Chapter 28 · Acute lower urinary tract conditions

Acute urethritis and periurethral complications

Definition

Acute urethritis is inflammation of the urethra, usually infectious (gonococcal or nongonococcal).

Microscopy of the discharge may be used to confirm inflammation and provide a preliminary assessment for gonococcal infection.
Main tests: NAAT or PCR for Neisseria gonorrhoeae and Chlamydia trachomatis; gonococcal culture with susceptibility testing when resistance or treatment failure is suspected.
Test for Mycoplasma genitalium in persistent or recurrent nongonococcal urethritis, or according to the local protocol. Routine testing for Ureaplasma spp. is not required in every patient.
Urethrography if a stricture is suspected.

Select empirical therapy according to the syndrome and local protocol. For probable uncomplicated gonorrhea, the international reference regimen is a single intramuscular dose of ceftriaxone 500 mg for patients weighing less than 150 kg, or 1 g for those weighing 150 kg or more; add doxycycline if chlamydial infection has not been excluded. Routine combination with azithromycin is not the standard for all patients.
Once test results are available, provide targeted therapy, check adherence, and assess persistent symptoms.
Sexual partners require evaluation and treatment according to epidemiological indications; advise abstinence until treatment and the specified waiting period are complete.
Drain an abscess.
Urethrotomy or dilatation for a stricture.

Step	Action
1	Assess discharge, dysuria, sexual history, complications, and allergies
2	NAAT or PCR for gonorrhea and chlamydia; gonococcal culture as indicated
3	Start syndromic treatment according to the local protocol; do not routinely combine ceftriaxone with azithromycin
4	Add appropriate treatment if chlamydial infection has not been excluded
5	Evaluate and treat partners; advise on abstinence and prevention
6	For persistent symptoms, assess for M. genitalium, resistance, an abscess, or a stricture