Urethritis is defined as infection-induced inflammation of the urethra. The term is typically reserved to describe urethral inflammation caused by a sexually transmitted disease (STD), and the condition is normally categorized as either gonococcal urethritis (GU) or nongonococcal urethritis (NGU).
Many patients with urethritis, including approximately 25% of those with NGU, are asymptomatic and present to a clinician following partner screening.  Up to 75% of women with Chlamydia trachomatis infection are asymptomatic.
Signs and symptoms in patients with urethritis may include the following:
Urethral discharge: May be yellow, green, brown, or tinged with blood; production unrelated to sexual activity
Dysuria (in men): Usually localized to the meatus or distal penis, worst during the first morning void, and made worse by alcohol consumption; typically not present are urinary frequency and urgency
Itching: Sensation of urethral itching or irritation between voids
Orchalgia: Heaviness in the male genitals
Worsens during menstrual cycle (occasionally).
Systemic symptoms (eg, fever, chills, sweats, nausea): Typically absent
See Presentation for more detail.
Most patients with urethritis do not appear ill and do not present with signs of sepsis. The primary focus of the examination is on the genitalia.
Examination in male patients with urethritis includes the following:
Inspect the underwear for secretions
Penis: Examine for skin lesions that may indicate other STDs (eg, condyloma acuminatum, herpes simplex, syphilis); in uncircumcised men, retract the foreskin to assess for lesions and exudate
Urethra: Examine lumen of the distal urethral meatus for lesions, stricture, or obvious urethral discharge; palpate along urethra for areas of fluctuance, tenderness, or warmth suggestive of abscess or for firmness suggesting foreign body
Testes: Examine for evidence of mass or inflammation; palpate the spermatic cord, looking for swelling, tenderness, or warmth suggestive of orchitis or epididymitis
Lymphatics: Check for inguinal adenopathy
Prostate: Palpate for tenderness or bogginess suggestive of prostatitis
Rectal: During the digital rectal examination, note any perianal lesions
Examine female patients in the lithotomy position. Include the following evaluation:
Skin: Assess for lesions that may indicate other STDs
Urethra: Strip the urethra for any discharge
Pelvis: Complete pelvic examination, including the cervix
Urethritis can be diagnosed based on the presence of one or more of the following:
A mucopurulent or purulent urethral discharge
Urethral smear that demonstrates at least 5 leukocytes per oil immersion field on microscopy
First-voided urine specimen that demonstrates leukocyte esterase on dipstick test or at least 10 WBCs/hpf on microscopy
All patients with urethritis should be tested for Neisseria gonorrhoeae and C trachomatis. Laboratory studies may include the following:
Endourethral and/or endocervical culture for N gonorrhoeae and C trachomatis
Urinalysis: Not useful test in urethritis, except to help exclude cystitis or pyelonephritis
Nucleic acid–based tests: For C trachomatis and N gonorrhoeae (urine specimens) and other Chlamydia species (endourethral samples)
Nucleic acid amplification tests (eg, PCR for N gonorrhoeae, Chlamydia species)
KOH preparation: to evaluate for fungal organisms
Wet mount preparation: To detect the movement/presence of Trichomonas
STD testing for syphilis serology (VDRL) and HIV serology
Nasopharyngeal and/or rectal swabs: For gonorrhea screening in men who have sex with men
Pregnancy testing: In women who have had unprotected intercourse
Imaging studies, specifically retrograde urethrography, are unnecessary in patients with urethritis, except in cases of trauma or possible foreign body insertion.
Patients with urethritis may undergo the following procedures:
Catherization: In cases of urethral trauma; to avoid urinary retention and tamponade urethral bleeding
Cystoscopy: In cases when catherization is not possible, for placement of a catheter; to remove foreign body or stone in the urethra
Dilation of urethral strictures with filiforms and followers
Placement of suprapubic tube: In severe cases of urethral trauma that prevent placement of urethral catheters or in the absence of adequate facilities for emergent cystoscopy; temporizing measure to divert urine and relieve patient discomfort
See Workup for more detail.
Symptoms of urethritis spontaneously resolve over time, regardless of treatment. Administer antibiotics that cover both GU and NGU. Regardless of symptoms, administer antibiotics to the following individuals:
Patients with positive Gram stain or culture results
All sexual partners of the above patients
Patients with negative Gram stain results and a history consistent with urethritis who are not likely to return for follow-up and/or are likely to continue transmitting infection
Antibiotics used in the treatment of urethritis include the following:
Urethritis is an inflammatory condition that can be infectious or posttraumatic in nature. Infectious causes of urethritis are typically sexually transmitted and categorized as either gonococcal urethritis (ie, due to infections with Neisseria gonorrhoeae) or NGU (ie, due to infections with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, or Trichomonas vaginalis).
Haemophilus species are an increasing cause of NGU, particularly in men who have unprotected oral sex with men. [2, 3] Rare infectious causes of urethritis include lymphogranuloma venereum, herpes simplex virus types 1 and 2, adenovirus, syphilis, mycobacterial infection, Corynebacterium,  and bacterial infections that are typically associated with cystitis (usually gram-negative rods) in the presence of urethral stricture. Other rare but reported causes of urethritis include viral, streptococcal, anaerobic, and meningococcal infections. However, none of the known viral or bacterial causes are found.in up to 35% of NGU cases. 
Posttraumatic urethritis can occur in 2%-20% of patients practicing intermittent catheterization and following instrumentation or foreign body insertion. Urethritis is 10 times more likely to occur with latex catheters than with silicone catheters.
