Urology
A 23 year old man presents to the Emergency Department complaining of penile irritation, dysuria and urethral discharge. On questioning he tells you he has recently returned from a holiday where he had unprotected sex with multiple partners. Urine dipstick is normal. What is the most likely diagnosis?
Answer:
- Suspect urethritis if a man presents with urethral discharge (this may be minimal or copious, may not be noticed by the man and may only be observable on urethral massage) and/or dysuria.
- Other symptoms which may be reported include:
- Penile irritation.
- Balanoposthitis.
- Urethral discomfort.
Urethritis
Sexual Health / Urology
Last Updated: 12th February 2021
Urethritis is inflammation of the urethra, and is usually (but not always) caused by a sexually transmitted infection.
Causes
Urethritis is classified as:
- Gonococcal urethritis
- Caused by Neisseria gonorrhoeae
- Non-gonococcal urethritis (NGU)
- Has no identifiable cause in over 50% of men.
- If an organism is identified Chlamydia trachomatis and Mycoplasma genitalium are most likely to be detected.
- Less common infective causes of NGU include:
- Ureaplasma urealyticum.
- Trichomonas vaginalis.
- Urinary tract infection, for example, Escherichia coli, Staphylococcus saprophyticus, and Proteus mirabilis.
- Adenoviruses.
- Herpes simplex virus.
- Non-infective causes of NGU include:
- Trauma (such as catheterisation).
- Irritation (for example soaps, lotions, spermicide creams, deodorants).
- Urethral stricture.
- Urinary calculi.
- Persistent/recurrent urethritis
- Urethritis that occurs 30–90 days after treatment for acute NGU.
- Usually has no identifiable cause.
Clinical features
- Suspect urethritis if a man presents with urethral discharge (this may be minimal or copious, may not be noticed by the man and may only be observable on urethral massage) and/or dysuria.
- Other symptoms which may be reported include:
- Penile irritation.
- Balanoposthitis.
- Urethral discomfort.
- Note: up to 25% of urethral infections are asymptomatic.
- In order to determine the likelihood of an STI, ask about the man's sexual history. Be aware that men are considered to have a higher risk of acquiring a STI if they:
- Have had more than one partner in the last year.
- Have a recent new partner.
- Have had a previous STI.
- Are aged 25 years of age or younger.
- If the risk of an STI is considered to be low consider differential diagnoses.
Differential diagnosis
- Physiological discharge — suggested by small amounts of clear or mucoid discharge upon sexual excitement.
- Balanitis — glans penis infection secondary to candidal infection.
- Acute prostatitis — suggested by blood-tinged discharge, dysuria and urgency, fever, and/or penile, perineal, rectal pain, and swollen and tender prostate upon examination.
- Cystitis — suggested by severe dysuria, visible haematuria (or incidentally discovered microscopic haematuria), nocturia, urinary frequency, and urgency.
Management
- Refer all men with suspected urethritis to a genitourinary medicine (GUM) clinic or other local specialist sexual health service for confirmation of the diagnosis (and treatment).
Complications
Symptoms of urethritis generally resolve within three days of antibiotic treatment. When recurrence occurs, this is usually due to reinfection or treatment failure. Local complications are rare if appropriate treatment is received, however, if urethritis is untreated or inadequately treated, potential complications depend on the underlying infective cause:
The complications of non-gonococcal urethritis (NGU) caused by chlamydia may include:
- Epididymo-orchitis.
- Sexually-acquired reactive arthritis (Reiter's syndrome).
The complications of gonococcal urethritis may include:
- Epididymitis.
- Penile lymphangitis.
- Periurethral abscess.
- Acute prostatitis.
- Seminal vesiculitis.
- Infection of the Tyson's and Cowper's glands.
- Disseminated gonococcal infection — skin lesions, arthralgia, arthritis and tenosynovitis.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
