Urethral discharge


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: 250 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 re-infection.

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.