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Urethritis (Urethra Infection) in Men and Women

What is urethritis?

Urethritis is the medical term for inflammation of the urethra, the muscular tube that carries urine from the bladder to pass it out into the external environment. Due to the frequency of urethritis occurring as a result of an infection, it is often accepted that the term urethritis is due to infection-induced inflammation of the urethra. However there are non-infectious causes of urethritis, although this is rare in comparison to infectious factors. Most non-infectious causes are related to mechanical or chemical trauma.

Most cases of urethritis are ascending urinary tract infections. The microorganisms gain entry into the urethra through the external meatus and spread up the urinary tract. In men, urethritis may progress to prostatitis (prostate infection) while in women, it may lead to cystitis (bladder infection). Urethritis may also lead to infection of the other components of the genitourinary system, including the ureters, kidney, epididymis or testes (men), as well as surrounding sites, like the rectum, vagina, ovaries or fallopian tubes (women), or even distant sites like the lungs.

The infection causes irritation of the urethral lining with the typical features of inflammation, like swelling and pain, arising. This may manifest as difficulty urinating, often with pain. Prolonged inflammation and inadequate treatment can lead to a urethral stricture (narrow urethra) due to scarring of the urethral lining.

Causes of Urethritis

Infection

Broadly urethritis, specifically infectious urethritis, can be divided into gonococcal or nongonococcal urethritis. While sexually transmitted infections are the more common cause, many cases of infectious urethritis also arises from other pathogens. Enteric organisms are the bacteria that live in the bowels and are one of the possible causes of urethritis that is not transmitted by sexual intercourse.

Gonococcal urethritis is more often due to infection with the pathogen Neiserria gonorrhoeae (gonorrhea – STD). The various organisms involved in nongonococcal urethritis includes :

  • Chlamydia trachomatis (chlamydia)
  • Ureaplasma urealyticum
  • Trichomonas vaginalis (trichomoniasis)
  • Mycoplasma hominis, Mycoplasma genitalium
  • Escherichia coli (E.coli)
  • Treponema pallidum (syphilis – rare)

Viral causes include herpes simples virus and cytomegalovirus (CMV) although the involvement of these pathogens in urethritis are rare.

Injury

Non-infectious causes of urethritis are due to trauma, either mechanical or chemical. Mechanical causes include catheterization, insertion of foreign bodies into the urethra, passage of kidney stones and vigorous sexual activity. These cases of urethritis are acute and often passes spontaneously unless the causative factor is not removed or a secondary infection of the urethra arises.

Chemical trauma may be due to condoms, lubricants, spermicides, soap, and fragrant topical applications. Usually there is a hypersensitivity to these chemicals and as with mechanical causes, it will often pass spontaneously once the causative factor is removed.

Signs and Symptoms of Urethritis

Urethritis can be asymptomatic (no symptoms). One or more of these symptoms in both men and women, usually between 4 days to 2 weeks after infection.

  • Pain and/or burning sensation when urinating (dysuria)
  • Frequent urination
  • Urgency to urinate
  • Pain during intercourse

It is important to note that frequent urination and urgency are uncommon in urethritis on its own. These symptoms usually arise once the prostate or bladder is involved, leading to prostatitis and cystitis respectively.

Urethritis Symptoms in Men

  • Blood in urine (hematuria) or semen (hematospermia)
  • Discharge from urethra (tip of penis)
  • Pain upon ejaculation
  • Itching and/or tenderness of the penis
  • Swelling of the tip of the penis

Urethritis Symptoms in Women

  • Vaginal discharge
  • Pelvic and/or lower abdominal pain
  • Fever and chills
  • Itching of the vulva/vagina
  • Swelling of the vulva

* Symptoms often aggravate during menstruation.

Other Signs and Symptoms in Men and Women

  • Bleeding between periods
  • Heavy periods
  • Scrotum swelling and pain (often on one side only)
  • Swollen groin lymph nodes
  • Anal itching
  • Rectal discharge (in the event of anal intercourse)
  • Bowel tenesmus – urging
  • Red bumps, blisters and ulcers (herpes simplex) on or around genitalia

Diagnosis of Urethritis

Urine (first void) and discharge (endourethral in men, endocervical in women) will be collected for cytology and culture.

  • Discharge
  • Gross appearance : mucopurulent
  • Microscopic examination : 5 leukocytes or more per oil immersion field
  • Urine
  • Gross appearance : sometimes cloudy, dark, orange to brown or red with a strong odor
  • Microscopic examination : 10 white blood cells or more per high-power field

Cytology and culture will provide a conclusive diagnosis for gonococcal or nongonococcal urethritis, however, other tests may also be considered. These include :

  • Complete blood count (CBC)
  • Nucleic acid amplification tests (NAATs) for chlamydia/gonorrhea (more sensitive than culture)

A pregnancy test and pelvic ultrasound may be necessary in women.

Complications of Urethritis

Gonococcal and nongonococcal urethritis are infection induced inflammation of the urethra. Most cases are a result of sexually transmitted infections, often associated with gonorrhea and chlamydia.

Treatment for both gonococcal and nongonococcal urethritis should begin immediately once the condition is diagnosed. Failure to commence with prompt treatment can progress to complications in most infectious cases of urethritis. Patients also need to be informed about preventative measures to avoid a recurrence of urethritis.

Some of the complications seen with untreated gonococcal or nongonococcal urethritis include :

  • Infection of other genitourinary organs – cystitis (bladder), prostatitis (prostate), epididymis (epididymis), orchitis (testes), cervicitis (cervix), pelvic inflammatory disease (PID – uterus, fallopian tubes, ovaries).
  • Urethral strictures
  • Abscess around the urethra
  • Urethral fistula
  • Urethral diverticula

These complications can progress to result in infertility, chronic pelvic pain or increase the risk of an ectopic pregnancy. Severe cases that lead to septicemia may be life threatening.

Treatment for Urethritis

Antibiotics are the main course of treatment for both gonococcal and nongonococcal urethritis. Acyclovir is used for for herpes simplex (viral) infection.

Types of Antibiotics for Urethritis

There are various types of antibiotics used in the treatment of urethritis, some of which may be effective for gonococcal and nongonococcal urethritis.

  • Oral
  • azithromycin (both)
  • ofloxacin (gonococcal)
  • ciprofloxacin (gonococcal)
  • cefixime (gonococcal)
  • doxycycline (nongonococcal)
  • Injectable
  • ceftriaxone (gonococcal)
  • spectinomycin (gonococcal)

Other antibiotics like trimethoprim-sulfamethoxazole may be prescribed if both gonorrhea and chlamydia has been excluded. Metronidazole and erythromycin may be prescribed for recurrent cases of nongonococcal urethritis.

Prevention of Urethritis

Education is the cornerstone for preventing urethritis, especially in high risk patients. Measures include :

  • Using adequate barrier protection like condoms.
  • Limiting the number of sexual contacts.
  • Encouraging partners to undergo treatment even if asymptomatic.
  • Practice good personal hygiene.
  • Discontinuing any sexual intercourse once symptoms like burning urination or discharge becomes apparent.

Patients also need to understand that their behavior may also put them at risk of contracting other sexually transmitted infections like syphilis, hepatitis B and HIV.