Daniel C. Parker, MD
Jack H. Mydlo, MD
BASICS
DESCRIPTION
• Gonococcal urethritis (GU) and nongonococcal urethritis (NGU) are urethral infections characterized by dysuria and urethral discharge
– Both types are STDs/STI
Neisseria gonorrhoeae (gram-positive diplococci) on culture/gram stain differentiates GU from NGU
Chlamydia trachomatis is the most common cause of NGU
EPIDEMIOLOGY
Incidence
• Estimated 820,000 new cases of gonococcal urethritis
– Most common reportable disease in the United States
• Over 3 million cases of non-gonoccal urethritis annually
• Both GU and NGU are belived to be significantly under repprted
Prevalence
• Gonococcal urethritis: 100.8 per 100,000 population
– Rate has increased among all gender/racial/ethnic groups since 2009 some data suggests NGU is increasing
RISK FACTORS
• Individuals aged 15–24 yr at highest risk
• African Americans
• Sexual Activity
– Risk of infection is 10% for men after a single exposure
– Multiple sexual partners
Genetics
No heritable form of transmission
PATHOPHYSIOLOGY
• GU
– Caused by N. gonorrhoeae
Coinfection with Chlamydia 4–35%
Incubation is 3–10 days
• NGU
– Chlamydia trachomatis most common (25–60%)
– Mollicutes: Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium in up to 40% of cases
– Trichomonas vaginalis, CMV, and HPV have been reported
– Incubation period is 7–21 days
• Both types acquired during sexual intercourse
• Urethritis is a difficult diagnosis in women because copious discharge may not be present; the hallmark is dysuria and frequency.
ASSOCIATED CONDITIONS
• Other STDs/STI
• Pendulous urethral stricture
• Epididymitis/orchitis
GENERAL PREVENTION
• GU and NGU
– Proper use of male and female condoms, if multiple sexual partners
DIAGNOSIS
HISTORY
• GU and NGU
– Systemic symptoms are rare
– Important information to gather
Relationship to sexual activity (when/type)
Number of episodes
Number of sexual partners
Nature of sexual relations
Severity of symptoms
Characteristics of dysuria and urethral discharge
• NGU
– Urethral discharge
Usually mild to moderate, clear or whitish fluid
– Dysuria
Mild burning with urination or absent
• GU
– Urethral discharge
Usually purulent, green/yellow/white, and copious
– Dysuria
Usually moderate to severe burning with urination
May present as urethral itching
PHYSICAL EXAM
• GU and NGU
– Pendulous urethra may be tender to palpation
– Abdomen and flanks palpated for tenderness, masses, and bladder distention
– Scrotal contents examined for testicular/epididymal size, consistency, and tenderness
– Digital rectal exam (DRE) for prostate size, tenderness, and consistency
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis
– Obtain 1–4 h after voiding
– ≥15 PMN leukocytes per HPF of spun sediment in the first-void urine specimen
– Positive leukocyte esterase on urine dip in the absence of UTI suggests urethritis
– Up to 30% of patients with urethritis will not have WBC in the urine
• Urethral smear for gram stain and culture
– Calcium alginate swab inserted 1–2 cm into urethra best to obtain 1–2 hours after voiding
– Culture plated on Thayer-Martin media for GU
• Sensitivity of DNA targeted assays is improving (1)[A]
– Nucleic Acid Amplified Test (NAAT) of urine—first 10–30 cc voided
– NAAT available for: C trachomatis and N gonorrhoeae. Labs can also test for Mycoplasma, Ureaplasma, and Trichomonas vaginalis but these assays are no commonly performed since they are very costly and may not alter the recommended antibiotic regimen
Imaging
Typically not necessary
Diagnostic Procedures/Surgery
Cystourethroscopy with dilation of pendulous urethra may be indicated for chronic cases resulting in urethral stricture.
Pathologic Findings
Urethral inflammation
DIFFERENTIAL DIAGNOSIS
• GU
• NGU
– Chlamydia trachomatis
– Mycobacterium genitalium
– Trichomonas vaginalis
– Ureaplasma urealyticum
• Uncommon infectious causes: TB, adenovirus, uropathogenic Escherichia coli (unprotected anal intercourse), herpes simplex, cytomegalovirus
• Urethral diverticulum
• Periurethral abscess
• Reactive urethritis (Formerly Reiter syndrome) associated with conjunctivitis, arthritis, and tenosynovitis
– No growth on culture
– Minimal number of leukocytes in urethral smear or urinalysis
• Miscellaneous: Urethral irritation from detergents, body soap, lotions, spermicides, contraceptives, manipulation, and/or foreign body insertion.
