Urethritis - male
Exam Tips
- In OSCE history, always time-lock sexual contacts/partners to the previous 3 months and ask exposure sites (urethral/oral/rectal risk).
- The hallmark sign is urethral discharge; if absent on inspection, examine after >=2 hours since last void and consider gentle urethral milking.
- First-void urine NAAT for chlamydia/gonorrhoea is core testing; MSU is for suspected UTI, not first-line STI diagnosis.
- Persistent/recurrent symptoms after treatment are more often reinfection or adherence failure than exotic pathology.
- Know UK empirical NGU regimen exactly: doxycycline 100 mg BD for 7 days; know alternatives and fluoroquinolone safety warning.
- Use image recall in viva: identify purulent meatal discharge and, in gonococcal disease, classic intracellular Gram-negative diplococci on microscopy figure from STI teaching slides.
Definition
Male urethritis is inflammation of the urethral mucosa, most often due to sexually transmitted infection, presenting typically with urethral discharge and/or dysuria. It is classified into gonococcal urethritis (caused by Neisseria gonorrhoeae), non-gonococcal urethritis (often chlamydia, Mycoplasma genitalium, or no organism identified), and persistent/recurrent urethritis when symptoms return 30-90 days after initial treatment.
Pathophysiology
Urethral epithelial infection triggers a neutrophil-predominant inflammatory response, producing mucous/purulent exudate, urethral irritation, and painful voiding. In gonococcal disease, N. gonorrhoeae adheres to and invades mucosa, often causing brisk purulent inflammation; in NGU, C. trachomatis and M. genitalium are common pathogens, though over half of cases have no identified organism despite testing. Ongoing inflammation after treatment is usually due to reinfection, non-adherence, coinfection, or antimicrobial resistance rather than extensive structural damage. Non-infective mechanisms include chemical irritation, instrumentation/trauma, and urethral stricture. See figure: typical urethral inflammatory pathway and common pathogen distribution in STI teaching resources.
Risk Factors
- Recent new or multiple sexual partners (especially within the last 3 months)
- Condomless vaginal/oral/anal sex
- Partner with STI symptoms or confirmed STI (including trichomoniasis)
- Previous STI history
- Sexual risk behaviours including chemsex/recreational drug and alcohol-associated high-risk sex
- Recent urethral trauma or instrumentation (for non-infective urethritis)
- Exposure to local irritants (soaps, lotions, spermicides, deodorants)
Clinical Features
Symptoms
- Dysuria
- Urethral discomfort, itch, or irritation
- Visible penile/urethral discharge (may be minimal and noticed mainly in the morning)
- Penile soreness/erythema
- Possible associated balanoposthitis symptoms
Signs
- Mucoid, mucopurulent, or purulent urethral discharge (key sign)
- Meatal redness or crusting
- Discharge elicited on gentle urethral milking if not spontaneously visible
- Penile erythema or balanoposthitis on genital examination
- Tender/boggy prostate on DRE if concurrent prostatitis is present
Investigations
Management
Lifestyle Modifications
- Refer all suspected cases to GUM/sexual health services for diagnostic confirmation, partner notification, and STI screening
- Abstain from sex (including oral sex) until patient and partners complete treatment and symptoms resolve
- Explain adherence importance and likely causes of recurrence (reinfection, non-adherence, resistance, coinfection)
- Promote safer sex with consistent, correct condom use
- Arrange partner notification/contact tracing for recent partners and advise attendance at sexual health services
- Follow up after 1-2 weeks if managed in primary care or if symptoms persist
Pharmacological Treatment
First-line empirical NGU antibiotic (tetracycline)
- Doxycycline 100 mg orally twice daily for 7 days
Preferred empirical treatment in primary care when specialist care is not immediately accessed. Contraindications/cautions: pregnancy, breastfeeding, age <12 years; counsel on photosensitivity and oesophageal irritation (take with water, remain upright).
Alternative macrolide (if doxycycline contraindicated or not tolerated)
- Azithromycin 1 g orally as a single dose on day 1, then 500 mg orally once daily for 2 days
Advise no sexual intercourse until 14 days after starting azithromycin and until symptoms resolve. Check interaction/QT-risk profile and local resistance considerations.
Reserve alternative fluoroquinolone
- Ofloxacin 200 mg orally twice daily for 7 days
- Ofloxacin 400 mg orally once daily for 7 days
Use only when commonly recommended alternatives are unsuitable. MHRA safety warning: systemic fluoroquinolones can cause disabling, prolonged or irreversible adverse effects (e. g, tendinopathy, neuropathy, CNS effects); avoid in those with previous serious quinolone reactions and use caution in higher-risk groups.
Pathogen-directed treatment when indicated
- Treat confirmed/suspected gonorrhoea with current UK gonorrhoea regimen per local/BASHH protocol
- Treat confirmed/suspected trichomoniasis with nitroimidazole regimen per UK guidance
Tailor to microbiology and local resistance patterns; ensure partner treatment and test-of-cure where indicated.
Complications
- Epididymo-orchitis (especially with chlamydial NGU)
- Sexually acquired reactive arthritis (Reiter-pattern illness)
- Acute prostatitis
- Disseminated gonococcal infection (rash/skin lesions, arthralgia, arthritis, tenosynovitis)
- Epididymitis
- Tyson's gland infection
- Penile lymphangitis
- Periurethral abscess
- Seminal vesiculitis
- Persistent or recurrent urethritis after treatment
Prognosis
Most men improve rapidly, with symptoms often settling within about 3 days of appropriate antibiotics, but recurrence/persistence is common (roughly 10-25% depending on cohort and definition). Prognosis is generally good with early treatment, partner management, and adherence; untreated or inadequately treated infection increases risk of local and systemic complications.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(2)
- Alprostadil[contraindications]
- Tetracycline[management.pharmacological]
✅NICE Guidelines(1)
- Urethritis - male[overview]
📖Textbook References(3)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1580)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1143)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1381)[context]