Infectious Disease Compendium



Pain and burning with urination.

Per CDC: Mucopurulent or purulent discharge. Gram stain of urethral secretions demonstrating >5 WBCs per oil immersion field. Gonococcal infection is established by documenting the presence of WBC's containing intracellular Gram-negative diplococci. Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating >10 WBC's per high power field.

Epidemiologic Risks

Often a sexually transmitted disease.


C. trachomatis, N. gonorrhea, HSV, ureaplasmas, T. vaginalis, Mycoplasm genitalium. In one study C. trachomatis, M. genitalium, M. hominis, U. parvum biovar 1, and U. urealytiucm biovar 2 were detected in 21.8%, 4.1%, 2.1%, and8.5%, respectively.

And N. meningititis can cause urethritis (PubMed).

In patients with chlamydia-negative GU, coinfection with M. genitalium was associated with a 14.54-fold greater risk of PGU and coinfection with U. urealyticum biovar 2 was associated with a 3.64-fold greater risk of PGU (PubMed).

Empiric Therapy

per the CDC.

Recommended Regimens

C. trachomatis urethritis: preferred: azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice a day for 7 days.

Alternative Regimens erythromycin base 500 mg orally four times a day for 7 days OR erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR levofloxacin 500 mg orally once daily for 7 days OR ofloxacin 300 mg orally twice a day for 7 days.

Chlamydia clearance rate is 94.8% with doxycycline arm and 77.4% for the azithromycin arm, while M. genitalium clearance rate is 30.8% with doxycycline and 66.7% for the azithromycin arm (PubMed).

Recommended Treatment for Recurrent / Persistent Urethritis

Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose PLUS azithromycin 1 g orally in a single dose (if not used for initial episode)

Mycoplasm genitalium may be better treated with azithromycin.

Persistence after therapy for NGU depends on what you used for treatment (PubMed):

"persistent Chlamydia in 12% and MG in 44% of participants at 4 weeks after therapy, which were associated with signs and symptoms of NGU. Persistent Chlamydia was detected in 23% of participants after azithromycin treatment vs 5% after doxycycline treatment (P = .011); persistent Mycoplasm was detected in 68% of participants after doxycycline vs 33% after azithromycin (P = .001). All but 1 Trichomonas infection cleared after tinidazole."

Expect a 25% failure rate no matter what you give (PubMed).

Mycoplasm genitalium is a common cause and resistance to availabe antibiotics is increasing (PubMed).



ICD9 Codes (Soon to be supplanted by ICD10)

Urethritis: 597.80; gonococcal (acute) 098.0; chronic or duration of 2 months or over 098.2; nongonococcal (sexually transmitted) 099.40; Chlamydia trachomatis 099.41; Reiter's 099.3; specified organism NEC 099.49; nonspecific (sexually transmitted) 099.40; not sexually transmitted 597.80; Reiter's 099.3; Trichomonas (vaginalis) 131.02; tuberculous (see also Tuberculosis) 016.3; venereal NEC 099.40.