Urethritis

What causes urethritis

Gonococcal urethritis

Caused by Neisseria gonorrhoeae. It typically causes a thick yellow-green discharge and burning within 2 to 7 days of exposure in men. See gonorrhea.

Nongonococcal urethritis (NGU)

• Chlamydia trachomatis: the most common identified cause, often mild or no symptoms
• Mycoplasma genitalium: an increasingly recognized cause, often resistant to some antibiotics
• Trichomonas vaginalis
• Ureaplasma, adenovirus and herpes simplex virus less commonly
• in many cases no organism is found

Non-infectious causes

• irritation from soaps, spermicides or douches
• injury from catheters, vigorous sex or masturbation
• reactive arthritis and other inflammatory conditions

Symptoms

In men

• burning or pain when urinating
• discharge from the penis, clear, white or yellow-green
• itching or irritation at the tip of the penis
• staining of underwear
• in some, no symptoms

In women

Urethritis in women often causes no symptoms, or is mistaken for a urinary tract infection:

• burning on urination and frequency
• abnormal vaginal discharge (from accompanying cervicitis)
• pelvic pain or bleeding after sex

Urethritis vs urinary tract infection

In young, sexually active people with burning on urination, STI testing is important even if a UTI is suspected.

Diagnosis

• nucleic acid amplification tests (NAATs) on first-catch urine (men) or vaginal swab (women) for gonorrhea, chlamydia and trichomonas. Testing for M. genitalium when symptoms persist or recur
• urethral swab with Gram stain to see white cells and gonorrhea bacteria
• urinalysis: white cells (leukocyte esterase) on first-void urine
• testing for HIV and syphilis, as recommended after any STI diagnosis

Treatment

Treatment follows CDC guidelines:

• Gonorrhea: a single ceftriaxone injection. If chlamydia has not been ruled out, doxycycline is added
• Chlamydia or NGU: doxycycline for 7 days is preferred. Azithromycin is an alternative, particularly in pregnancy
• Mycoplasma genitalium: doxycycline followed by moxifloxacin, guided by resistance testing where available
• Trichomonas: metronidazole

Avoid sex until 7 days after treatment is completed and symptoms have resolved, and until partners have been treated. Recent partners, usually within the past 60 days, should be tested and treated. Expedited partner therapy, providing medicine for partners, is allowed in most US states. Retesting for chlamydia and gonorrhea is recommended about 3 months after treatment because reinfection is common.

Complications

• epididymitis and orchitis in men
• pelvic inflammatory disease in women, with infertility, ectopic pregnancy and chronic pelvic pain
• reactive arthritis: joint pain, eye inflammation and urethritis
• urethral stricture after repeated infections
• increased risk of acquiring or transmitting HIV
• passing infection to a newborn during birth

Prevention

• use condoms consistently and correctly
• regular STI testing if you have new or multiple partners
• annual chlamydia and gonorrhea screening for sexually active women under 25, and for others at risk
• discuss doxycycline post-exposure prophylaxis (doxy-PEP) with a clinician if you are at high risk

Frequently asked questions

What are the symptoms of urethritis?

Common symptoms are burning or pain when urinating, discharge from the penis or urethra, and itching at the urethral opening. Women may have no symptoms, or burning, frequent urination and abnormal vaginal discharge.

What causes urethritis?

Most urethritis is caused by sexually transmitted infections, mainly gonorrhea and chlamydia, and also Mycoplasma genitalium and trichomonas. Less commonly, it results from irritation by soaps or spermicides, injury or catheters.

What is nongonococcal urethritis?

Nongonococcal urethritis (NGU) is urethritis not caused by gonorrhea. Chlamydia is the most common cause, followed by Mycoplasma genitalium and trichomonas. Often no specific cause is found. It is usually treated with doxycycline.

How is urethritis treated?

Treatment depends on the cause. Gonorrhea is treated with a ceftriaxone injection, and chlamydia and NGU usually with doxycycline. Sexual partners must also be tested and treated, and sex avoided until treatment is complete.

Can urethritis go away on its own?

Symptoms sometimes fade without treatment, but the infection often persists and can still spread to partners and cause complications such as epididymitis, pelvic inflammatory disease and infertility. Testing and treatment are always recommended.