Editing Urethritis

{{Short description|Inflammation of the urethra}}
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'''Urethritis''' is the [[inflammation]] of the [[urethra]]. The most common symptoms include [[dysuria|painful or difficult urination]] and urethral discharge.<ref name="Young_2020"/> It is a commonly treatable condition usually caused by [[infection]] with [[bacteria]].<ref>{{cite web |title=WebMD - Better information. Better health. |url=https://www.webmd.com/default.htm |access-date=2022-04-25 |website=WebMD |language=en}}</ref> This bacterial infection is often [[sexually transmitted infection|sexually transmitted]], but not in every instance; it can be [[idiopathy|idiopathic]], for example.<ref name=":0">{{cite web | publisher =Harvard Health Publishing |title=Urethritis|date=July 2019|url=https://www.health.harvard.edu/a_to_z/urethritis-a-to-z|access-date=2020-07-27 }}</ref> Some incidence of urethritis can appear asymptomatic as well.<ref>{{cite journal | vauthors = Gillespie CW, Manhart LE, Lowens MS, Golden MR | title = Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology | language = en-US | journal = Sexually Transmitted Diseases | volume = 40 | issue = 3 | pages = 271–274 | date = March 2013 | pmid = 23407472 | doi = 10.1097/OLQ.0b013e31827c9e42 | doi-access = free }}</ref>

==Symptoms and signs==
Symptoms vary based on the cause of the diseases. For infectious causes of urethritis, symptoms may start a few weeks to several months after infection. Non-infectious causes of urethritis commonly show symptoms after a few days.<ref name=":1" /> Common symptoms include painful urination, continuous urge to urinate, itching, and urethral discharge. Additional symptoms vary based on sex.<ref name="Young_2020" /> Men may experience blood in the urine or semen, itching, tenderness, or swelling of the penis, enlarged lymph nodes in the groin area, and/or pain with intercourse or ejaculation. Women may experience abdominal pain, pelvic pain, pain with intercourse, or vaginal discharge.<ref name=":2">{{cite web|title=Urethritis: MedlinePlus Medical Encyclopedia|url=https://medlineplus.gov/ency/article/000439.htm|access-date=2020-07-30|website=medlineplus.gov|language=en}}</ref> [[Non-gonococcal urethritis]] typically does not have noticeable symptoms in women, however, the infection can spread to parts of the reproductive system.<ref name=":1" />

=== Complications ===
Serious, yet rare complications associated with ''[[Neisseria gonorrhoeae]]'', may include penile edema, abscessed tissue surrounding the urethra, urethral strictures such as scarring, and penile lymphangitis.<ref name="Young_2020" /> If left untreated, the bacteria that cause [[non-gonococcal urethritis]] can lead to various complications. In males, complications can lead to [[epididymitis]], [[reactive arthritis]], [[conjunctivitis]], skin lesions, and discharge. In females, complications can lead to [[pelvic inflammatory disease]], chronic pelvic pain, [[vaginitis]], mucopurulent [[cervicitis]], and [[miscarriage]]s.<ref>{{cite web|title=Non-Gonococcal Urethritis|url=http://www.idph.state.il.us/public/hb/hbngu.htm|access-date=2020-08-02|website=www.idph.state.il.us}}</ref>

==Causes==
The disease is classified as either [[Gonorrhea|gonococcal urethritis]], caused by ''[[Neisseria gonorrhoeae]]'', or [[non-gonococcal urethritis]] (NGU), most commonly caused by ''[[Chlamydia trachomatis]],'' which is accounted for 20-50% of routinely tested cases.<ref>{{cite web |date=2017-02-07 |title=Urethritis: Symptoms, causes, and treatment |url=https://www.medicalnewstoday.com/articles/264903 |access-date=2022-04-25 |website=www.medicalnewstoday.com |language=en}}</ref><ref name = "Moi_2015">{{cite journal | vauthors = Moi H, Blee K, Horner PJ | title = Management of non-gonococcal urethritis | journal = BMC Infectious Diseases | volume = 15 | issue = 1 | pages = 294 | date = July 2015 | pmid = 26220178 | pmc = 4518518 | doi = 10.1186/s12879-015-1043-4 | doi-access = free }}</ref> NGU, sometimes called nonspecific urethritis (NSU), has both infectious and noninfectious causes.

