Urethritis differential diagnosis

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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.

Disease	Findings
Cystitis	Bladder inflammation; features with increased frequency and urgency, dysuria, and suprapubic pain; is more common among women. E. coli is the most common causative pathogen.
Urethritis	Infection of the urethra; causes dysuria and urethral discharge
Bacterial vulvovaginitis	Presents with dysuria and pruritus; vaginal discharge and odor are almost always present; caused by Gardnerella species
Cervicitis	Often asymptomatic; some women have an abnormal vaginal discharge and vaginal bleeding (especially after sexual intercourse)
Prostatitis	Bacterial infection of the prostate; causes discomfort during ejaculation
Epididymitis	Presents with scrotal pain and swelling accompanied by fever and lower urinary tract irritation symptoms (dysuria and increased frequency)
Syphilis	Presents with generalized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic. It is classically described as 1) non-pruritic bilateral symmetrical mucocutaneous rash; 2) non-tender regional lymphadenopathy; 3) condylomata lata; and 4) patchy alopecia.

Diseases	Diagnostic tests			Physical Examination				Symptoms					Past medical history	Other Findings
	Urinalysis	Urine Culture	Gold Standard	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Hematuria	Pyuria	Frequency	Urgency	Dysuria
Urethritis	Positive leukocyte esterase test or >10 WBCs Mucous threads in the morning urine	-	Gram stain & Mucoid or purulent discharge	+	-	Urethral 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	Leukocytes Positive nitrite	Identifies causative bacteria	Imaging and culture	+	Flank or costovertebral angle	+	+	+	+	-	-	+	History of pyelonephritis Recent history of hospitalisation Nephrolithiasis Immunosupression	Costovertebral angle tenderness Patient is in acute distress Look for obstructive causes
Cystitis	Positive nitrite Positive leukocyte esterase WBCs RBCs	>100,000CFU/mL	Urine culture	+	Suprapubic	-	+	+	+	+	+	+	Recent catheterisation Pregnancy recent intercourse Diabetes Personal or family history of UTI Known abnormality of the urinary tract BPH or HIV	Imaging studies help differentiate the various types May acompany 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	In acute prostatitis, palpation reveals a tender and enlarged prostate[1][3] In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate[1] A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis
Bacterial Vulvovagintis	-	-	Gram stain & Culture of discharge	+	-	Vaginal 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	-	-	culture for gonococcal cervicitis	+	Cervical	endocervical exudate	-	-	+	-	-	+	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	Hematuria may be seen	+	Culture	+	Testicular & Suprapubic	+/- urethral discharge	+	+	-	+	+	+	Scrotal pain: starts gradually, is usually unilateral and localized 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