Urethritis in Adolescents

00:01 In this lecture, we will discuss urethritis and pelvic inflammatory disease or PID.

00:07 Let’s first talk about urethritis. In sexually active males, this is usually a sexually transmitted disease.

00:14 Classically, it’s either Chlamydia trachomatis which is a symptom in maybe half of males versus Neisseria gonorrhoeae which is symptomatic in almost all males. Basically, this is an infection of the epithelial cells lining the urethra. This leads to inflammation and transmission is typically through unprotected sexual contact. In the majority of cases in chlamydia, there are no symptoms unlike the symptoms in most cases of gonorrhea. So, what are those symptoms? Well, there’s dysuria, urinary frequency, urethral discharge, pruritus at the meatus, and hematuria which is rare.

00:52 In males with urethritis, the physical exam is often unremarkable. You can check for urethral discharge when milking the penis. Additionally, you should examine for inguinal lymphadenopathy which may be present. During the exam, you should inspect the skin very carefully for other signs of sexually transmitted diseases such as herpes. Diagnostic testing of urethritis may include a urinalysis.

01:20 Such testing will reveal a positive leukocyte esterase on the urine dip. Microscopy of a urethral swab may show more than 10 white blood cells per high power field. And you maybe will see gram negative diplococci on the gram stain of urethral discharge. However, the testing of choice is the nucleic acid amplification test or the NAAT. That looks specifically for genetic material of chlamydia or gonorrhea infections. So, how do we treat these infections? Generally antibiotics, antibiotics prevent complications and prevent transmission and generally can cure the disease. The antibiotic of choice for Neisseria gonorrhoeae is ceftriaxone. Oral third generation cephalosporins are now no longer effective against gonorrhea. There are some emerging species of gonorrhea that are resistant to everything which is why condom use is the most important thing. The treatment of chlamydia is azithromycin. If that doesn’t work, you can also use doxycycline. For Trichomonas vaginalis, we would give a course of Flagyl. Also for Mycoplasma genitalium, we might do azithromycin or moxifloxacin if that’s resistant. What’s key in all these infections though is treatment of the infected partner. In most places in the United States, you can legally write a prescription for the partner without having seen them in your office so that you can spread the infection less often.

02:58 Single dose therapy is usually preferred when possible such as with Neisseria gonorrhoeae, one shot of intramuscular ceftriaxone. That improves compliance. We should notify sexual partners to seek treatment if we are unable to treat them. Patients should be told to abstain from having sex for 7-14 days after treatment to prevent spread of the organism. We should encourage the use of barrier contraception in these patients. So, let’s talk now about females. Females can get urethritis, vaginitis or cervicitis. These can all be due to sexually transmitted diseases. Examples of the infections are Chlamydia trachomatis and Neisseria gonorrhoeae just like in men, Trichomonas vaginalis which is symptomatic in women, whereas in men it’s usually asymptomatic and Mycoplasma genitalium and other species. For all these infections, it is possible for a woman to remain asymptomatic for a period of time and then present with a more severe infection. Infection of epithelial cells usually happens along the urethra which can lead inflammation and dysuria.

04:13 Transmission of these organisms is usually through unprotected sexual contact.