Urethritis- It May Be More Than a Simple Urinary Tract Infection (UTI)

What is urethritis?

When the opening of the urinary system— the urethra, becomes inflamed, it is medically known as urethritis or an infection of the lower urinary tract [1]. This medical condition can be due to an infection, or other non-infectious related causes such as excessive physical pressure, exposure to irritants, and catheter insertion.

Hence, it is worth paying attention to your symptoms and addressing the underlying condition rather than fobbing the symptoms off as a general discomfort or aches and pains.

What are the signs and symptoms of urethritis?

While some patients may have no symptoms, some patients exhibit the following:

• Urethral discharge
• Painful urination
• Itching, stinging
• Painful testicles
• Worsening symptoms during menstrual cycle

If you develop any unusual symptoms to suggest urethritis, speak to your doctor for further screening.

What are the possible causes of urethritis?

Common infectious causes of urethritis include [1]:

• Sexually transmitted infections (STIs): such as Chlamydia Trachomatis, Neisseria Gonorrhoeae, Mycoplasma Genitalium, Trichomonas Vaginalis, and Ureaplasma Urealyticum. Gonococcal infection (due to Neisseria Gonorrhoeae) can be associated with a co-infection of Chlamydia in up to 40% of infectious urethritis cases [2].
  
  While this may be lesser known, Mycoplasma Genitalium bacteria is on the rise as the common cause of infectious urethritis and accounts for up to 25% of cases [3]. Other less common infectious pathogens include Haemophilus Species (transmitted through oral sex), Herpes, Syphilis, Mycobacterial infection, Streptococcus, Cytomegalovirus, Adenovirus, and others.

• Traumatic procedures: such as catheterisation or instrumentation of a foreign body.
  
• Anatomical abnormalities: such as urethral strictures, abscess, foreign bodies, and injury to the genitourinary system are also possible causes of urethritis.

Unfortunately, up to 35% of urethritis has no reason found [4].

Your physician will obtain a medical history and assess your symptoms to discuss with you further on the possible causes and triggers of your urethritis symptoms.

How common is infectious urethritis?

Infectious urethritis related to STIs is on a resurging trend over the years. Interestingly, in 2021, the CDC STD epidemiology report showed a significant rise in syphilis, gonorrhea, and chlamydia cases [5]. The reduction of chlamydial infection reports may be secondary to limited access to medical services during the COVID-19 pandemic and due to asymptomatic/minimal symptoms presentation.

Urethritis can occur in any person who is sexually active, though it is most common in the younger cohort between the ages of 20-24 [4].

What are the red flags of urethritis and when should I see my doctor for urethritis?

Although some patients may have no symptoms in urethritis, others may experience symptoms such as painful urination, increased urinary frequency, lower pelvic pain, lymph node swelling, or abnormal vaginal discharge/smell (in females). Please seek medical attention for further evaluation if you are experiencing any of these symptoms.

What should I expect when I see my doctor for urethritis?

Your doctor will take a medical history including your social/sexual history and examine you physically. Physical examination includes examination of the genital region for abnormal skin changes, discharge, and swelling (this includes your lymph nodes). 

Most patients with urethritis may not have any signs of infection. Depending on your individual risk factors and presentation, your doctor may offer you urine tests or swab tests to screen further for possible infectious causes of urethritis.

What are the tests available for screening of urethritis?

• Gram stain: useful to screen for diplococci intracellular or without diplococci. This will determine the treatment option for urethritis. With the advancement of tests such as Nucleic Acid Amplification Tests (NAATs) or Polymerase chain reaction (PCR) tests, gram stain may not be required.
• Culture of urethral discharge: useful to screen for Chlamydia Trachomatis and Neisseria Gonorrhoeae. Culture results can facilitate physicians on antibiotic choices to reduce treatment failure rate.
• Urinalysis: used as an adjuvant to exclude other causes such as urinary tract infections, cystitis, or kidney infections.
• NAATs/PCR test: preferred test for screening of Chlamydia Trachomatis and Neisseria Gonorrhoeae due to its convenience, high sensitivity, and high specificity. In males, a first-pass urine sample is required, in women, a vaginal swab/first-pass urine sample is required.
• Blood tests/rapid tests: may be advised for further screening of STIs such as HIV/syphilis.
• Potassium hydroxide (KOH) test: useful to screen for fungal causes.

As every patient may have a different cause of urethritis, it is worth discussing your symptoms and letting your doctor examine you further to determine the next course of testing for further evaluation of your condition.

What are the treatment options for urethritis?

Treatment of urethritis is dependent on the underlying cause. Commonly, if urethritis is associated with an underlying infection, your doctor may offer you antibiotics for further treatment of the condition. If there are concerns of an STI, your doctor may advise your sexual partners to be treated as well to avoid recurrence or reinfection.

Will I have recurring urethritis?

Thankfully, most patients recover well following antibiotics treatment for urethritis. While some may take time to recover, most patients’ symptoms resolve spontaneously over time after treatment.

Approximately 10-20% of patients may have persistent symptoms or recurring infection after treatment.

It is important for patients to be followed-up if their symptoms are non-resolving or persistent. Adherence to antibiotic treatment therapy is also important and a reassessment of reinfection by an untreated partner or new partners are important to anaylse treatment options.

In recurring urethritis patients, after ruling out infectious causes/treatment failure, one should consider non-infectious causes including trauma or anatomical abnormalities that have been discussed previously. You will have to work with your doctor for further evaluation of your symptoms.

What should I do after treatment of urethritis to avoid recurrence?

To avoid recurrence of urethritis, you should:

• Avoid sexual activities 1 week after beginning antibiotics treatment, and ensure all sexual partners are treated before resuming sexual activities.
• Reduce the number of sexual partners and always engage in safe sex with barrier contraception to reduce chances of infection.
• Hold off on urethral irritants such as frequent masturbation/intercourse, body soap/wash/lotion/lubricants.
• Seek medical attention if urethritis symptoms persist or worsen.
• Avoid chem-sex, avoid being sexually active at a young age.
• Avoid intercourse with someone who is known to have infections.

References

1. Young, A., Toncar, A., & Wray., A. A. (2022). Urethritis. Treasure Island (FL): StatPearls Publishing.
2. Herchline, T. E. (n.d.). Urethritis. Infectious Disease and Antimicrobial Agents.
3. Joseph U. Igietseme, Y. O. (2015). Molecular Medical Microbiology (Second Edition). Academic Press.
4. Whitaker, D. L. (2022, October 3). Urethritis. Retrieved from Medscape: https://emedicine.medscape.com/article/438091-overview
5.  CDC . (2023). U.S. STI Epidemic Showed No Signs of Slowing in 2021 – Cases Continued to Escalate. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/nchhstp/newsroom/2023/STD-Surveillance-Report-2021-media-statement.html