Urethritis

Definition

Urethritis is the inflammation of the urethra, the tube that carries urine from the bladder to the outside of the body. It is often caused by infection, but can also result from injury or chemical irritation.

Aetiology

Urethritis can be classified as either gonococcal urethritis (GU) caused by Neisseria gonorrhoeae or non-gonococcal urethritis (NGU) caused by other pathogens. Common causes include:

Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis
Herpes simplex virus (HSV)
Chemical irritants: Such as spermicides, soaps, or lotions.

Pathophysiology

The inflammation of the urethra is typically triggered by infection with bacteria, viruses, or other pathogens. The infectious agents invade the mucosal lining of the urethra, leading to an inflammatory response characterized by swelling, redness, and discharge. Non-infectious causes involve irritation from chemicals or physical injury to the urethral lining.

Risk Factors

Unprotected sexual intercourse
Multiple sexual partners
History of sexually transmitted infections (STIs)
Use of chemical irritants or spermicides
Insertion of foreign objects into the urethra

Signs and Symptoms

Dysuria: Painful or difficult urination
Urethral discharge: May be clear, cloudy, or purulent
Itching or irritation at the urethral opening
Pelvic or lower abdominal pain
Increased frequency or urgency of urination

Investigations

Clinical history and physical examination
Urethral swab: To identify the causative organism through culture or nucleic acid amplification tests (NAATs)
Urinalysis: To detect white blood cells and other abnormalities
Sexually transmitted infection (STI) screening: Tests for common STIs, including gonorrhoea and chlamydia
Blood tests: To screen for other infections such as HIV or syphilis

Management

Primary Care Management

Empirical antibiotic therapy: Based on likely pathogens. For example, doxycycline 100 mg twice daily for 7 days or azithromycin 1 g as a single dose and then 500 mg OD for 2 days.
Analgesia: NSAIDs or paracetamol to manage pain and discomfort.
Hydration: Encourage increased fluid intake to help flush the urinary tract.
Patient education: Importance of completing the full course of antibiotics, avoiding sexual intercourse until treatment is completed and symptoms have resolved, and informing sexual partners to prevent reinfection.
Referral to a specialist: If symptoms persist or if there are complications such as recurrent infections or pelvic inflammatory disease (PID).

Specialist Management

Further diagnostic evaluation: Including more specific cultures or NAATs for persistent or recurrent infections.
Advanced antibiotic therapy: Tailored to the specific pathogen identified and based on culture sensitivities.
Management of complications: Addressing any complications such as PID, epididymitis, or urethral strictures.
Counselling and support: For patients with recurrent or persistent infections, including safe sex practices and regular STI screening.

Example Management for Urethritis

A patient presenting with symptoms of urethritis, such as dysuria and urethral discharge, should be treated empirically with antibiotics such as doxycycline 100 mg twice daily for 7 days or azithromycin 1 g as a single dose and then 500 mg OD for 2 days. Pain can be managed with NSAIDs or paracetamol. Patients should be advised to increase fluid intake, complete the full course of antibiotics, and avoid sexual intercourse until treatment is completed and symptoms have resolved. Referral to a specialist is recommended if symptoms persist or if there are complications. Regular follow-up is essential to ensure resolution of symptoms and to manage any underlying conditions.

References

NICE. (2024). Urethritis: Diagnosis and Management. Retrieved from NICE
NHS. (2023). Urethritis. Retrieved from NHS
Centers for Disease Control and Prevention (CDC). (2021). Sexually Transmitted Infections Treatment Guidelines. Retrieved from CDC
European Association of Urology (EAU). (2022). Guidelines on Urological Infections. Retrieved from EAU