What is Urethritis?
Urethritis is an infection of the lower urinary tract which results in swelling of the urethra. The urethra is a tube-like structure in both men and women’s bodies that allows urine to leave the body. In men, it also acts as an exit for semen. This condition is often linked with sexually transmitted infections (STIs) and can be categorized as either gonococcal (caused by the bacteria Neisseria gonorrhoeae) or nongonococcal. The main causes of this condition are sexually transmitted infections, specifically from the bacteria Neisseria gonorrhoeae and Chlamydia trachomatis.
The most frequently observed symptom of urethritis is a discharge from the urethra. The causes of urethritis can vary based on location and sexual behaviors, making it imperative to gain a thorough understanding of a patient’s medical and sexual history. Additionally, proper testing is vital to confirm the patient’s health history and diagnose this condition accurately.
What Causes Urethritis?
The urethra (the tube that carries urine out of the body) can become inflamed due to an infection, with Sexually Transmitted Infections (STIs) being the primary cause.
There are two types of urethritis that can be transmitted sexually. The first type is nongonococcal urethritis, typically caused by bacteria such as C trachomatis or Mycoplasma genitalium. The second type, gonococcal urethritis, results from an infection with N gonorrhoeae.
C trachomatis is a common bacterium that causes nongonococcal urethritis. Transmitted through sexual activity, this bacterium causes inflammation in men’s urine tubes. Infections from C trachomatis might not show symptoms but can decrease male fertility.
The leading cause of urethritis is N gonorrhoeae, which is transmitted through sexual intercourse. It can cause infections in men within 2 to 5 days of exposure and can also bring about lower fertility. It’s common for patients to have both N gonorrhoeae and chlamydia.
Other infections that can cause urethritis include Adenovirus, Candida spp (a common fungal yeast), Corynebacterium glucuronolyticum (a bacterium that can cause inflammation in the prostate), Haemophilus influenzae (usually transmitted orally), and herpes simplex virus, which can cause a genital infection.
M genitalium is common in men with nongonococcal urethritis not due to chlamydia. As it grows slowly and can’t be stained for study, M genitalium can be difficult to detect. Treponema pallidum, a bacterium, can cause urethritis due to an endourethral syphilitic chancre. This is not very common.
Other causes of urethritis include Trichomonas vaginalis (a parasitic infection), U urealyticum and U parvum (usually present in younger men), and physical irritation or trauma in the genital area. The latter can occur due to tight clothing, certain physical activities, irritants like soaps and douches, or insertion of foreign objects.
In women, urethritis can also occur due to menopause-related changes, specifically the thinning and drying of the urethra and bladder’s tissues. A decrease in estrogen levels leads to the development of atrophic vaginitis – this condition can cause irritation and inflammation in the urethra.
Risk Factors and Frequency for Urethritis
Urethritis is a condition that affects around 4 million people in the U.S. every year. The disease can be caused by different agents, but most commonly it’s due to either N gonorrhoeae (gonococcal urethritis) with over 600,000 new cases per year, or a non-gonococcal type that accounts for about 3 million new cases annually. Worldwide, we see around 62 million new cases of gonococcal urethritis and 89 million of the non-gonococcal type each year.
In a study that examined 424 men showing symptoms of acute urethritis, 30% were found to have the N gonorrhoeae infection. Of the remaining men with non-gonococcal urethritis, almost half were traced back to the C trachomatis infection.
For the subset of men with non-chlamydial non-gonococcal urethritis, various agents were identified as the cause:
- M genitalium (22.7%)
- U urealyticum (19.5%)
- Human adenovirus (16.2%)
- H influenzae (14.3%)
- U parvum (9.1%)
- HSV-1 (7.1%) and HSV-2 (2.6%)
- M hominis (5.8%)
- N meningitidis (3.9%)
- T vaginalis (1.3%)
Urethritis tends to be diagnosed more in males, potentially because about 75% of women with the disease do not show symptoms or show symptoms of other conditions like cervicitis, cystitis, or vaginitis. The people at most risk include those in their early to mid-twenties, people who have unprotected sex, men who have sex with men, and people with multiple sexual partners.
N gonorrhoeae, one of the most common sexually transmitted diseases, is responsible for gonococcal urethritis in men and cervicitis in women. Similarly, C trachomatis, another common sexually transmitted disease, is the leading cause of non-gonococcal urethritis in men and cervicitis in women. T vaginalis, despite many cases not showing symptoms and not being reported, is also a prevalent cause of non-gonococcal urethritis, particularly in Africa. M genitalium, although not as common, is found in about 15% to 25% of male non-gonococcal urethritis cases.
