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Urethritis in men

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Urethritis in men article more useful, or one of our other health articles.

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What is urethritis?

Urethritis describes inflammation of the urethra and can be the result of infectious or non-infectious causes but is primarily a sexually transmitted disease.

Urethritis in men can be diagnosed if any of the following are present:

  • Mucopurulent or purulent discharge from urethral meatus.

  • Gram stain of urethral smear showing >5 polymorphonuclear (PMN) cells per high power field. This is the preferred test as it is rapid, highly sensitive and specific for both nonspecific urethritis and gonorrhoea in asymptomatic men.1

  • First pass urine (FPU) positive for >10 PMN per high power field. Some advocate the use of positive leukocytes in FPU - but the sensitivity is low.

Causes of male urethritis2

  • Gonococcal urethritis - caused by Neisseria gonorrhoeae.

  • Non-gonococcal urethritis (NGU) - caused by a number of organisms other than N. gonorrhoeae as well as non-infective agents.

  • Persistent or recurrent urethritis - 10-20% of cases treated for NGU.

Causes of non-gonococcal urethritis13

  • The most common organisms implicated are Chlamydia trachomatis and Mycoplasma genitalium. Chlamydia and M. genitalium are more likely to be detected in younger patients with NGU (although this association is not as strong for M. genitalium) and those presenting with a urethral discharge and/or dysuria.

  • The two organisms only infrequently co-exist in the same individual with NGU but dual infections have been identified in up to 10% of men in some studies.

  • Men with a urethral discharge have a higher bacterial load than those without.

  • In 30-80% of the cases with NGU neither C. trachomatis nor M. genitalium is detected. Pathogen-negative NGU is more likely with increasing age and the absence of discharge or urethritis symptoms.

  • Trichomonas vaginalis is more common in non-white ethnic groups and appears to be uncommon in the UK. T. vaginalis isolation is greater in men aged over 30 years and may not always be associated with symptoms.

  • Ureaplasmas have been inconsistently associated with NGU. Earlier studies did not differentiate between two biovars: Ureaplasma urealyticum (biovar 2) and Ureaplasma parvum (biovar 1). There is increasing evidence that it is only U. urealyticum (biovar 2) which is pathogenic in some men at least but not U. parvum. U. urealyticum may account for 5-10% of cases of acute NGU.

  • A urinary tract infection may account for 6.4% of cases, although this is based upon the results of a single study.

  • Adenoviruses may account for perhaps 2-4% of symptomatic patients and are often associated with a conjunctivitis.

  • Herpes simplex viruses types 1 and 2 are an uncommon cause of NGU (2-3%).

  • Epstein Barr virus, Neisseria meningitidis, Haemophilus spp., Candida spp., urethral stricture and foreign bodies have all been reported in a few cases and probably account for a small proportion of NGU.

  • The cause of organism-negative NGU (also called idiopathic urethritis) is unclear and has recently been reviewed. Some of these cases are almost certainly non-infective but the tools to be able to differentiate between infective and non-infective cases are not currently available.

Causes of persistent or recurrent urethritis2

Probable multifactorial causes but usually no identifiable cause. However, M. genitalium (20-40% of cases), U. urealyticum (tetracycline-resistant) and T. vaginalis have been implicated.

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How common is urethritis in men? (Epidemiology)4

  • Data from France suggests that the incidence rates for male urethritis diagnosed in primary care remained at around 200 cases per 100,000 men (aged over 15 years) per year between 2007 and 2017.

  • Non-gonococcal urethritis (NGU) is thought to be more common than gonococcal urethritis. Out of 392,453 people diagnosed with a sexually transmitted infection in England in 2022, 50.8% were diagnosed with chlamydia, and 21.1% were diagnosed with gonorrhoea.

  • Persistent urethritis occurs in 15–25% of people treated for NGU and recurrent urethritis occurs in 10-20% of people.

Symptoms of urethritis in men (presentation)

  • May be asymptomatic (90-95% of men with gonorrhoea, 50% of patients with chlamydial infections).5

  • Urethral discharge - mucopurulent or purulent; with or without blood; more noticeable after holding urine overnight and more common in gonococcal infection.6 May have gone unnoticed by the patient and be seen only on examination

  • Urethral pruritus, dysuria or penile discomfort with a risk of sexually transmitted infection (sexually active and has not used a condom or has a recent new sexual partner).

