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Non-gonococcal urethritis

Key sources
The following summarized guidelines for the evaluation and management of non-gonococcal urethritis are prepared by our editorial team based on guidelines from the Japanese Association for Infectious Disease (JAID/JSC 2021), the Center for Disease Control (CDC 2021), the British Association for Sexual Health and HIV (BASHH 2018), and the International Union Against Sexually Transmitted Infections (IUSTI 2016).
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Guidelines

1.Screening and diagnosis

Diagnosis
Confirm urethritis by demonstrating polymorphonuclear leukocytes from the anterior urethra using a Gram or methylene-blue stained urethral smear, which should contain 5 polymorphonuclear leukocytes/hpf (averaged over 5 fields with the greatest concentration of polymorphonuclear leukocytes).
Consider diagnosing urethritis based on the following criteria if microscopy is not available:
presence of a mucopurulent or purulent urethral discharge on examination
≥ 1+ on a leukocyte esterase dipstick in a first void urine specimen
threads in a first void urine specimen (threads may be physiological, such as semen)
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2.Classification and risk stratification

Classification: classify urethritis into gonococcal and non-gonococcal depending on the causative microorganism.
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classify non-gonococcal urethritis further into chlamydial urethritis and non-chlamydial non-gonococcal urethritis.
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3.Diagnostic investigations

Indication for testing: evaluate for urethritis in patients with symptoms or visible discharge.
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More topics in this section

  • First void urine

  • Urethral smear

  • Vaginal smear

  • Antimicrobial susceptibility testing

  • Assessment of sexual partners

4.Medical management

Empirical therapy: do not initiate empirical treatment without verifying the presence of urethritis, as there is a risk of perpetuating the symptoms.
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  • First-line therapy

  • Second-line therapy

5.Patient education

Avoidance of sexual intercourse: as per JAID 2021 guidelines, evaluate and treat sexual partners of male patients with urethritis.
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6.Follow-up and surveillance

Follow-up testing: obtain a test of cure in all patients 5 weeks after the start of treatment (and no sooner than 3 weeks to avoid false negative results) to ensure microbiological cure and to help identify emerging resistance.
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More topics in this section

  • Evaluation of persistent/recurrent disease

  • Management of persistent/recurrent disease