Signs and Symptoms of Urethritis
Urethritis is a condition that often doesn’t show any symptoms, especially in women. But when symptoms do appear, they can vary depending on the organism causing the infection. Common symptoms of urethritis are discomfort while urinating (dysuria) or discharge from the urethra.
Symptoms can include:
- Discomfort while urinating, often worse in the morning and brought on by alcohol consumption. This is usually found in men and the pain typically occurs around the opening of the urethra or the tip of the penis.
- Testicular pain, mainly experienced by male patients.
- Worsening of symptoms during the menstrual cycle – a symptom occasionally observed in women.
- Systemic symptoms, including chills, excessive sweating, fever, malaise, and nausea. But these are generally not present.
- A discharge from the urethra, which can vary in color from brown, green, white, yellow, or even have a hint of blood. It’s important to note that the discharge doesn’t necessarily relate to sexual activity. However, if it’s yellow-green and thick, that could point to gonorrhea. Chlamydia, on the other hand, often results in a thicker discharge that’s clear or whitish.
Itching or a stinging sensation in the urethra can also occur, especially when not urinating, while urinary frequency or urgency is typically not present. Patients report these symptoms less frequently.
Different organisms cause urethritis and give rise to specific symptoms. For example,
- Adenovirus often causes severe discomfort while urinating, instead of urethral irritation, helping to distinguish it from other causes of nongonococcal urethritis. It’s primarily spread through oral sex, and patients with this infection are more likely to show upper respiratory tract symptoms during fall and winter.
- C glucuronolyticum commonly causes discomfort while urinating and produces a small to moderate clear discharge. It’s often found in patients who have been treated for chlamydia.
- Herpes simplex virus generally causes severe discomfort while urinating. On examination, a small amount of discharge might be found, often accompanied by inflammation of the head of the penis and the foreskin.
- N gonorrhoeae infections in men often result in a large amount of yellowish-green, pus-like or mucopurulent urethral discharge. However, these infections can also be asymptomatic. In women, gonorrheal urethritis is often associated with inflammation of the cervix or may show no symptoms. In instances where urinary symptoms are present, discomfort while urinating is the most common. Additionally, symptoms in women might include increased urinary frequency and urgency.
- Golden or pus-like discharge from the urethra.
- Presence of more than two white blood cells in a urethral swab test.
- A positive result for an inflammation indicator called leukocyte esterase or presence of 10 or more white blood cells in a urine sample that doesn’t have an urinary tract infection.
- Prostatitis (inflammation of the prostate)
- Epididymitis (inflammation of the tube at the back of the testicle)
- Cystitis (inflammation of the bladder)
- Proctitis (inflammation of the lining of the rectum)
- Orchitis (inflammation of one or both testicles)
- Chancroid (a bacterial sexually transmitted infection)
- Human papillomavirus (a viral infection that is passed through sexual contact)
- Urethral trauma
- Urethral strictures (a narrowing of the urethra caused by inflammation or the presence of scar tissue)
- Chemical irritation
- Cervicitis (inflammation of the cervix)
- Cystitis
- Pelvic inflammatory disease (an infection of the female reproductive organs)
- Proctitis
- Urethral pain syndrome (persistent pain in the region of the urethra)
- Vaginitis (inflammation of the vagina)
- Pelvic inflammatory disease
- Infertility
- Ectopic pregnancy (a pregnancy outside the womb)
- Fitz-Hugh-Curtis syndrome (a complication of pelvic inflammatory disease)
- Proctitis
- Lymphogranuloma venereum (a sexually transmitted disease caused by specific types of chlamydia)
- Fistulas (abnormal connections between organs)
- Strictures
- Reactive arthritis
- Eye problems like conjunctivitis and iritis
- Lung conditions, like bronchopulmonary dysplasia and pneumonia
- Being a sex worker
- Having sex with many partners or frequently
- Being homeless (in such cases, one-time treatments are preferred)
- Using illegal drugs
- Having sex with someone known to have an infection or past STIs
- Not using protection (condoms) during sex
- Men who have sex with men are at the highest risk
- Initiating sexual activity at a young age
During a physical examination for suspected urethritis, the doctor might perform several checks on male patients, focusing on the abdomen, pelvis, and genitals. These might include checking for evidence of discharge on underwear or any urethral secretions. Additionally, the doctor will examine the penis and external genitalia for any skin lesions that are indicative of a sexually transmitted infection. For uncircumcised individuals, the foreskin will be retracted for a thorough inspection. A check before voiding can be helpful since urination could wash away evidence of discharge.
