empirical treatment of undiagnosed urethritis in a male

Last edited 09/2018 and last reviewed 07/2021

Once the diagnosis of urethritis is made treatment should be started immediately (without the results of Chlamydia or Gonorrhoea tests) since it helps to improve the symptoms as well as arrest the transmission of the disease (1,2)

Ideally management should be

• effective (microbiological cure >95%)
• easy to take (not more than twice daily)
• with a low side-effect profile, and cause minimal interference with lifestyle (1)
• via a GUM clinic - however if a man is unlikely or unable to attend follow-up then empirical antibiotic treatment may be appropriate (2):
• in some cases it may be anticipated that men are unlikely to attend a follow-up appointment because either they exhibit erratic health-care seeking behaviour, or they are unable to attend (e.g. they are travelling). In these circumstances it may be appropriate to treat the urethritis empirically (1) - an empirical regime should cover both Chlamydia trachomatis (most common organism associated with urethritis) and gonococcal urethritis.

Consider local antibiotic resistance patterns and follow local guidelines if these exist - allternatively, the first-choice therapeutic option is:

• for chlamydia and non-gonococcal urethritis 
• recommended regimen
• Azithromycin 1g orally in a single dose or
• has the advantage of good compliance
• is thought to induce macrolide resistance in M. genitalium to a higher extent than the five day Azithromycin treatment
• Doxycycline 100 mg twice a day orally for 7 days
• is more than 95% effective in men who are chlamydia-positive
• as effective as azithromycin 1g in men who are U. urealyticum-positive   
• alternative regimes include
• Azithromycin 500mg stat then 250mg daily for the next 4 days  or
• Ofloxacin 200mg twice a day or 400mg once a day for 7 days (1) - this regime is appropriate because ofloxacin is effective against both Neisseria gonorrhoea and Chlamydia trachomatis
• expert view is that if purulent discharge is present, gonococcal urethritus should be suspected and treatment for both NGU and gonococcal urethritis should be commenced (2)
• if resistance to quinolone antibiotics is likely to be a problem (e.g. urethritis contracted from abroad), or if quinolones are contraindicated, consider the use of combination antibiotics to treat both Neisseria gonorrhoea and Chlamydia trachomatis:
• ceftriaxone 250 mg by intramuscular injection (single dose) or oral cefixime 400 mg stat + azithromycin 1g orally in a single dose or doxycycline 100 mg twice a day orally for 7 days
• cefotaxime 500 mg by intramuscular injection (single dose) + azithromycin 1g orally in a single dose or doxycycline 100 mg twice a day orally for 7 days

Reference:

1. Horner P et al. 2015 UK National Guideline on the management of non-gonococcal urethritis. Int J STD AIDS. 2016;27(2):85-96.
2. Royal College of General Practitioners 2005. Sexually Transmitted Infections in Primary Care
3. British Association for Sexual Health and HIV. 2007 UK National Guideline on the Management of Nongonococcal Urethritis