Ep 125: A 19-Year-Old Man with Dysuria
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Hi, everyone. Welcome back to Harrison's Pod Class. We're your co-hosts. I'm Dr. Kathy Handy. And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. Welcome to Episode 125, A 19-Year-Old's Man with Dysuria.

Kathy, today's patient is a 19-year-old male college student who comes to the clinic reporting three to four days of painful urination. He thought he was dehydrated, but despite vigorous fluid intake, his symptoms have not abated. He's sexually active with a number of women and rarely uses barrier contraceptives. He denies any fever, chills, arthritis, or skin rash. There's no significant past medical history, and he takes no medications.

On examination, his only notable finding is that you're able to express purulent material from his urethra. Okay, so we have a young man with symptomatic urethritis. What's the question? Well, it's a two-part question. The first part is, all of the following are likely causes of his symptoms except option A is chlamydia trachomatis, option B is Gardnerella vaginalis, option C is herpes simplex virus,

Option D is Neisseria gonorrhea. And option E is Trichomonas vaginalis.

All right. Common causes of urethral discomfort and discharge in men include chlamydia trachomatis, naseria gonorrhea, mycoplasma genitalium, which you didn't mention, urea plasma, uroliticum, trichomonas vaginalis, HSV, and then rarely adenovirus. Until recently, chlamydia trachomatis caused 30 to 40% approximately of cases of non-gonococcal urethritis.

particularly in heterosexual men. However, the proportion of cases due to this organism has probably declined in some populations served by effective chlamydial control programs, and older men with urethritis appear less likely to have chlamydial infection.

HSV and T vaginalis each cause a small proportion of non-gonococcal urethritis cases in the United States. Recently, multiple studies have consistently implicated M genitalium as a probable cause of many chlamydia negative cases. We used to talk more about urea plasmas, but fewer studies than in the past have implicated them as a pathogen. So the only organism that we mentioned that is not a common cause of male urethritis is Gardnerella, right? Right.

Yes, so answer B, Gardonella vaginalis is the usual cause of bacterial vaginosis in women. It's not a pathogen in men. Okay, well let's talk more about our patient. You mentioned distinguishing between gonococcal and non-gonococcal urethritis. How do we make that distinction?

First thing you can do is a gram stain of the discharge. When there's urethritis, you should see at least two neutrophils per high-power field. In gonococcal infection, you'll see gram-negative intracellular diplococci. If you can't express a discharge, you can obtain an anterior urethral specimen by passing a small urethral genital swab two to three centimeters into the urethra.

Patients with symptoms who lack objective evidence of urethritis generally do not benefit from repeated courses of antibiotics. And in those cases, other etiologies of symptoms such as trauma or reactive urethritis or prostate disease should be considered. Okay, we're going to get to treatment in a minute, but any additional workup on our patient?

Yes. While the Gram stain is 98% sensitive for gonococcal infection, many clinics are not set up to effectively do the test. It is best to simultaneously assess for infection with gonorrhea and C. trachomatis by nucleic acid amplification testing, or NAAT or NAT, of first-catch urine. The urine specimen tested should consist of the first 10 to 15 milliliters of the stream, and if possible, patients should not have waited for the prior two hours.

This is highly sensitive and specific for the diagnosis of gonococcal or chlamydia urethritis in men. Okay, back to our patient. This patient's Gram-SYNC does show greater than five polys per high power field and no intracellular diplococci. Okay, so our patient has non-gonococcal urethritis. Exactly. And the question asks, which of the following is the appropriate treatment for him at this time?

And the options are A, ceftriaxone, B, doxycycline, C, fluconazole, D, metronidazole, or E, nitrofurantoin. The treatment of choice for non-gonococcal urethritis is doxycycline. So the answer is B. And this will effectively treat the organisms, including chlamydia, but not gonococcus that we mentioned earlier.

Azithromycin is also an option, but recent studies have demonstrated doxycycline is superior, likely due to resistance of organisms such as mycoplasma. If you're not sure that you fully ruled out gonococcus, enceptriaxone can also be considered.

Just for completeness, what about the other antibiotics? Fluconazole is used for fungal infections, notably Canada. Metronidazole is effective treatment for trichomonas. And nitrofurantoin is often used in urinary tract infection, but has no activity against the common causes of urethritis. He should also contact his recent partners, right? Yes, they should be tested, particularly for chlamydial infection, which may be subclinical in women, but can cause complications if it's not diagnosed and treated.

Okay, so the teaching points in this case is that urethritis in men can be distinguished between gonococcal and non-gonococcal urethritis. There are a number of organisms that can cause non-gonococcal urethritis, and the treatment for non-gonococcal urethritis is doxycycline. You can check out this question and other questions like it in Harrison's review questions and learn more about this topic in the Harrison's chapter on urinary tract infections.

Visit the show notes for links to helpful resources, including related chapters and review questions from Harrisons. And thank you so much for listening. If you enjoyed this episode, please leave us a review so we can reach more listeners just like you.