Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 5) 1. Treat urethritis promptly, while test results are pending. Table 124-4 summarizes the steps in management of sexually active men with urethral discharge and/or dysuria. Table 124-4 Management of Urethral Discharge in Men Usual causes Chlamydia trachomatis Neisseria gonorrhoeae Usual initial evaluation Demonstration of urethral dis charge or pyuria Exclusion of local or systemic Mycoplasma genitalium Ureaplasma urealyticum Trichomonas vaginalis Herpes simplex virus complications Urethral Gram's stain to confirm urethritis, detect gram-negative diplococci Test for N. gonorrhoeae, C. trachomatis Initial Treatment for Patient and Partners Treat gonorrhea (unless excluded): plus Treat chlamydial infection: Ceftriaxone, 125 mg IM; or Azithromycin, 1 g PO; or Cefpodoxime, 400 mg PO; or Doxycycline, 100 mg bid for 7 days Cefixime, 400 mg PO a Management of Recurrence Confirm objective evidence of urethritis. If patient was reexposed to untreated or new partner, repeat treatment of patient and partner. If patient was not reexposed, consider infection with T. vaginalis b or doxycycline-resistant M. genitalium or Ureaplasma, and consider treatment with metronidazole, azithromycin, or both. a Updates on the availability of cefixime can be obtained from the Centers for Disease Control and Prevention or state health departments. b In men, the diagnosis of T. vaginalis infection requires culture (or nucleic acid amplification test, where available) of early-morning first- voided urine sediment or of a urethral swab specimen obtained before voiding. Urethritis in Men: Treatment In practice, if Gram's stain does not reveal gonococci, urethritis is treated with a regimen effective for NGU, such as azithromycin (1.0 g PO in a single dose) or doxycycline (100 mg PO bid for 7 days). Both are effective, although azithromycin may give better results in M. genitalium infection. If gonococci are demonstrated by Gram's stain or if no diagnostic tests are performed to exclude gonorrhea definitively, treatment should include a single-dose regimen for gonorrhea (Chap. 137) plus azithromycin or doxycycline treatment for C. trachomatis, which frequently occurs as a urethral co-infection in men with gonococcal urethritis. Sexual partners should be tested for gonorrhea and chlamydial infection and should receive the same regimen given to the male index case. Patients with confirmed persistence or recurrence of urethritis after treatment should be re-treated with the initial regimen if they did not comply with the original treatment or were reexposed to an untreated partner. Otherwise, an intraurethral swab specimen and a first-voided urine sample should be tested for T. vaginalis (currently best done by culture, although NAATs appear to be more sensitive and are likely to become commercially available in the future). If compliance with initial treatment is confirmed and reexposure excluded, the recommended treatment is with metronidazole or tinidazole (2 g PO in a single dose) plus azithromycin (1 g PO in a single dose); the azithromycin component is especially important if this drug has not been given during initial therapy. . Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 5) 1. Treat urethritis promptly, while test results are pending. Table 124- 4 summarizes. are pending. Table 124- 4 summarizes the steps in management of sexually active men with urethral discharge and/ or dysuria. Table 124- 4 Management of Urethral Discharge in Men Usual causes. repeat treatment of patient and partner. If patient was not reexposed, consider infection with T. vaginalis b or doxycycline-resistant M. genitalium or Ureaplasma, and consider treatment with