Urethral Discharge (Male)

Background

• In the UK, the most important causes are Chlamydia and Gonorrhoea
  • The remainder is usually ‘non-specific urethritis’, which may be caused by Trichomonas vaginalis, HSV, mycoplasmas or other organisms

History

• PC; HPC (description (purulent; mucopurulent; bloody), onset, duration, timing, progression, severity, associated features)
  • Gonococcal disease usually presents within 7 days of exposure; whereas Chlamydia can take longer (1-4 weeks)
    • Gonococcal symptoms also tend to be more severe e.g. more volume/purulent discharge
  • Associated symptoms to ask about include pain, dysuria, pruritus; haematuria, frequency, urgency, nocturia, other LUTS (e.g. hesitancy, dribbling etc); flank pain; any ulceration
    • Also ask about systemic symptoms e.g. fever, arthralgia, arthritis, conjunctivitis; malaise etc
• SHx- sexual exposure (without protection; multiple partners)

Examination

• Examine the penis
  • Inspect for discharge, redness, ulcerations, lesions and hygiene
  • Try to express discharge- gently massage the urethra from the ventral penis towards the meatus (‘milking’)
    • Swab a sample if possible for microscopy/culture & sensitivity
• Examine for inguinal lymphadenopathy
• Examination of the scrotum for evidence of epididymitis/orchitis (tenderness) is advised; as is digital rectal examination of the prostate for evidence (particularly) of prostatitis

Investigations

• Urethral swab
  • Microscopy
    • Gram negative intracellular diplococci
  • Culture and sensitivity for gonorrhoea (if suspected)
• First void urine sample
  • Nucleic acid amplification test (NAAT) for chlamydia/gonorrhoea
• If there is a history of orogenital sex, a pharyngeal swab may be indicated (treatment for airway gonorrhoea differs from genital gonorrhoea; If there is a history of anal sex, a swab from the rectum may be indicated

Management

• Depending on cause
  • Gonorrhoea/Chlamydia is generally treated with a single dose of azithromycin 1g (or Doxycycline 100mg BD for 7 days)
    • +500mg IM ceftriaxone for gonorrhoea
• In general, urethritis is often treated empirically as for chlamydia

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