  • Other symptoms associated with the cause - for example, skin lesions in herpes simplex virus.

  • Systemic symptoms if there is involvement of other organs - for example, conjunctivitis or arthritis.

Examination may be normal or may reveal haematuria and/or lymphadenopathy.

There is currently a national screening programme for chlamydia.7

Identify high-risk patients 8

  • Sexually active.

  • Male.

  • Unprotected vaginal sex.

  • Males who have sex with males.

  • More common in cities.

  • Age <35 years.

  • Recent partner change.

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Diagnosing urethritis in men (investigations)9

Ideally this should be performed in a GUM clinic or primary care clinic which provides sexual health facilities as an enhanced service.

The diagnosis of urethritis is confirmed by demonstrating an excess of polymorphonuclear leukocytes in the anterior urethra. This is usually assessed using a urethral smear but a first-pass urine test specimen can also be used.1 Check with the local laboratory to see which investigations they provide.

  • FPU for NAAT is the best option to exclude chlamydia in men, as it is as accurate as, but less invasive than, a urethral swab. The sample should be collected at least one hour and preferably two hours after previous voiding.10

  • The local laboratory may be able to do NAAT on an FPU for gonorrhoea as well but, if not, a urethral smear will be required. Specimens should be sent to the laboratory as soon as possible. If there is likely to be considerable delay getting swabs from primary care to the laboratory, it may be preferable to ask the patient to attend a GUM clinic.

  • NAATs are the test of choice for testing asymptomatic individuals for urethral infection with N. gonorrhoeae.5

  • Pharyngeal and rectal swabs may also be needed.

  • A stick test of urine should be performed to exclude urinary tract infection.

General advice

  • Diagnose urethritis if there is urethral discharge present or if symptoms are in a high-risk patient.

  • Explain the likely causes.

  • Stress the importance of partner notification.

  • Explain the complications of inadequate treatment.

  • Emphasise the importance of abstaining from sexual activity (including oral sex) for fourteen days after treatment (if azithromycin is used) or on completion (if doxycycline used) and until symptoms have resolved and partners have also completed treatment.

Differential diagnosis4

Associated diseases11

Patients with urethritis should be counselled and offered testing for HIV, hepatitis B and syphilis.

Approach to a patient with potential urethritis symptoms

  • Full history including full sexual history.

  • Examination: local - looking for discharge, skin lesions and systemic examination.

  • Refer to a GUM clinic, unless providing sexual healthcare as an enhanced service in primary care.

  • Arrange an FPU and, if necessary, a urethral smear.

  • If a smear is positive - manage as below.

  • If a smear is negative and there is no definitive evidence of urethritis then defer treatment and re-examine one week later. Also, check MSU sample for urinary tract infection.

  • Screen for other sexually transmitted infections.

  • There is some debate as to whether there should be blind treatment of those with urethritis symptoms and at high risk of infection or those unlikely to return for follow-up.

Management of urethritis in men212

Urethritis should be treated as early as possible and should be treated empirically as a presumed chlamydial infection, as this is the most common cause.

Refer all men with suspected urethritis to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service for confirmation of the diagnosis and treatment. Treatment is the same in HIV-negative and HIV-positive patients. Always use local guidelines where possible.

If the man is unable or unwilling to attend such a clinic then manage in primary care as follows:

  • Offer empirical treatment for non-gonococcal urethritis with doxycycline 100 mg twice daily for 7 days. Where doxycycline is contraindicated or not tolerated, possible alternatives are:

    • Azithromycin 1g, single dose for 1 day, then 500 mg once daily for 2 days (people taking azithromycin should be advised to abstain from sexual intercourse until 14 days after the start of treatment and until symptoms have resolved).

    • Ofloxacin 200 mg twice daily or 400 mg once daily for 7 days. Systemic fluoroquinolones must only be prescribed when other commonly recommended antibiotics are inappropriate.

  • If gonococcal urethritis is suspected (for example, local outbreak of gonorrhoea), consider treating for gonorrhoea.

  • If trichomoniasis is suspected (for example, partner has trichomoniasis), consider treating for trichomoniasis.

