Non-gonococcal urethritis

Updated July 28, 2024

Guidelines

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 Center for Disease Control (CDC 2021), the Japanese Association for Infectious Disease (JAID/JSC 2021), the British Association for Sexual Health and HIV (BASHH 2018), and the International Union Against Sexually Transmitted Infections (IUSTI 2016).

Screening and diagnosis

Diagnosis

As per IUSTI 2016 guidelines:

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).

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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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Classification and risk stratification

Classification: as per JAID/JSC 2021 guidelines, 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.

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Diagnostic investigations

Indication for testing: as per IUSTI 2016 guidelines, evaluate for urethritis in patients with symptoms or visible discharge.

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Medical management

Empirical therapy: as per IUSTI 2016 guidelines, do not initiate empirical treatment without verifying the presence of urethritis, as there is a risk of perpetuating the symptoms.

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Patient education

Avoidance of sexual intercourse: as per JAID/JSC 2021 guidelines, evaluate and treat sexual partners of male patients with urethritis.

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Follow-up and surveillance

Follow-up testing: as per BASHH 2018 guidelines, 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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