Urethral discharge

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    Last updated: August 2022

     

    Urethral discharge is seen almost exclusively in men. The principal causative organisms are Neisseria gonorrhoeae (gonorrhoea) and Chlamydia trachomatis (chlamydia).

    Abnormal discharge should be confirmed by performing a clinical examination a Citation a. In areas where lymphatic filariasis is endemic, be careful not to confuse purulent urethral discharge with milky or rice-water urine (chyluria) suggestive of lymphatic filariasis. . In males, the urethra should be milked gently if no discharge is visible. Furthermore, specifically check for urethral discharge in patients complaining of painful or difficult urination (dysuria).

    Case management

    Algorithme Urethral discharge

    Laboratory

    • C. trachomatis cannot easily be identified in a field laboratory. In the absence of validated rapid diagnostic tests, the treatment is empiric.
    • In men, a methylene blue or Gram stained smear from a urethral swab may be used to detect gonococci (Gram negative intracellular diplococci).

    Treatment of the patient

    • In women: same treatment as cervicitis.
    • In men:
      • If microscopy of a urethral smear has been performed: in the absence of gonococci, treat for chlamydia alone; in the presence of gonococci, treat for chlamydia AND gonorrhoea.
      • When no laboratory is available, treat for chlamydia AND gonorrhoea as below:
    Treatment for chlamydia   Treatment for gonorrhoea
    azithromycin PO: 1 g single dose
    or
    doxycycline PO: 100 mg 2 times daily for
    7 days
    PLUS ceftriaxone IM: 500 mg single dose
    or, if ceftriaxone is not available,
    cefixime PO: 400 mg single dose

     

    If urethral discharge persists or reappears after 7 days:

    • Verify that the patient has received an effective treatment (i.e. one of the combinations above).
    • Gonococcal resistance is a possibility if another treatment (e.g. co-trimoxazole or kanamycin) has been administered: re-treat for gonorrhoea as above (chlamydia is rarely resistant).
    • If an effective antibiotic therapy has been given, consider trichomoniasis (tinidazole or metronidazole PO, 2 g single dose); also consider reinfection.

    Treatment of the partner

    The sexual partner receives the same treatment as the patient, whether or not symptoms are present.

     

    Footnotes
    • (a)In areas where lymphatic filariasis is endemic, be careful not to confuse purulent urethral discharge with milky or rice-water urine (chyluria) suggestive of lymphatic filariasis.