Urethral discharge

Last updated: July 2021


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 examination1 . 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

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

azithromycin PO: 1 g single dose
or
doxycycline PO: 100 mg 2 times daily for 7 days

PLUS

Treatment for gonorrhoea

ceftriaxone IM: 500 mg single dose
or, if ceftriaxone is not available,
cefixime PO: 400 mg single dose
or
spectinomycin IM: 2 g 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
Ref Notes
1 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.