Urethritis

Urethral discharge and/or dysuria are typical symptoms of male urethritis. Make a clinical diagnosis of gonorrhoea or non-gonococcal urethritis (NGU) and treat accordingly.

Most common causes: Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae. Other organisms: HSV, adenovirus, Trichomonas vaginalis. Ureaplasma urealyticum is considered normal urethral flora.

Doxycycline is preferred over azithromycin for NGU/M. genitalium — azithromycin fails to eradicate ~10% of susceptible infections, selecting for resistance, while doxycycline doesn’t select resistance.

Clinical features

• Discharge: gonorrhoea usually copious/purulent (more common in MSM and Indigenous populations); NGU usually less discharge
• Dysuria in a young man indicates an STI until proven otherwise
• Urinary frequency suggests bladder infection

Diagnosis

• First-pass urine (FPU): chlamydia and gonorrhoea PCR. If negative and symptoms persist, test FPU for M. genitalium, HSV and adenovirus
• Urethral swab MC&S if discharge is present
• MSM — additional tests: ano-rectal swabs (chlamydia/gonorrhoea PCR), throat swab (gonorrhoea PCR), blood tests (syphilis, HIV, hepatitis A/B); consider hepatitis C if injecting drug use history or HIV-positive

Management

Scenario	Regimen
NGU likely	Doxycycline 100mg BD for 7 days, OR azithromycin 1g stat
Gonorrhoea likely	Ceftriaxone 500mg in 2mL 1% lignocaine IMI stat, PLUS azithromycin 1g stat OR doxycycline 100mg BD for 7 days
M. genitalium	After completing doxycycline, use azithromycin or moxifloxacin — seek specialist advice for the alternative regimen

Contact tracing for gonorrhoea/chlamydia is high priority in all confirmed infections; for NGU, trace partners back a minimum of 4 weeks.