TREATMENT
GENERAL MEASURES
• Cases are reportable to health department.
• Sexual intercourse should be avoided until cure.
• Sexual partners within 60 days of diagnosis or symptoms should be evaluated and treated.
• Dual treatment for both N. gonorrhoeae and C. trachomatis is recommended.
ALERT
The CDC now recommends against the use of quinolones and oral cephalosporins for treatment of gonococcal urethritis in the US due to widespread bacterial resistance (2)[A].
MEDICATION
First Line
• GU
– CDC recommends dual therapy for GU and NGU
– Ceftriaxone 250 mg IM once
Efficacious in 99% of cases
Also treat for NGU (Chlamydia)
• NGU
– Azithromycin 1 g PO once, or doxycycline 100 mg PO b.i.d. for 10–14 days
Second Line
• GU
– Cefixime 400 mg PO once
– Azithromycin 2 g PO once for pregnant women or cephalosporin allergy.
• NGU
– Erythromycin 500 mg PO q.i.d. for 7 days
– Ofloxacin 300 mg PO b.i.d. for 10–14 days
SURGERY/OTHER PROCEDURES
Surgery typically not indicated
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Patient education
– Proper use of condoms and safe sexual practice
– Reduce number of sexual partners
– Evaluation and treatment of sexual partners at risk (3)[A]
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Generally good prognosis with treatment for both GU and NGU
– Systemic manifestations of gonococcal dissemination are rare today:
Arthritis
Dermatitis
Meningitis
Endocarditis
COMPLICATIONS
• GU
– Periurethritis
May lead to abscess
– Urethral fibrosis
May lead to stricture
– Epididymitis/orchitis
May lead to testicular atrophy or infertility
– Prostatitis
May lead to abscess
• NGU
– Emotional sequelae are common
Fear of loss of sexual function or guilt may produce depression
– Epididymitis and/or nonbacterial prostatitis
– Usually does not cause severe physical complications in men
FOLLOW-UP
Patient Monitoring
• GU and NGU
– Post therapy culture and urethral smear to confirm response to therapy
Patient Resources
• CDC. STD fact sheets. http://www.cdc.gov/std
• MedlinePlus: Urethritis. http://www.nlm.nih.gov/medlineplus/ency/article/000439.htm
REFERENCES
1. Whiley DM, Garland SM, Harnett G, et al. Exploring ‘best practice’ for nucleic acid detection of Neisseria gonorrhoeae . Sex Health. 2008;5(1):17–23.
2. Del Rio C. Update to CDC’s sexually transmitted disease treatment guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR. 2012;61(31):590–594.
3. Hogben M, Kidd S, Burstein GR, et al. Expedited partner therapy for sexually transmitted infections. Curr Opin Obstet Gynecol. 2012;24(5):299–304.
ADDITIONAL READING
• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59 (No. RR-12).
• Nguyen HT. Bacterial infections of the genitourinary tract. In: Tanagho EA, McAninch JW, eds. Smith’s General Urology. 17th ed. New York, NY: McGraw-Hill; 2008.
• Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier; 2011.
• www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm
See Also (Topic, Algorithm, Media)
• Gonorrhea
• Gonorrhea Microscopic Image 
• Sexually Transmitted Diseases (STD), General
• Urethra, Stricture, Male
• Urethral Discharge
• Urethra Discharge Algorithm 
CODES
ICD9
• 098.0 Gonococcal infection (acute) of lower genitourinary tract
• 099.40 Unspecified other nongonococcal urethritis [NGU]
• 131.02 Trichomonal urethritis
ICD10
• A54.01 Gonococcal cystitis and urethritis, unspecified
• A59.03 Trichomonal cystitis and urethritis
• N34.1 Nonspecific urethritis
CLINICAL/SURGICAL PEARLS
• GU is caused by the gram-positive diplococci Neisseria gonorrhoeae.
• NGU is most commonly caused by Chlamydia trachomatis.
• Up to 35% of cases of GU are coinfected with chlamydia.
• The CDC recommends simultaneous treatment for both GU and NGU in patients presenting with urethritis.
• Sexual partners within 60 days of diagnosis or symptom onset should be evaluated and treated.