Females might also undergo physical examination, during which the doctor may visually inspect the skin and external genitals for STI-related lesions, examine the urethra for signs of inflammation or discharge, and perform a comprehensive pelvic examination.
Testing for Urethritis
Urethritis, an inflammation of the urethra that often results in pain during urination, is generally suspected in sexually active individuals with symptoms such as an itchy urethra, discharge, or painful urination. Diagnosing this condition typically involves a combination of reviewing your medical history, a physical examination, and specific laboratory tests for a more accurate diagnosis.
The doctor may determine if you have urethritis based on whether you show any of these signs:
A simple urine test alone cannot diagnose urethritis, but can help rule out a urinary tract infection. Importantly, over 30% of patients with non-gonococcal (not caused by a bacteria called gonorrhea) urethritis may not have white blood cells in their urine.
If bacteria called gram-negative intracellular diplococci are observed under a microscope or a positive methylene blue/gentian violet (MB/GV) smear test result (a staining test), it usually indicates gonococcal urethritis (caused by gonorrhea). If these bacteria aren’t found, it is classified as nongonococcal urethritis. More specific testing such as nucleic acid amplification test (NAAT) might be used if available.
Patients diagnosed with urethritis should undergo testing for C trachomatis and N gonorrhoeae – two types of bacteria that can cause urethritis. NAAT is commonly performed using a urine sample or a urethral swab. In addition, NAAT for T vaginalis should also be considered, as well as testing for M genitalium if available.
Additional laboratory tests might include things like urethral cultures, gram staining (a bacterial coloring method), testing for fungi, swabs for bacterial infections or sexually transmitted infections, testing for pregnancy or conducting a urinalysis to check for urinary tract infections or cystitis (bladder inflammation).
The preferred method of diagnosing gonococcal urethritis is an NAAT test, which can be performed on urine, cervical, or urethral swabs. In Chlamydial urethritis, urine test often shows pyuria (an excess of white blood cells into the urine) without any organisms seen on a gram stain or culture. In these cases, NAAT is the preferred test.
Identifying M genitalium, a common cause of non-gonococcal urethritis, can be challenging as NAAT, the specific test for it, is not yet widely available in most clinics, and was approved by the US Food and Drug Administration (FDA) only in 2019.
In addition, Haemophilus, a type of bacteria, is becoming more common in causing nongonococcal urethritis, particularly among men and individuals who engage in oral sexual contact.
Reactive Arthritis, a condition characterized by conjunctivitis (inflammation of the eye), urethritis, and arthritis, normally develops a few days to several weeks after a gastrointestinal or genitourinary infection. While the condition is rare, it most commonly occurs in younger men during their 20’s and 30’s. The diagnosis is established based on clinical findings and elevated levels of C-reactive protein, an inflammation marker in the blood.
Treatment for reactive arthritis generally focuses on management of symptoms, often involving anti-inflammatory drugs, extended courses of antibiotics if there is evidence of ongoing infection, and potentially, steroid injections. In resistant cases, other medications like methotrexate and azathioprine may be used.
Treatment Options for Urethritis
Urethritis, which is an inflammation of the urethra, can actually improve over time without any treatment. Despite this, healthcare providers will usually recommend treatment to hasten your recovery and prevent potential complications.
Antibiotic treatment is often recommended. This is especially the case for patients who have a noticeable presence of bacteria in their urine or cultures, those who’ve had sexual contact with someone who’s infected, or in cases where patients show symptoms of urethritis but tests come back negative.
In cases where the exact cause of the urethritis isn’t clear, medications that target a broad range of bacteria, including both gonococcal (related to the sexually transmitted infection gonorrhea) and nongonococcal organisms, are typically suggested. The specific types of antibiotics used can depend on a number of factors, including local resistance to certain antimicrobial agents and the patient’s specific health factors, such as allergies.
In cases where the cause of urethritis is gonorrhea, a particular dose of a specific antibiotic, ceftriaxone, is recommended. If another sexually transmitted infection called Chlamydia hasn’t been definitively ruled out, additional treatment with doxycycline may be given. In cases where the cause of urethritis is not related to gonorrhea (nongonococcal), initial treatment typically involves doxycycline. If the particular cause is identified later, the treatment might be adjusted.