Other causes include:<ref name="Young_2020"/><ref name="cdc">{{cite web|year=2015|title=Disease characterized by urethritis and cervicitis|url=https://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm|access-date=4 August 2020|publisher=Centers for Disease Control and Prevention}}</ref>
* ''[[Mycoplasma genitalium]]'':<ref name="CDC_2015_TG">{{cite web|url=https://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm|title=Diseases Characterized by Urethritis and Cervicitis - 2015 STD Treatment Guidelines|website=www.cdc.gov|language=en-us|access-date=2017-12-08}}</ref> second most common cause accounting for 15-20% of non-gonococcal urethritis<ref>{{cite book | vauthors = Territo H, Ashurst JV | chapter =Nongonococcal Urethritis (NGU)|date=2020|chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK535411/| title =StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=30571032|access-date=2020-07-31 }}</ref>
* ''[[Trichomonas vaginalis]]'':<ref name="CainiGandini2014">{{cite journal | vauthors = Caini S, Gandini S, Dudas M, Bremer V, Severi E, Gherasim A | title = Sexually transmitted infections and prostate cancer risk: a systematic review and meta-analysis | journal = Cancer Epidemiology | volume = 38 | issue = 4 | pages = 329–338 | date = August 2014 | pmid = 24986642 | doi = 10.1016/j.canep.2014.06.002 }}</ref> accounts for 2-13% of cases in the US; infection is mainly asymptomatic in most cases<ref name="Hakenberg_2017">{{cite journal| vauthors = Hakenberg OW, Harke N, Wagenlehner F |date=2017-04-01|title=Urethritis in Men and Women |journal=European Urology Supplements|series=Incorporating the EAU-EBU Update Series |volume=16|issue=4|pages=144–148|doi=10.1016/j.eursup.2017.01.002 }}</ref>
* [[Adenoviridae]]
* [[Uropathogenic Escherichia coli|Uropathogenic ''Escherichia coli'']] (UPEC)
* [[Herpes simplex]] virus
* ''[[Cytomegalovirus]]''
* [[Reactive arthritis]]: urethritis is part of the triad of reactive arthritis, which includes arthritis, urethritis, and conjunctivitis.<ref>{{cite web |title=What is Reactive Arthritis? |url=https://www.niams.nih.gov/health-topics/reactive-arthritis |website=niams.nih.gov |date=7 April 2017 |publisher=National Institutes of Health |access-date=5 April 2021}}</ref>
* ''[[Ureaplasma urealyticum]]''
* ''[[Methicillin-resistant Staphylococcus aureus]]''<ref>{{cite journal | vauthors = Sharma P, Singal A | title = Methicillin-resistant Staphylococcus aureus non-gonococcal urethritis | journal = Acta Dermato-Venereologica | volume = 79 | issue = 5 | pages = 415 | date = September 1999 | pmid = 10494743 | doi = 10.1080/000155599750010599 | doi-access = free }}</ref>
* ''[[Streptococcus agalactiae|Group B streptococcus]]''<ref>{{cite journal | vauthors = Chowdhury MN, Pareek SS | title = Urethritis caused by group B streptococci: a case report | journal = The British Journal of Venereal Diseases | volume = 60 | issue = 1 | pages = 56–57 | date = February 1984 | pmid = 6365237 | pmc = 1046272 | doi = 10.1136/sti.60.1.56 }}</ref>
* Irritation of the genital area:<ref name="Young_2020">{{cite book | vauthors = Young A, Wray AA |chapter = Urethritis |date=2020 | chapter-url= http://www.ncbi.nlm.nih.gov/books/NBK537282/ | title =StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing|pmid=30725967|access-date=2020-07-28}}</ref> for example catheter-induced, physical activity, tight clothing or soaps
* Fungal urethritis in immunosuppressed individual<ref name = "Hakenberg_2017" />
* Menopause<ref name="Young_2020"/>

==Diagnosis==
Urethritis is usually diagnosed through collecting history on the individual and through a physical examination. In  women, urethritis can be diagnosed with a number of tests including: urine test, blood test, vaginal culture, [[Cystoscopy|cytoscopy]], or a nucleic acid test.<ref>{{cite web|title=Urethritis in Women|url=https://www.saintlukeskc.org/health-library/urethritis-women|access-date=2020-07-30|website=Saint Luke's Health System|language=en}}</ref> Women will also have abdominal and pelvic exams to check for urethral discharge, and tenderness of the lower abdomen or urethra.<ref name=":2" />

In men, urethritis is diagnosed by at least one of the following: [[Mucopurulent discharge|mucopurulent]] or purulent urethral discharge on examination,  ≥ 2 white blood cells per oil immersion field from a [[Gram stain]] of a urethral swab, or positive [[leukocyte esterase]] and/or ≥10 white blood cells per [[high power field]] of the first-void urine. Men who meet the criteria for urethritis commonly get [[Nucleic acid testing|nucleic acid amplification testing]] for ''[[Chlamydia trachomatis]]'' and ''[[Neisseria gonorrhoeae]]'' to determine the type of urethritis.<ref name="Young_2020" /> Men will have an exam on the abdomen, bladder area, penis, and scrotum.<ref name=":2" /> Additionally, a digital [[rectal examination]] of the prostate may be used if rectal pain is reported or if the individual is of older age.<ref>{{cite journal | vauthors = Brill JR | title = Diagnosis and treatment of urethritis in AMAB individuals | journal = American Family Physician | volume = 81 | issue = 7 | pages = 873–878 | date = April 2010 | pmid = 20353145 | url = https://www.aafp.org/afp/2010/0401/p873.html }}</ref>

==Prevention==
Primary prevention can be accomplished by the reduction of modifiable risk factors that increase the likelihood of developing urethritis. These factors include, but are not limited to, sexual intercourse (particularly unprotected intercourse) and genital irritation from contact with tight clothing, physical activity, and various irritants such as soap, lotion and [[spermicides]].<ref name="Young_2020" />

Bacterial infections leading to gonococcal and non-gonococcal urethritis can be prevented by:
* [[sexual abstinence]]
* use of barrier contraception, such as [[condom]]s
* pre-exposure vaccination: [[HPV vaccine|HPV]] and [[Hepatitis B vaccine]]s
* reducing number of sexual partners<ref>{{cite web|date=2020-07-21|title=Clinical Prevention Guidance - 2015 STD Treatment Guidelines|url=https://www.cdc.gov/std/tg2015/clinical.htm|access-date=2020-07-31|website=www.cdc.gov|language=en-us}}</ref>

[[Chlorhexidine]] is an antibacterial agent that covers a wide spectrum of gram-positive and gram-negative bacteria. Rinsing with 15 ml of a 0.12% or 10 ml of 0.2% [[chlorhexidine]] solution for 30 seconds produced large and prolonged reductions in salivary bacterial counts within 7 hours of its use. One hypothesis in 2010 posed the potential use of [[chlorhexidine]] rinsing before oral sex as a prevention strategy of recurrent non-gonococcal urethritis caused by bacteria entering the urethra from oral cavity following "insertive oral intercourse", particularly in men.<ref>{{cite journal | vauthors = Kolahi J, Abrishami M, Fazilati M, Soolari A | title = Chlorhexidine rinse for prevention of urethritis in AMAB individuals linked to oral sex | journal = International Archives of Medicine | volume = 3 | issue = 1 | pages = 9 | date = June 2010 | pmid = 20540731 | pmc = 2892434 | doi = 10.1186/1755-7682-3-9 | doi-access = free }}</ref> However, actual clinical studies are yet to be carried out in order to prove this hypothesis.

==Treatment==
Antimicrobials are generally the drug of choice for gonococcal and non-gonococcal infections. The CDC in 2015 suggests using a dual therapy that consists of two antimicrobials that have different mechanisms of action would be an effective treatment strategy for urethritis and it could also potentially slow down antibiotic resistance.<ref name = "CDC_2015">{{cite web|date=2019-03-15|title=Gonococcal Infections - 2015 STD Treatment Guidelines|url=https://www.cdc.gov/std/tg2015/gonorrhea.htm|access-date=2020-07-30|website=www.cdc.gov|language=en-us}}</ref>

A variety of drugs may be prescribed based on the cause of urethritis:
* '''Gonococcal urethritis (caused by ''[[Neisseria gonorrhoeae|N. gonorrhoeae]]'')''': The CDC recommends administering an injection dose of [[ceftriaxone]] 250&nbsp;mg intramuscularly and oral dose of [[azithromycin]] 1g simultaneously.<ref name = "CDC_2015" /> [[Cefixime]] 400&nbsp;mg oral single dose can be used as an alternative if [[ceftriaxone]] is not available.
* '''Non-gonococcal urethritis (caused by ''[[Chlamydia trachomatis]]'')''': The CDC recommends administering an oral single dose of [[azithromycin]] 1g or a 7-day course of [[doxycycline]] 100&nbsp;mg orally twice daily.'<ref name = "CDC_2015_TG" />
** Alternative treatments can also be used when the above options are not available:<ref name = "CDC_2015_TG" />
*** [[Erythromycin|Erythromycin base]] 500&nbsp;mg orally four times daily for 7 days
*** [[Erythromycin|Erythromycin ethylsuccinate]] 800&nbsp;mg orally four times daily for 7 days
*** [[Levofloxacin]] 500&nbsp;mg orally once daily for 7 days
*** [[Ofloxacin]] 300&nbsp;mg orally twice daily for 7 days

Treatment for both gonococcal and non-gonococcal urethritis is suggested to be given under direct observation in a clinic or healthcare facility in order to maximize compliance and effectiveness.

For non-medication management, proper [[Perineum|perineal]] hygiene should be stressed. This includes avoiding use of vaginal deodorant sprays and proper wiping after urination and bowel movements. Sexual intercourse should be avoided at least 7 days after completion of treatment (and until symptoms resolves, if present).<ref name = "CDC_2015_TG" /> Past and current sexual partners should also be assessed and treated.<ref name=":1">{{cite web|date=2017-10-23|title=Non-gonococcal urethritis|url=https://www.nhs.uk/conditions/non-gonococcal-urethritis/|access-date=2020-08-02|website=nhs.uk|language=en}}</ref>

Individuals displaying persistence or recurrence of symptoms should be instructed for possible re-evaluation. Although there is no standard definition, persistent urethritis is defined as urethritis that has failed to display improvement within the first week of initial therapy. Additionally, recurrent urethritis is defined as urethritis reappearing within 6 weeks after a previous episode of non-gonococcal urethritis.<ref>{{cite book |last1=Grant|first1=Philip M. |last2=Hooton|first2=Thomas M. | chapter = Chapter 7. Persistent & Recurrent Urethritis|date=2007|url=http://accessmedicine.mhmedical.com/content.aspx?aid=3027260| title = Current Diagnosis & Treatment of Sexually Transmitted Diseases|place=New York, NY|publisher=The McGraw-Hill Companies|access-date=2020-07-31 |editor-last=Klausner|editor-first=Jeffrey D. |editor2-last=Hook|editor2-first=Edward W.}}</ref> If recurrent symptoms are supported by microscopic evidence of urethritis, then re-treatment is appropriate.<ref name = "Moi_2015" /> The following treatment recommendations are limited and based on clinical experience, expert opinions and guidelines for recurrent or persistent [[non-gonococcal urethritis]]:<ref name = "Moi_2015" />
* If [[doxycycline]] was prescribed as initial therapy, give [[azithromycin]] 500&nbsp;mg or 1 gram for the first day, then give [[azithromycin]] 250&nbsp;mg once daily for 4 days plus [[metronidazole]] 400 – 500&nbsp;mg twice daily for 5 days
* If [[azithromycin]] was prescribed as initial therapy, then give [[doxycycline]] 100&nbsp;mg twice daily for 7 days plus [[metronidazole]] 400 – 500&nbsp;mg twice daily for 5 – 7 days
* [[Moxifloxacin]] 400&nbsp;mg orally once daily for 7 – 14 days can be given with use of caution, if macrolide-resistant [[Mycoplasma genitalium|''M. genitalium'']] infection is demonstrated <ref name = "Moi_2015" />

Appropriate treatment for these individuals may require further referral to a [[Urology|urologist]] if symptoms persist after initial treatment.<ref name = "CDC_2015_TG" />

== Epidemiology ==
Urethritis is one of the most common [[sexually transmitted infection]]s found in men. [[Gonorrhea]] and [[chlamydia]] are the main pathogens causing urethritis.<ref name="Young_2020" /> Health organizations break down the rate of urethritis based on its etiology. The estimated global prevalence of gonorrhoea is 0.9% in women and 0.7% in men. An estimated 87 million new infections of gonorrhoea occurred in 2016. Low-income countries have the highest prevalence of gonorrhoea.<ref name=":3">{{cite journal | vauthors = Rowley J, Vander Hoorn S, Korenromp E, Low N, Unemo M, Abu-Raddad LJ, Chico RM, Smolak A, Newman L, Gottlieb S, Thwin SS, Broutet N, Taylor MM | display-authors = 6 | title = Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016 | journal = Bulletin of the World Health Organization | volume = 97 | issue = 8 | pages = 548–562P | date = August 2019 | pmid = 31384073 | pmc = 6653813 | doi = 10.2471/BLT.18.228486 }}</ref> Gonorrhea is more commonly seen in males than in females and infection rates are higher in adolescents and young adults.<ref name="Young_2020" />

The estimated global prevalence of chlamydia, which is the most common cause of non-gonococcal urethritis, is 3.8% in women and 2.7% in men. An estimated 127 million new chlamydia cases occurred in 2016. Upper-middle income countries had the highest prevalence of chlamydia.<ref name=":3" /> The rate of chlamydia is around two times higher in females than in males. Rates are also higher among adolescents and young adults.<ref name="Young_2020" />

== References ==
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{{Medical resources
|  DiseasesDB     = 27902
| ICD11           = {{ICD11|GC02}}
|  ICD10          = {{ICD10|N|34||n|30}}
|  ICD9           = {{ICD9|597}} {{ICD9|099.4}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    = 000439
|  eMedicineSubj  = med
|  eMedicineTopic = 2342
|  MeshID         = D014526
}}

{{Urinary tract disease}}
{{Authority control}}

[[Category:Inflammations]]
[[Category:Infectious diseases]]
[[Category:Urethra disorders]]