It is very unusual for a woman to complain specifically of urethral discharge and if a woman reports dysuria it is usually due to a urinary tract infection. Only rarely does chlamydia cause dysuria in women. However, urethritis due to an STI should always be suspected in a man who complains of these symptoms.
• Ask about the onset of symptoms and any associated problems, e.g. ulceration on the
outside of the penis might indicate that there could also be ulcers in the urethra.
• Have any of his sexual partners recently been diagnosed with anything? Scrotal contents pain might be due to epididymo-orchitis; if this is confirmed on examination it would necessitate different treatment from an uncomplicated urethritis.
• Ask about other urinary symptoms such as frequency, urgency or haematuria, which could indicate that this is a urinary tract infection (urinary tract infection) after all.
• Has he had any STls before? If a partner was not treated last time, he could have the same one back again.
• A sexual history is essential, although do not rule out an STI just because his history is low risk. Remember that most STIs can be acquired through oral sex too.
• Ask about drug treatment. Has he taken any antibiotics for the problem, either prescribed or bought over the counter, as is possible in South East Asia and other regions. Note any drug allergies.
• Initial examination is best performed with the patient standing, since this enables easy examination of the scrotal contents. Some clinicians feel uncomfortable having a semi-naked man standing in front of them and prefer the patient to sit or lie on a couch.
• Check for inguinal lymphadenopathy. If found, this could be a clue toward a diagnosis of herpes, even if no ulceration is seen on further examination.
• Lymphadenopathy is very unusual in chlamydial or gonorrhoeal urethritis. If found, this should raise suspicions of lymphogranuloma venereum
• Examine the scrotal contents. This is a good opportunity to discuss the importance of testicular self-examination. Check for swelling and/or tenderness of the epididymi and the testes themselves. Interpreted in conjunction with the sexual history, such signs could indicate the need to treat for epididymitis.
• Look for ulceration or blistering of the genital skin. Even in a first episode of genital herpes, such signs could be very mild. If herpes is healing you might just see a small area of scabbed skin.
• If the man is uncircumcized, ask him to pull back his foreskin or do it yourself. A penile discharge might actually be caused by a problem under the foreskin such as a malignancy. Other causes of a subpreputial discharge include anaerobic balanitis and certain dermatoses such as erosive lichen planus.
• Next look at the urethral meatus. There might be an obvious urethral discharge but if not, milk the urethra to try and elicit one. This is best done by holding the penis in one hand and placing the index finger of the other hand over the urethra on the underside of the penis just in front of the scrotum. If you then move your finger forward on the urethra, this can squeeze discharge forward to appear at the meatus.
• If you see an obvious yellow/greenish discharge, it is almost certainly gonorrhoea (and maybe chlamydia too). If you see a clear discharge it is probably not gonorrhoea but could be chlamydia or another cause of urethritis.
The main conditions one needs to consider in a man presenting with symptoms of urethritis are chlamydia and gonorrhoea. A large number of other conditions can also cause urethritis (non-specific urethritis), although tests for most of them are not widely available.
Which tests you do depends on the setting you are working in and the facilities you have available. Although all sexual health clinics will test for chlamydia and gonorrhoea, the specimens and tests used vary round the world. The most likely specimens and tests would be:
• one urethral swab, which is used for:
– preparing a slide for Gram-stained microscopy
– inoculating an agar plate for gonorrhoea culture
– a nucleic acid amplification test (e.g. polymerase chain reaction (PCR) or strand displacement amplification (SDA)).
• or one urethral swab and a 20-ml first-void urine sample, which are used for:
– preparing a slide for Gram-stained microscopy (swab)
– gonorrhoea culture (direct plating as above or sent to lab in charcoal transport medium) (swab)
– chlamydia nucleic acid amplification test (NAAT) as above or enzyme immunoassay (EIA) (urine).
or two urethral swabs, which are used for:
– preparing a slide for Gram-stained microscopy (first swab)
– gonorrhoea culture (direct plating as above or sent to lab) (first swab)
– chlamydia NAAT or El A (second swab).
Over the next few years, NAAT tests for gonorrhoea will become more widely available in the UK — this will enable testing for chlamydia and gonorrhoea from a single specimen of first-void urine.
If you are working in primary care the tests you use will vary depending on what tests the lab offers.
The flow chart gives an outline of what should be done for a man presenting to primary care complaining of discharge or dysuria.
If the chlamydia and gonorrhoea tests are negative and the urethral smear microscopy comes back normal, despite the man holding his urine for a prolonged period, then he probably does not have urethritis. Unfortunately, the causes of a sensation of urethral irritation in the absence of inflammation are poorly understood. A variety of conditions/activities are anecdotally thought to be associated with the symptom including:
- neuropathic pain
- chronic pelvic pain
- repeated squeezing of the urethra
- over-enthusiastic masturbation or sexual activity
- concentrated urine caused by dehydration
- alcohol — perhaps more likely the concentrated urine of the following morning
- allergies, e.g. to shower gels used as an aid to masturbation.
The man should be reassured that he does not have a sexually transmitted infection and given appropriate advice depending on the suspected cause.