Male Urethritis

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Urethral discharge, dysuria, and exposure to a sexually transmitted infection (STI) are frequent presentations of urethritis in the male population. Recent research has focused on cost-effective antibiotic therapy and concern for emergence of antibiotic resistance among both typical and atypical organisms. The goal of initial therapy is to optimize compliance and prevent recurrence of this disease, which is predominantly sexually transmitted. ^{[1, 2, 3, 4, 5, 6, 7, 8]}

Inflammation of the urethra is more frequently infectious than posttraumatic, with STIs being the most common cause. Sexually transmitted urethritis is classified as either gonococcal urethritis (GCU) following infection with Neisseria gonorrhoeae, or nongonococcal urethritis (NGU).

For cases of NGU, Chlamydia trachomatis remains a primary concern, although Mycoplasma genitalium and Trichomonas vaginalis are increasingly recognized as important pathogens, and less commonly Ureaplasma parvum, Ureaplasma urealyticum, Mycoplasma hominis, and Gardnerella vaginalis. ^{[9, 10, 11]}

In one study of 424 men with signs and symptoms of acute urthritis, 127 (30%) were found to be infected with N gonorrhoeae. In 297 men with nongonococcal urethritis, C trachomatis was detected in 143 (48.1%). In 154 men with nonchlamydial nongonococcal urethritis, M genitalium (22.7%), M hominis (5.8%), U parvum (9.1%), U urealyticum (19.5%), H influenzae (14.3%), N meningitidis (3.9%), T vaginalis (1.3%), human adenovirus (16.2%), and herpes simplex virus types 1 (7.1%) and 2 (2.6%) were detected. ^[12]

M genitalium, not routinely tested by polymerase chain reaction (PCR) in many locations, may cause up to 10-30% of NGU cases ^{[1, 2, 13]} and, like chlamydia, may be associated with human immunodeficiency virus (HIV), human papilloma virus (HPV), and herpes simplex transmission and infection. M genitalium has been associated with treatment failure to presently recommended single-dose therapy, owing to macrolide resistance, ^{[14, 15, 3, 16, 13, 17, 4]} and has potential for quinolone resistance as well. ^{[16, 4, 18, 15]} Couldwell et al describe rates of resistance of 15% for quinolones and 43% for macrolides among 143 M genitalium specimens in Australia in 2013. ^[16]

Idiopathic urethritis, defined as urethritis in the absence of nucleic acid amplification testing (NAAT) evidence for the most common infectious causes (N gonorrhoeae, C trachomatis, M genitalium, and T vaginalis), may be considered the largest category. ^{[19, 20]}

Unusual infectious causes of urethritis include herpes genitalis, syphilis, mycobacterium, adenovirus, cytomegalovirus, as well as typical bacteria (usually gram-negative rods) associated with cystitis in the presence of urethral stricture or following insertive anal sex.

Urethritis following trauma is less common, but it can occur with intermittent catheterization or after urethral instrumentation or foreign body insertion. Fewer than 20% of patients practicing intermittent catheterization suffer urethritis; however, use of latex instead of silicone catheters significantly increases this risk. Symptoms of urethritis (urethral syndrome) can also be due to sensitivity to chemicals in spermicidal or contraceptive jellies or foams.

Idiopathic urethritis of childhood is of uncertain cause, perhaps related to dysfunctional elimination syndrome, ^[21] and presents as blood-stained urethral discharge, bleeding between micturition, or dysuria in the 5- to 15-year-old male, and can result in urethral stricture. ^{[22, 23]}

Urethritis involves local mucous membrane epithelial cell damage or invasion by an infectious agent (bacterial, viral, or fungal) followed by inflammatory changes including accumulation of leukocytes and chemical mediators (antibodies, cytokines, and interleukins) with resultant swelling, discharge, and pain.

Urethritis usually resolves without complication, even if untreated, yet it can result in urethral stricture, stenosis, or abscess formation in rare cases. Urethritis can occur in a continuum with concomitant seminal vesiculitis and epididymitis. ^[24]

Recurrent urethritis may occur from reinfection, therapeutic failure or “venereophobia,” an old term describing fear of recurrence where men can induce urethral inflammation and drainage (negative by white blood cell or Gram stain criteria) by repeatedly milking the urethra checking for infection. ^[25] .

Urethritis is predominantly a disease of adolescent and adult men. The prevalence is greatest in men younger than 25 years.

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Michael C Plewa, MD Research Director, Department of Emergency Medicine, Mercy Emergency Care Services, Inc, and Mercy Health Saint Vincent Medical Center

Michael C Plewa, MD is a member of the following medical societies: American College of Emergency Physicians, American Academy of Emergency Medicine, American Medical Association, Physicians for Social Responsibility, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Male Urethritis

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