 by the provider, 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 alterative regimens. However, because men with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months after treatment (251,252), repeat testing of 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 (251).

Partner Referral

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 nonchlamydial NGU are infected with chlamydia, partner management is recommended for males with NGU regardless of whether a specific etiology is identified. All sex partners within the preceding 60 days should be referred for evaluation, testing, and empiric treatment with a drug regimen effective against chlamydia. Expedited partner treatment and patient referral are alternative approaches to treating partners (71).

Recurrent and Persistent Urethritis

Objective signs of urethritis should be present before the initiation of antimicrobial therapy. In persons who have persistent symptoms after treatment without objective signs of urethritis, the value of extending the duration of antimicrobials has not been demonstrated. Persons 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 reexposed to an untreated sex partner. Persistent urethritis after doxycycline treatment might be caused by doxycycline-resistant U. urealyticum orM. genitalium. T. vaginalis is also known to cause urethritis in men; a urethral swab, first void urine, or semen for culture or a NAAT (PCR or TMA) on a urethral swab or urine can be performed. If compliant with the initial regimen and re-exposure can be excluded, the following regimen is recommended while awaiting the results of the diagnostic tests.

Recurrent Urethritis

Recurrent Non-gonococal Urethritis Preferred Regimen ▸ Metronidazole 2 gm po single dose PLUS ▸ Azithromycin 1 gm po x 1 dose Alternative Regimen ▸ Tinidazole 2 gm po x 1 dose PLUS ▸ Azithromycin 1 gm po x 1 dose