A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health, or a general practice providing an enhanced sexual health service.

• If urethritis is suspected, test for:
• Chlamydia trachomatis — send a first-void urine sample for nucleic acid amplification testing (NAAT).
• Gonorrhoea — check with the local laboratory whether a urethral swab is needed (see testing). Some laboratories use NAAT for gonococcal infection (see the CKS topic on Gonorrhoea).
• Trichomoniasis (see the CKS topic on Trichomoniasis).
• Other STIs (such as HIV, syphilis, hepatitis). It is recommended that everybody at risk of an STI should be offered an HIV test.
• If a urinary tract infection is suspected, send a mid-stream urine sample for culture and sensitivity (see the CKS topic on Urinary tract infection (lower) - men).
• If the man is at low risk for an STI, consider other causes of urethritis, and check for:
• Penile irritation or trauma (for example catheterization, sexual trauma).
• Urethral stricture and penile ulceration (see the CKS topic on Herpes simplex - genital).
• Urinary tract infection, prostatitis, epididymitis, and inguinal lymphadenopathy (see the CKS topic on Prostatitis - acute).
• Adenoviral infection.
• Skin rashes which also involve mucosal surfaces (for example Stevens–Johnson Syndrome).
• Urinary calculi.

These recommendations are based on a UK National Guideline on the Management of non-gonococcal urethritis (NGU), published by the British Association for Sexual Health and HIV [BASHH, 2007], a European guideline [Shahmanesh et al, 2009], and a Canadian guideline [Public Health Agency of Canada, 2008].

History and examination

• Most men with urethritis will have a sexually transmitted infection (STI). It is important to assess the man's risk of STI, and if this is considered to be very low, an alternative cause for urethritis may be considered (for example prostatitis, irritation).

Testing for chlamydia and gonorrhoea

• Investigations are necessary to distinguish between infectious causes of urethritis as clinical features are unreliable [RCGP and BASHH, 2006].
• If chlamydia is suspected, a first-void urine sample should be sent for a nucleic acid amplification test (NAAT), as urine is obtained easily and more comfortably than a urethral swab [BASHH, 2004].
• The use of NAAT for gonorrhoea is complicated because of variable specificity between the commercial tests available, and concerns about the positive predictive value, particularly in low prevalence populations [HPA, 2009].
• If gonorrhoea is suspected, a urethral swab should be sent for culture and sensitivity testing [BASHH and HPA, 2010].
• Urethral swabs need to be sent to the laboratory promptly, otherwise the sensitivity of the test is markedly decreased [BASHH, 2004; BASHH, 2005].

Testing for urinary tract infection

• Urinary tract infections are unusual in young men. It is thought that up to 6% of non-gonococcal urethritis is caused by a urinary tract infection [Leung et al, 2002].

A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health, or a general practice providing an enhanced sexual health service. The following recommendations apply to men who cannot access these services within a reasonable time frame, or are unwilling to attend despite receiving appropriate advice.

• Treat empirically for chlamydial infection following local antibiotic policy. If no policy exists, prescribe:
• Doxycycline 100 mg twice a day for 7 days, or
• Azithromycin 1 gram, single dose.
• If gonococcal urethritis is suspected (for example if there is a purulent discharge), or there is a local outbreak of gonorrhoea, consider treatment for gonorrhoea after discussing this with a specialist (see the CKS topic on Gonorrhoea).
• If trichomoniasis is suspected (for example if the man's partner has trichomoniasis), see the CKS topic on Trichomoniasis.
• Provide advice, offer follow up, and ensure partner notification is undertaken for all men with urethritis.
• Assess the sexual partners of men with urethritis before offering empirical treatment.
• For at-risk sexual partners, offer empirical treatment (doxycycline 100 mg twice a day for 7 days or azithromycin 1 gram as a single dose) without waiting for microbiological diagnosis.
• For partners of men with proven chlamydial or gonorrhoeal infection, see the CKS topics on Chlamydia - uncomplicated genital and Gonorrhoea.

A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health, or a general practice providing an enhanced sexual health service. The following recommendations apply to men who cannot access these services within a reasonable time frame, or are unwilling to attend.

