II. Causes
- Infection
- Urinary Tract Infection
- Urethritis (Gonorrhea and Chlamydia)
- Prostatitis (Enterobacteriaceae)
- Epididymitis and Orchitis (Enterobacteriaceae, Mumps)
- Meatitis and Urethritis (HSV II infection)
- Balanitis
- Obstructive Uropathy
- Benign Prostatic Hypertrophy
- May also predispose to Urinary Tract Infection
- Urethral stricture
- Benign Prostatic Hypertrophy
- Miscellaneous Causes
- Prostadynia
- Non-gender specific causes
- See Dysuria
III. Symptoms and Signs
- See related conditions
- Urinary Tract Infection
- Hematuria, frequency, nitrite positive
- Pyelonephritis
- Fever, flank pain, White Blood Cell casts
- Prostatitis
- Prostatic tenderness
- Epididymitis or Orchitis (consider Testicular Torsion)
- Unilateral tenderness, swelling at epididymis
- Urinary Tract Infection
- Penile discharge suggests Urethritis (STD)
-
Penile Lesion present
- Vesicles: Genital Herpes
- Ulcer: See Genital Ulcer
- Chancroid (painful ulcer, associated inguinal adenopathy)
- Genital Herpes (painful ulcer)
- Syphilis (painless ulcer)
- Glans irritation: Balanitis
- Scrotal Pain
- Perineal or Rectal Pain or Prostate pain on palpation
- Prostatitis
- Prostadynia
IV. Evaluation
- Labs in all patients
- Urinalysis with microscopy
- Urine Culture
- Sexually active patient
- If obtaining STD testing via PCR probe from urine
- Void into non-sterile cup (without cleaning tip of penis)
- Stop, clean tip of penis with wipe
- Void into sterile cup for Urinalysis and Urine Culture
- Routine PCR swab for Gonorrhea and Chlamydia (from "dirty" urine or Urethra)
- Urethral discharge
- Urethral smear for diplococci (Gonococcus)
- Urethral culture
- Offer other STD Testing (blood testing)
- Rapid plasmin reagin (RPR) or VDRL
- Human Immunodeficiency Test (HIV)
- Hepatitis B Testing (HBsAg)
- If obtaining STD testing via PCR probe from urine
- Symptoms of Prostatitis
- Consider Expressed Prostatic Secretion exam (rarely done)
- Do not perform Prostatic Massage in Acute Prostatitis
V. Management: General when STD unlikely
- Treat underlying condition
- See Urinary Tract Infection
- See Prostatitis
- See Epididymitis
- Consider topical or systemic genitourinary irritants (see Dysuria)
- Consider imaging and/or Consultation
- Persistent Hematuria without pyuria (e.g. CT Urogram, Cystoscopy)
- Urine Culture confirmed Urinary Tract Infection (e.g. post-void residual, renal/Bladder Ultrasound)
VI. Management: Empiric for sexually active patients with risk of STD
-
Chlamydia coverage
- Azithromycin 1 gram orally for 1 dose or
- Doxycycline 100 mg orally twice daily for 7 days
-
Gonorrhea coverage (consider waiting for results if low Prevalence in community)
- Ceftriaxone 250 mg IM
- Cefixime (Suprax) is not recommended due to increasing resistance
- Previously dosed at 400 mg orally for 1 dose
- Recurrent symptoms with same partner (cover Trichomonas and Ureaplasma)
- Drug 1: Metronidazole 500 mg orally daily for 5 days AND
- Drug 2: Choose one of the following
- Azithromycin 500 mg orally once daily for 5 days or
- Doxycycline 100 mg once daily for 7 days
