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Non-gonococcal urethritis

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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).


1.Screening and 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.
classify non-gonococcal urethritis further into chlamydial urethritis and non-chlamydial non-gonococcal urethritis.

3.Diagnostic investigations

Indication for testing: evaluate for urethritis in patients with symptoms or visible discharge.
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  • 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.

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.

More topics in this section

  • Evaluation of persistent/recurrent disease

  • Management of persistent/recurrent disease