• Try to persuade the man to attend an appropriate service. Explain this will provide:
• Care that is non-judgemental and confidential.
• Screening for STIs (such as HIV, syphilis, and hepatitis).
• Partner notification and treatment.
• Do not offer empirical treatment to the partners of men with urethritis without their prior assessment. For men with proven chlamydial or gonorrhoeal infection, see the CKS topics on Chlamydia - uncomplicated genital and Gonorrhoea for information on the management of their partners.
• Give advice (both verbal and written) about:
• The most likely cause of urethritis which is usually, but not always, due to an STI.
• Abstaining from sex (including oral sex) until 7 days after treatment if azithromycin is used or on completion of doxycycline treatment; and until symptoms have resolved and any partners have been treated.
• The importance of safer sexual practices in reducing the future risk of acquiring STIs (for example the use of condoms, minimizing the number of sexual partners).
• Not squeezing or massaging the urethra repeatedly, as this could lead to aggravation of symptoms.
• The broader health implications for the man and his partner if urethritis is left untreated (such as persistent symptoms, risk of infertility in women if the urethritis is due to an STI, spread of infection, and increased susceptibility to HIV infection).
• For more information and resources, see www.fpa.org.uk.

A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health, or a general practice providing an enhanced sexual health service.

• There are three methods of partner notification:
• Patient referral — the man is encouraged to notify his past and present partners (this is the usual method in primary care).
• Provider referral — the healthcare professional notifies the man's partners on his behalf (provider referral should be facilitated by a trained health adviser).
• Contract referral — the man is encouraged to notify his partners, with the understanding that a healthcare professional will later notify those partners who do not visit the health service within an allotted time.
• For each method, all actions and outcomes should be documented by the healthcare professional.
• For specific advice on partner notification for chlamydia and gonococcal infection, see the CKS topics on Chlamydia - uncomplicated genital and Gonorrhoea.

A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health or a general practice providing an enhanced sexual health service. The following recommendations apply to men who cannot access these services within a reasonable time frame, or are unwilling to attend despite receiving appropriate advice.

• Advise the man to re-attend in 2 weeks if his symptoms have not resolved.
• If chlamydia is isolated, the man should have a follow-up interview which may be conducted by telephone.
• Ask whether:
• Symptoms have resolved.
• Treatment has been adhered to.
• All his partners have been notified.
• The man has had sex with an untreated partner.
• Do not routinely test for microbiological cure if treatment was taken appropriately, there has been no sexual contact for 7 days, and symptoms have resolved.
• If symptoms have not resolved, see Treatment failure.
• If gonorrhoea is isolated, see the CKS topic on Gonorrhoea.
• If trichomoniasis is isolated, see the CKS topic on Trichomoniasis.

A sexually transmitted infection (STI) is generally considered to be the underlying cause of urethritis in most, (but not all), men. Ideally, urethritis should be managed in a service specializing in sexual health, or a general practice providing an enhanced sexual health service. The following recommendations apply to men who cannot access these services within a reasonable time frame, or are unwilling to attend despite receiving appropriate advice.

• If symptoms have improved but have not completely resolved and provided treatment has been adhered to and sexual intercourse with an untreated partner has not occurred, explain that symptoms may take 2–3 weeks to resolve, despite effective treatment.
• If the man has not adhered to treatment or has had sexual intercourse with an untreated partner, re-treat (with azithromycin 1 gram as a single dose, or doxycyline 100 mg twice a day for 7 days) with appropriate partner notification.
• If symptoms have not improved 1–2 weeks after treatment (or have not completely resolved 2–3 weeks after treatment) and the man has adhered to treatment and has not had sex with an untreated partner:
• Exclude other causes of urethritis (such as trauma and irritation), or other diagnoses (such as prostatitis or malignancy).
• Discuss with the local genito-urinary medicine clinic and advise the man that referral is appropriate. If the man refuses to attend a specialist centre, consider:
• Azithromycin 500 mg dose once only, then 250 mg for the next 4 days, plus metronidazole 400 mg to 500 mg twice daily for 5 days.

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).