Non-specific Urethritis and Urethral Irritation
Diagnosis and management
Diagnosis
Management
Patient education
Follow-up
Persistent NSU
Urethral Irritation
Non-Specific Urethritis (NSU) is diagnosed in males
only, from microscopic examination of a gram
stain made from a urethral swab. Diagnosis requires the following:
- evidence of urethritis (5 or more polymorphs per high
power field)
and
- absence of gonococci or chlamydia
trachomatis
Passage of urine may
flush out urethral polymorphs, thus a urethral swab should be taken
optimally 4 hours after the
last void.
NSU may be diagnosed if
there is evidence of inflammation even in the absence of symptoms such as
urethral discharge or dysuria if there is no other obvious cause for
inflammation such as herpes, balanitis or dermatitis.
Management
Treatment
Antibiotic
treatment should not be commenced until
urethral swabs have been taken.
Standard
therapy
azithromycin
1 g orally as one dose
or
doxycycline
200 mg orally daily for 10 days
In
settings where microscopic examination of a urethral smear is unavailable on
site, treatment of presumptive NSU is justified in symptomatic men.
The
following points should be covered:
·
Chlamydia and gonorrhoea test
results will be pending at the first visit
·
Abstinence
from sex for one week until results are given
·
The
nature of the infection
·
It is
benign and there is no equivalent in females
·
Symptoms
may be slow to resolve despite treatment
Note:
The significance of ureaplasma is uncertain and its detection does
not alter management. Neisseria
meningitidis is occasionally identified on urethral culture in
asymptomatic men. Its finding is usually incidental and does not require
treatment. However, in the presence of symptoms N.
meningitidis is assumed to be the cause of urethritis.
Contact
tracing
This
is only required if chlamydia or gonorrhoea is isolated.
The
patient should be clinically reviewed 5 to 10 days after the completion of
medication, for the following:
·
Review results of gonococcal
culture and chlamydia tests.
·
Check on medication compliance
·
Evaluate symptoms and signs
·
Check reaction to medication
·
Enquire about sexual activity
since treatment
·
If symptoms persist, repeat
urethral smear for polymorphs, at least 4 hours after voiding.
In
some men, the symptoms of urethritis do not resolve despite compliance with
antibiotic therapy and abstinence from sexual activity. In these men, where
the urethral smear still shows 5 or more polymorphs per high power field the
following treatment regimen is recommended:
Standard
therapy
doxycycline
200 mg orally for 10 days
plus
metronidazole
400 mg orally 12 hourly for 5 days
Alternate
therapy
roxithromycin
150 mg orally twice daily for 10 days
plus
metronidazole
400 mg orally 12 hourly for 5 days
The diagnosis is made
in men with dysuria and/or urethral discharge but no microscopic evidence of
urethritis. (In
settings where microscopy of a urethral smear is not available, this
diagnosis cannot be reliably made.)
Management
The
patient should be reassured that the symptoms are due to a mild irritation
and not infection. Possible causes may include trauma, eg vigorous sexual
activity or masturbation, or irritants such as alcohol. No antibiotic
treatment is required. The symptoms subside in one to two weeks.
The
patient should be advised to avoid manipulation of the penis (no squeezing
or milking of the urethra) and he should abstain from sexual activity and
masturbation.
Ensure
that tests for gonorrhoea and chlamydia (and urinary tract infection if
clinically indicated) have been done to exclude these infections. The
patient should return for these results in 1 week, and should not have sex
until negative gonorrhoea and chlamydia tests are confirmed. |
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