Urethritis may be associated with other infectious syndromes, such as the following:
Urethritis occurs in 4 million Americans each year. The incidence of gonococcal urethritis is estimated at over 700,000 new cases annually, and the incidence of NGU is approximately 3 million new cases annually. Both infections are significantly underreported. The incidence of gonococcal urethritis declined steadily from 2000 to 2009, but then began an intermittent rise, and the incidence of NGU is increasing.  NGU incidence is highest in the summer months.
Worldwide, approximately 62 million new cases of gonococcal urethritis and 89 million new cases of NGU are reported each year.
Approximately 10%-40% of women with urethritis eventually develop pelvic inflammatory disease (PID), which may subsequently cause infertility and ectopic pregnancy secondary to postinflammatory scar formation in the fallopian tubes. PID can occur even in women with asymptomatic infections.
Children born to mothers with Chlamydia infection may develop conjunctivitis, iritis, otitis media, or pneumonia if exposed to the organism while passing through the birth canal. Performing cesarean delivery in patients with known chlamydial infections and routine treatment of all newborns with antichlamydial eyedrops has decreased the incidence of this problem in developed countries.
Disseminated gonococcal infection (DGI) and reactive arthritis develop in fewer than 1% of female patients with urethritis. Reactive arthritis is characterized by NGU, anterior uveitis, and arthritis and is strongly associated with the gene for HLA-B27. Rare but serious complications of DGI include arthritis, meningitis, and endocarditis.
Morbidity due to urethritis in males is less common (1%-2%), typically taking the form of urethral stricture or stenosis due to postinflammatory scar formation. Other potential complications of urethritis in males include prostatitis, acute epididymitis, abscess formation, proctitis, infertility, abnormal semen, DGI, and reactive arthritis.
Mortality rates are minimal in patients with gonococcal urethritis or NGU.
Urethritis has no racial predilection. However, persons of low socioeconomic class are affected more often than persons of higher socioeconomic class.
Urethritis has no sexual predilection; however, data may be skewed because urethritis is underrecognized in women. Up to 75% of females with the condition can be asymptomatic or may instead present with cystitis, vaginitis, or cervicitis.  Homosexual males are at a greater risk for urethritis than are heterosexual males or females in general.
Urethritis may occur in any sexually active person, but incidence is highest among people aged 20-24 years.
All patients with uncomplicated urethritis spontaneously recover with or without treatment.
Gillespie CW, Manhart LE, Lowens MS, Golden MR. Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology. Sex Transm Dis. 2013 Mar. 40(3):271-4. [Medline].
Magdaleno-Tapial J, Valenzuela-Oñate C, Giacaman-von der Weth MM, Ferrer-Guillén B, Martínez-Domenech Á, García-Legaz Martínez M, et al. Haemophilus Species Isolated in Urethral Exudates as a Possible Causative Agent in Acute Urethritis: A Study of 38 Cases. Actas Dermosifiliogr. 2018 Oct 31. [Medline].
Horie K, Ito S, Hatazaki K, Yasuda M, Nakano M, Kawakami K, et al. ‘Haemophilus quentini’ in the urethra of men complaining of urethritis symptoms. J Infect Chemother. 2018 Jan. 24 (1):71-74. [Medline].
Meštrović T. A microbial game of whack-a-mole: clinical case series of the urethral uncloaking phenomenon caused by Corynebacterium glucuronolyticum in men treated for Chlamydia trachomatis urethritis. Infection. 2018 Aug 30. [Medline].
Frølund M, Wikström A, Lidbrink P, Abu Al-Soud W, Larsen N, Harder CB, et al. The bacterial microbiota in first-void urine from men with and without idiopathic urethritis. PLoS One. 2018. 13 (7):e0201380. [Medline]. [Full Text].
Sexually Transmitted Disease Surveillance 2017. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/std/stats17/default.htm. September 2018; Accessed: December 12, 2018.
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[Guideline] 2015 Sexually Transmitted Diseases Treatment Guidelines: Diseases Characterized by Urethritis and Cervicitis. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm. June 4, 2015; Accessed: December 12, 2018.
Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis. Sex Transm Dis. 2008 Nov. 35(11):946-59. [Medline].
[Guideline] World Health Organization. WHO Guidelines for the Treatment of Neisseria gonorrhoeae. Available at http://www.who.int/reproductivehealth/publications/rtis/gonorrhoea-treatment-guidelines/en/. 2016; Accessed: September 7, 2016.
Mugo PM, Duncan S, Mwaniki SW, Thiong’o AN, Gichuru E, Okuku HS, et al. Cross-sectional survey of treatment practices for urethritis at pharmacies, private clinics and government health facilities in coastal Kenya: many missed opportunities for HIV prevention. Sex Transm Infect. 2013 May 22. [Medline].
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Bachmann LH, Manhart LE, Martin DH, Seña AC, Dimitrakoff J, Jensen JS, et al. Advances in the Understanding and Treatment of Male Urethritis. Clin Infect Dis. 2015 Dec 15. 61 Suppl 8:S763-9. [Medline].
Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia at Augusta University; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, Society of Women in Urology
Disclosure: Nothing to disclose.
Michael Kemper, MD Resident Physician, Department of Urology, Medical College of Georgia at Augusta University
Disclosure: Nothing to disclose.
Kamran P Sajadi, MD Assistant Professor, Department of Urology, Oregon Health and Science University School of Medicine
Kamran P Sajadi, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, Endourological Society, Oregon Medical Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, Western Section of the American Urological Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.
Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University
Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, Society of Urologic Oncology
Disclosure: Received consulting fee from GSK for consulting; Received honoraria from Astra Zeneca for speaking and teaching; Received consulting fee from Watson Pharmaceuticals for consulting.
Research & References of Urethritis|A&C Accounting And Tax Services