Ryan Cleary, MD
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• Urethral discharge is abnormal fluid (not urine or semen) released through the urethra most commonly as a result of increased local inflammation.
– Inflammation secondary to infection, neoplasm, trauma, or local irritation
• Most common symptom of a sexually transmitted infection (STI/STD) in men and most commonly a manifestation of urethritis.
• Appearance of the fluid is commonly characterized as purulent or mucopurulent; scant, watery, or mucoid; or bloody.
EPIDEMIOLOGY
Incidence
Gonorrhea (a common cause of urethral discharge) in men reported to the CDC: 98.7 per 100,000 men
Prevalence
N/A
RISK FACTORS
• Male sex
• Urinary tract infection
• Recent instrumentation or catheterization
• Urothelial carcinoma
• Urethral mass
• Benign prostatic hypertrophy
• Unprotected sexual intercourse
Genetics
N/A
PATHOPHYSIOLOGY (1)
• Urethritis
– Neisseria gonorrhea
May present as urethritis, epididymitis, proctitis, or prostatitis
Male—Purulent discharge, dysuria
Female—Usually asymptomatic, but may have pelvic discomfort, dysuria, dyspareunia
– Non-gonococcal (Chlamydia trachomatis, Mycoplasma, Ureaplasma urealyticum)
Chlamydia—Frequently asymptomatic, may present with urethritis, epididymitis, or prostatitis. Gonorrhea may coexist.
25% of women are symptomatic and can have a mucopurulent cervical discharge.
40% of untreated women will develop pelvic inflammatory disease (PID). PID is associated with infertility and ectopic pregnancy.
– Trichomonas vaginalis
Male—Present with urethritis but often asymptomatic.
Female—Malodorous, yellow-green vaginal discharge with vulvar irritation.
ASSOCIATED CONDITIONS
With STI coinfection is common (ie, gonorrhea and chlamydia)
GENERAL PREVENTION
• For STI:
– Abstinence
– Female and male condoms
– Education and awareness of risky behavior
DIAGNOSIS
HISTORY
• Age, sex, and duration?
– Males are more likely to have discharge from a venereal cause
– STIs are most common in the 15–24–yr-old age group
– Venereal or traumatic cause is more likely to have acute onset while chronic inflammation or tumor is usually insidious
• Obtain thorough sexual history to discover risk of STI/STD
– Sex with men, women, or both?
– Oral, vaginal, or anal intercourse
– Condom usage
– How many partners in last month?
– History of STI/STD
– Dyspareunia?
• Ask the time since onset, any inciting events, quality or character, quantity, prior treatments, associated symptoms
• History of irritative or obstructive voiding symptoms
– Hematuria, dysuria, frequency, urgency, incontinence, post void dribbling, straining, incomplete emptying
Hematuria noted at beginning, middle or total hematuria, or end of stream helps localize bleeding source to urethra, bladder or upper tracts, or prostate
Frequency and urgency can indicate an acute inflammatory response
Incontinence can indicate a diverticular source
Straining and incomplete emptying indicate obstructive cause
• History of perineal, scrotal, or penile pain
– Assists in localizing source of discharge
• Any vaginal symptoms?
– Vaginal mass, discharge, or irritation can indicate presence of urethral diverticulum
• Past medical and surgical history
– Gonorrhea can have systemic effects
– Reactive arthritis (arthritis, conjunctivitis, and urethritis) often presents initially with urethral complaints Prior urethral surgery such as sling for incontinence of artificial urinary sphincter. Erosion of prosthetic material can cause discharge.
• Other symptoms
– Constitutional symptoms indicate systemic process (fevers, chills, fatigue)
– In women clearly delineate urethral discharge form vaginal discharge.
PHYSICAL EXAM
• Men
– Request the patient avoid urination before being examined.
– Genital skin exam to evaluate for evidence of trauma, ulcers, rashes, abrasions, or masses
– If no discharge is seen, the urethra should be gently massaged from the ventral part of the penis toward the meatus.
– Examination of testicles and spermatic cord, scrotum, and inguinal lymph nodes
• Women
– Genital skin exam to evaluate for evidence of trauma, ulcers, rashes, abrasions, masses, or fissures
– External genitalia inspection
– Palpation of urethra for mass, fluctuance, or discharge
– Bimanual exam to evaluate for tenderness, mobility, and masses
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis
– Positive leukocyte esterase on first void urine is diagnostic of urethritis.
• Gram stain of discharge
– >5 WBCs/oil immersion field → Urethritis
– Presence of gram (−) intracellular diplococci on gram stain is 99% specific and 95% sensitive for gonococcal urethritis
– Negative gram stain does not rule out gonococcal urethritis
– When gonococcal urethritis is suspected and investigatory tests cannot confirm the diagnosis, consider Neisseria meningitidis infection (2).
• Repeated nucleic acid amplification testing (NAAT) is the most sensitive test for chlamydia and gonorrhea.
– Vaginal, endocervical, or urethral swab or first catch urine from men or women
– Additional PCR-based genotyping is necessary to differentiate lymphogranuloma venereum (LGV) from chlamydia.
