Urethritis, or inflammation of the urethra, is a multifactorial condition which is sexually acquired in the majority of (but not all) cases.
As per the table below, the commonest organisms implicated are C. trachomatis and M. genitalium. These are most likely to be detected in younger patients, those with urethral discharge and/or dysuria. However, in 30-80% of NGU cases, neither organism is detected.
Pathogen negative NGU is more likely with increasing age and the absence of symptoms. Trichomonas vaginalis detection is dependent on prevalence in the community. Other more uncommon causes include urinary tract infection, adenovirus, herpes simplex viruses.
It is recommended that asymptomatic men are not tested for NGU.
Only symptomatic patients and/or those with a visible discharge or presence of balano-posthitis should be assessed for the presence of urethritis (IV, C).
If microscopy is not available:
Patients should be referred to a service providing microscopy, but urethritis may be diagnosed by:
Investigation of symptomatic patients with a negative urethral smear
The Treatment Guidelines were updated in December 2018. Please find below the recommendations of the May 2018 update (or click here). The original recommendations of the 2015 Guideline are also reproduced below.
Update to the 2015 BASHH UK National Guideline on the management of non-gonococcal urethritis
Up to 25% of uncomplicated cases of non-gonococcal urethritis (NGU) are caused by infection with Mycoplasma genitalium (Mgen). This organism is likely to be implicated in an even higher proportion of cases of recurrent or persistent NGU. However, many men with Mgen infection will not develop NGU.
Optimal management of NGU requires testing for Mgen in addition to C. trachomatis, and providing appropriate antimicrobial therapy in the presence of a positive test (and carrying out a test-of-cure if necessary). The prevalence of pre-treatment macrolide resistance in Mgen in the United Kingdom is almost certainly >40%, which is probably due to the widespread use of azithromycin 1g to treat STIs and the limited availability of diagnostic tests for Mgen.
Pending widespread availability of Mgen detection assays, the Clinical Effectiveness Group has considered the best available evidence and updated the NGU guideline so that treatment regimens are consistent with the revised chlamydia and the new Mgen guideline.
TREATMENT OF FIRST EPISODE NGU
Doxycycline 100mg twice daily for 7 days
Azithromycin 1g stat then 500mg once daily for the next 2 days (three days total treatment)*
NB Patients should be advised to abstain from sexual intercourse until 14 days after the start of treatment, and until symptoms have resolved. This is likely to reduce the risk of selecting/inducing macrolide resistance if exposed to Mgen or Neisseria gonorrhoeae which would make these infections more difficult to treat.*
Ofloxacin 200mg twice daily, or 400mg once daily, for 7 days
*While there are no data on the utility of this regimen in treating NGU caused by Mgen without pre-existing macrolide resistance mutations, it will be at least as effective as 500mgs then 250mgs once daily for the next four days for which there is moderate but conflicting data, and probably more so. Azithromycin has a long half life (68 hours) with sub-MIC levels persisting for 2-4 weeks and probably longer intracellularly; the higher the total dose the longer the persistence of sub-MIC levels. BASHH took the pragmatic approach of increasing the total dose from 1.5 g but not to 2.5 g total used by Read et al which would be associated with a longer duration of intracellular sub-MIC levels (see BASHH Mgen guideline) and recommending no sexual intercourse with a new partner for 2 weeks after commencing therapy.
TREATMENT OF RECURRENT OR PERSISTENT NGU
If treated with doxycycline regimen first line:
Azithromycin 1g stat then 500 mg once daily for the next 2 days, plus metronidazole 400mg twice daily for five days
Azithromycin should be started within 2 weeks of finishing doxycycline. This is not necessary if the person has tested Mgen-negative.
NB patients should be advised to abstain from sexual intercourse until 14 days after the start of treatment and until symptoms have resolved.* (see above)
If treated with azithromycin regimen first line:
Moxifloxacin 400mg once daily for 10 days, plus metronidazole 400mg twice daily for five days
Doxycycline 100mg twice daily for 7 days, plus metronidazole 400mg twice daily for five days**
**In the event of non-availability of Mgen detection assays, it may be reasonable to try this regimen before using moxifloxacin.2
In the absence of MG testing, it is reasonable to provide epidemiological treatment to the partners of men with NGU using the same antimicrobial regimen that resulted in cure in the index case.
These recommendations are subject to change in light of new available evidence. We recommend that clinicians appraise and share data regarding NGU causes, treatment and outcomes to develop the evidence base in the UK.
2015 Guidelines FOR INFORMATION ONLY:
Recommended regimens (A)
Alternative regimens (A)
Indicated only if Chlamydia confirmed or persistent symptoms. Those remaining symptomatic should return to clinic and retreated appropriately and assessed for risk of re-infection (IV,C).
Persistent and recurrent NGU
Continuing symptoms (limited evidence)
Consider quinolone antimicrobial resistance as a cause of treatment failure in men who remain M. genitalium-positive after treatment with moxifloxacin. At present no registered antibiotics are available for treatment. Pristinamycin is registered in France and may be effective in most cases.