If the first round of treatment isn’t successful, meaning that the infection continues or comes back, providers might prescribe a different antibiotic. In cases where antibiotic sensitivity can’t be determined, another course of doxycycline followed by a different antibiotic called moxifloxacin may be tried.
For pregnant women, the recommended treatments are the same as for non-pregnant women if they can tolerate them. However, if they can’t, other options include amoxicillin and erythromycin. Certain antibiotics — fluoroquinolones, doxycycline, and certain types of erythromycin — are not recommended for use during pregnancy or breastfeeding.
Treatment differs in response to the specific cause of urethritis. For example, if irritation from clothing is the cause, changing to a milder soap or wearing looser clothing may be advised. If the cause is adenovirus, a common cause of respiratory issues, supportive care such as hydration and rest are usually recommended, as this condition usually improves on its own.
What else can Urethritis be?
Genitourinary infections and sexually transmitted infections might impact any part of the genitourinary system, which includes the urethra. These infections can happen all at once or separately. Conditions like urinary tract infections, reactive arthritis, and interstitial cystitis can also cause symptoms that are similar to urethritis, which is inflammation of the urethra.
In some instances, dysuria – a condition that makes urination painful, may not have a clear cause. This is known as idiopathic. For men, other potential conditions that could cause similar symptoms include:
For women, similar symptoms could be due to various conditions, such as:
What to expect with Urethritis
When diagnosed and treated appropriately, patients usually have a great recovery rate. Addressing treatment for sexual partners becomes particularly important for specific sexually transmitted infections. This is because many sexually active people often get reinfected by their partners who remain untreated.
If the inflammation of the urethra, often referred to as urethritis, persists even after initial treatment, it may be important to explore the presence of multiple infections or less common causes is necessary. Rapid recognition and treatment is critical when dealing with several of these potential infections, as they may lead to severe complications if not managed timely.
It’s worth noting that nongonococcal urethritis, a type of infection not caused by the commonly known gonorrhea bacteria, is generally a self-limited disorder. This means it usually gets better over time without progressing to serious complications in most cases.
Possible Complications When Diagnosed with Urethritis
Urethritis, inflammation of the urethra, can lead to several complications. Some of the most common causes of urethritis can lead to male infertility, unusual swelling of the penis, abscesses around the urethra, strictures (narrow areas) after inflammation, and inflammation of the penis’s lymph vessels.
Some rare complications include inflammation of the epididymis (a tube at the back of the testicles that carries sperm), proctitis (inflammation of the rectum’s lining), and reactive arthritis (joint pain and swelling triggered by an infection in another part of your body).
Women experience complications from non-gonococcal urethritis more often than men, up to 40% of the time. This often leads to pelvic inflammatory disease, an infection of a woman’s reproductive organs.
Urethral infections caused by the bacteria Chlamydia trachomatis can lead to various complications for both men and women.
Complications for Women:
If a woman is pregnant, urethritis can potentially lead to ectopic pregnancies, infertility, and pelvic inflammatory disease. Newborns born to mothers with Chlamydia trachomatis can develop several problems as well:
Newborn Complications:
The regular use of antibiotic eye ointment for newborns largeley prevents these types of infections.
With chlamydia urethritis, patients also risk developing lymphogranuloma venereum that leads to inflammation of the lymph vessels, genital sores, blockage of the lymphatic systems, and fistulas.
A rare syndrome known as reactive arthritis triad, or Reiter’s syndrome, is typically triggered by a C. trachomatis infection. It includes arthritis, conjunctivitis and urethritis. Besides these, it can also lead to sudden inflammation of the epididymis, testicles, and prostate.
Preventing Urethritis
If a sexually transmitted infection (STI – a contagious disease passed from one person to another through sexual contact) is identified, it is crucial to teach the patient about safe sexual habits. This means talking about the need to inform their partners and encouraging them to also get tested. It’s also crucial to highlight that the infection can come back even if their partners don’t show any symptoms, as they might still be infected without knowing it.
All of anyone’s sexual contacts from the past 60 days who has been diagnosed with urethritis (an inflammation of the urethra, the tube that carries urine from the body) caused by specific bacteria like C. trachomatis, N. gonorrhoeae, or T. vaginalis should be tested for these infections and usually treated, unless they’ve been confirmed to not have the disease. Some specialists also recommend getting tested for M. genitalium. It’s important to teach patients to abstain from sex until both they and their partners are completely treated and symptom-free.
The following are known factors that increase the risk for urethritis:
