Urethritis: Overview for Dental Professionals

Urethritis is an inflammation of the urethra, typically accompanied by symptoms such as painful or difficult urination and urethral discharge. It is a treatable condition, often caused by bacterial infections, which are frequently sexually transmitted. However, urethritis can also be idiopathic or asymptomatic.

Symptoms and Signs

Symptoms of urethritis vary based on the underlying cause and can appear within a few days to several months post-infection. Common symptoms include painful urination, the continuous urge to urinate, itching, and urethral discharge. Additional symptoms differ between men and women:

• Men: Blood in urine or semen, itching, tenderness or swelling of the penis, enlarged lymph nodes in the groin, pain during intercourse or ejaculation.
• Women: Abdominal or pelvic pain, pain during intercourse, and vaginal discharge. Non-gonococcal urethritis often lacks noticeable symptoms in women but can spread to the reproductive system.

Complications

Complications, though rare, can be severe. For Neisseria gonorrhoeae, these include penile oedema, abscesses, urethral strictures, and penile lymphangitis. Untreated non-gonococcal urethritis can lead to:

• Men: Epididymitis, reactive arthritis, conjunctivitis, skin lesions, discharge.
• Women: Pelvic inflammatory disease, chronic pelvic pain, vaginitis, mucopurulent cervicitis, miscarriages.

Causes

Urethritis is classified as gonococcal or non-gonococcal. Gonococcal urethritis is caused by Neisseria gonorrhoeae, whereas non-gonococcal urethritis (NGU) is most commonly due to Chlamydia trachomatis. Other causes include:

• Mycoplasma genitalium
• Trichomonas vaginalis
• Adenoviridae
• Uropathogenic Escherichia coli (UPEC)
• Herpes simplex virus
• Cytomegalovirus
• Reactive arthritis
• Ureaplasma urealyticum
• Methicillin-resistant Staphylococcus aureus
• Group B streptococcus
• Irritation from catheterisation, physical activity, tight clothing, or soaps
• Fungal infections in immunosuppressed individuals
• Menopause

Diagnosis

Diagnosis involves a detailed patient history and physical examination. For women, methods include urine tests, blood tests, vaginal cultures, cytoscopy, or nucleic acid tests, along with abdominal and pelvic exams. For men, diagnosis relies on criteria such as mucopurulent discharge, white blood cells in a Gram stain, or leukocyte esterase in urine. Further nucleic acid amplification tests may be conducted to identify specific pathogens.

Prevention

Primary prevention focuses on reducing modifiable risk factors such as unprotected sexual intercourse and genital irritation. Preventative measures against bacterial infections include:

• Sexual abstinence
• Use of barrier contraception like condoms
• Pre-exposure vaccination (e.g., HPV, Hepatitis B)
• Limiting the number of sexual partners

Chlorhexidine rinsing before oral sex has been hypothesised as a preventative measure for recurrent non-gonococcal urethritis, but clinical studies are needed to confirm its efficacy.

Treatment

Antimicrobials are the primary treatment for urethritis. The CDC recommends dual therapy with two antimicrobials that have different mechanisms of action to treat gonococcal and non-gonococcal infections effectively and reduce antibiotic resistance.

Treatment Protocols

• Gonococcal urethritis (N. gonorrhoeae): Ceftriaxone 250 mg intramuscularly and azithromycin 1g orally. Cefixime 400 mg orally is an alternative.
• Non-gonococcal urethritis (Chlamydia trachomatis): Azithromycin 1g orally or doxycycline 100 mg orally twice daily for 7 days. Alternatives include erythromycin, levofloxacin, or ofloxacin.

Non-medication management includes proper perineal hygiene, avoiding vaginal deodorants, and abstaining from sexual intercourse for at least 7 days post-treatment. Past and current sexual partners should also be evaluated and treated.

For persistent or recurrent urethritis, re-treatment may involve alternative antibiotics and a referral to a urologist if symptoms persist.

Epidemiology

Urethritis is a common sexually transmitted infection, particularly among men. Gonorrhoea and chlamydia are the primary pathogens. The global prevalence of gonorrhoea is 0.9% in women and 0.7% in men, with an estimated 87 million new infections in 2016. Chlamydia has a global prevalence of 3.8% in women and 2.7% in men, with 127 million new cases in 2016. Infection rates are higher in low-income countries and among adolescents and young adults.

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Self-assessment MCQs (single best answer)

What is the primary cause of gonococcal urethritis?

Which symptom is commonly associated with urethritis in both men and women?

What complication is associated with untreated non-gonococcal urethritis in men?

What is the first-line treatment for non-gonococcal urethritis caused by Chlamydia trachomatis?

Which method is used to diagnose urethritis in men?

What preventative measure can help reduce the risk of urethritis?

Which pathogen is NOT typically associated with urethritis?

Which of the following is a symptom of urethritis in women?

What is the recommended dual therapy for treating gonococcal urethritis?

What is a rare but severe complication of Neisseria gonorrhoeae infection in men?