LGV is caused by specific strains of Chlamydia (L1, L2, L3).
• CBC if evidence of systemic involvement
• BMP if concern for obstruction from prostatic enlargement
Imaging
• If the cause of the discharge is unclear additional imaging
• Men
– Scrotal ultrasound
– Renal/bladder ultrasound
– CT abdomen and/or pelvis
– MRI pelvis
• Women
– Pelvic ultrasound (transabdominal or transvaginal)
– Renal/bladder ultrasound
– CT abdomen and/or pelvis
– MRI pelvis
Diagnostic Procedures/Surgery
• Cystourethroscopy
– Normally needed for more atypical presentations and if discharge persists in spite of adequate medical therapy
– Evaluate for mass, erythema, false passage, stricture, or diverticulum of urethra
– Inspect prostate for friability, vascularity, hypertrophy, narrowing, and areas of visual fluctuance
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Inflammatory causes
– Gonococcal urethritis
– Non-gonococcal urethritis
Chlamydia trachomatis
Mycobacterium genitalium
Trichomonas vaginalis
Ureaplasma urealyticum
– Urethral diverticulum
– Trichomoniasis
– TB
– Periurethral abscess
– Reactive arthritis (Previously called Reiter syndrome)
• Masses
– Urethral tumor
– Urethral caruncle
– Urethral hemangioma
– Urethral condyloma
– Urethral carcinoma
• Trauma/iatrogenic
– Acute external force
– Recent instrumentation
– Recent catheterization
– Eroded urethral sling or implanted prosthesis
• Mucosal hyperemia
– Benign Prostatic Hypertrophy often can have initial hematuria due to dilated prostatic vessels (3).
TREATMENT
GENERAL MEASURES
Cause of discharge dictates treatment
MEDICATION
First Line
• Gonococcal and non-gonococcal urethritis
– Azithromycin 1 g PO × 1 or doxycycline 100 mg PO BID × 7 days plus ceftriaxone 125 mg IM × 1 or cefixime 400 mg PO × 1 is first-line empiric therapy
• Trichomoniasis
– Metronidazole 2 g PO × 1 or 250 mg TID × 7 days
• Reactive arthritis
– NSAIDs, methotrexate, cyclosporine, and sometimes corticosteroids
• BPH
– 5α-reductase inhibitors can be used for refractory prostatic bleeding
Second Line
Please refer to the CDC’s published Sexually Transmitted Diseases Treatment Guidelines 2010 for updates and alternatives
SURGERY/OTHER PROCEDURES
• Urethral mass
– Often surgical excision is preferred approach
– Urethral carcinoma can be treated effectively with surgical excision—better control with anterior involvement in males (vs. posterior)
– Diverticulum requires diverticulectomy
• Trauma
– Radiographic interrogation of anatomy
– Retrograde urethrogram, cystogram, cystoscopy, CT cystogram
– Urethral injuries can be repaired surgically after several months of recovery
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
For STI/STD consider screening and treating partner
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
N/A
COMPLICATIONS
• Urethral stricture
• Local spread to other genitourinary organs – cystitis, prostatitis, epididymitis, orchitis
• Abscess formation in urethra, prostate, epididymis, or testicle
• Systemic infection
• Local invasion or metastasis of malignant lesion
• Recurrent pain
FOLLOW-UP
Patient Monitoring
Follow-up is dictated by any associated findings and etiology of discharge
Patient Resources
• Medline Plus: Gram stain of urethral discharge.http://www.nlm.nih.gov/medlineplus/ency/article/003749.htm
REFERENCES
1. Center for Disease Control and Prevention. (2013). Sexually Transmitted Diseases. Retrieved from http://www.cdc.gov/std.
2. Genders RE, Spitaels D, Jansen CL, et al. A misleading urethral smear with polymorphonuclear leucocytes and intracellular diplococci; case report of urethritis caused by Neisseria meningitidis . J Med Microbiol. 2013;62(Pt 12):1905–1906.
3. Memis A, Ozden C, Ozdal OL, et al. Effect of finasteride treatment on suburethral prostatic microvessel density in patients with hematuria related to benign prostate hyperplasia. Urol Int. 2008;80(2):177–180.
ADDITIONAL READING
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59 (No. RR-12).
See Also (Topic, Algorithm, Media)
• Gonorrhea Microscopic Image 
• Urethra, Bleeding (Blood at Meatus)
• Urethral Carcinoma, General Considerations
• Urethral Condyloma
• Urethral Diverticulum
• Urethral Hemangioma
• Urethritis, Gonococcal and Non-gonococcal
CODES
ICD9
• 098.0 Gonococcal infection (acute) of lower genitourinary tract
• 788.1 Dysuria
• 788.7 Urethral discharge
ICD10
• A54.01 Gonococcal cystitis and urethritis, unspecified
• R30.0 Dysuria
• R36.9 Urethral discharge, unspecified
CLINICAL/SURGICAL PEARLS
• Character, color, and acuity of discharge can usually direct diagnosis.
• Urethral discharge is the most common symptom of an STI/STD in men.
• Carcinoma of the urethra must be ruled out in the presence of bloody urethral discharge.