Patient education

  • There is the need to explain the diagnosis, treatment, adverse effects and importance of completing the course of antibiotics.

  • Discuss methods of prevention, including advice on safe sex - for example, condom use.

  • Stress to the patient that sexual intercourse should be avoided until the infection has cleared up and that partners should be checked out.

  • Contact tracing - it is important to maintain patient confidentiality. It is necessary to trace sexual contacts from the previous four weeks and up to six months if asymptomatic (for NGU). National guidelines on the management of gonorrhoea recommend that male patients with symptomatic urethral infection should notify all sexual partners within the preceding two weeks or their last partner if longer than two weeks.5

Further management

  • Patients should be followed up for review at approximately two weeks. Take this opportunity to reinforce health education. Assess compliance and efficacy.

  • Test of cure should be performed for gonorrhoea in all cases - for example, NAAT after seven days or repeat culture 72 hours after treatment has finished.5 It is not routine for chlamydia unless the patient is pregnant, noncompliance is suspected or re-exposure may have occurred.13

Urethritis treatment failure

If urethritis symptoms persist or recur after treatment is completed, the man should be strongly advised to attend a GUM clinic or other local specialist sexual health service. If this is declined or not possible:

  • Check compliance with the initial drug treatment regime.

  • Exclude the possibility of re-infection. Check that current partner(s) have been treated appropriately and simultaneously.

  • Reconsider the diagnosis.

  • If treated with doxycycline regimen first line: azithromycin 1 g single dose for one day, then 500 mg once daily for the next 2 days, plus metronidazole 400 mg twice daily for 5 days. Azithromycin should be started within 2 weeks of finishing doxycycline. Advise to abstain from sexual intercourse until 14 days after the start of treatment and until symptoms have resolved.

  • If treated with azithromycin regimen first line: moxifloxacin 400 mg once daily for 10 days, plus metronidazole 400 mg twice daily for 5 days. Alternatively, doxycycline 100 mg twice daily for 7 days, plus metronidazole 400 mg twice daily for 5 days.

  • If symptoms persist despite a second course of antibiotics then seek specialist advice.

Complications of urethritis in men2

Prognosis4

  • Symptoms of urethritis generally resolve within 3 days of antibiotic treatment. However, further sexual contact should be avoided until treatment has been completed.

  • Recurrence is usually due to reinfection or treatment failure. Treatment failure may be caused by non-compliance with incomplete antibiotic treatment, co-infection with other organisms, or drug resistance.

  • Around 10–20% of people with non-gonococcal (NGU) have recurrent or persistent symptoms following initial treatment.

Further reading and references

  1. BASHH 2015 UK National Guideline on the management of non-gonococcal urethritis; International Journal of STD & AIDS. Last updated 2018,
  2. Young A, Toncar A, Leslie SW, et al; Urethritis. StatPearls, January 2025.
  3. Leslie SW, Ashurst JV; Nongonococcal Urethritis. StatPearls, January 2025.
  4. CKS Urethritis - male; NICE CKS, May 2024 (UK access only)
  5. 2018 UK national guideline for the management of infection with Neisseria gonorrhoeae; British Association for Sexual Health and HIV (BASHH) - 2018: reviewed 2020
  6. Richens J; Main presentations of sexually transmitted infections in men. BMJ. 2004 May 22;328(7450):1251-3.
  7. National Chlamydia Screening Programme; Public Health England
  8. Iser P, Read TH, Tabrizi S, et al; Symptoms of non-gonococcal urethritis in heterosexual men: a case control study. Sex Transm Infect. 2005 Apr;81(2):163-5.
  9. BASHH; Summary Guidance on Testing for Sexually Transmitted Infections, May 2023
  10. Summary Guidance on Testing for Sexually Transmitted Infections; British Association for Sexual Health and HIV. 2023.
  11. Brill JR; Diagnosis and treatment of urethritis in men. Am Fam Physician. 2010 Apr 1;81(7):873-8.
  12. EAU: Urological infections 2024
  13. Nwokolo NC, Dragovic B, Patel S, et al; 2015 UK national guideline for the management of infection with Chlamydia trachomatis.

Article history

The information on this page is written and peer reviewed by qualified clinicians.

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