Sexual and Reproductive Health

at a Glance

Catriona Melville

Case Studies

Case 8: Urethral discharge

A 19-year-old man attends your busy drop-in clinic complaining of a 3-day history of urethral discharge. He also complains of pain on passing urine. He has had sexual contact with six casual female partners in the last 3 months. His last sexual contact was a week ago. He says that he thinks it was only vaginal sex he had with these partners but is not sure as he had been drinking alcohol. He also can’t remember using a condom on any occasion.

On examination he has a clear urethral discharge.

  • 1. What are the possible causes of his symptoms?

    Correct answer: This man has symptoms and signs consistent with urethritis. This can be caused by a variety of conditions (see chlamydia, gonorrhoea and NGU chapter). The commonest causes are infection with chlamydia or gonorrhoea.

  • 2. What investigations should you perform?

    Correct answer: This depends on the clinical setting. If on-site microscopy is available a Gram stained urethral smear should be examined by high power microscopy (×1,000). Alternatively an air dried slide can be transported to the laboratory for Gram stain and microscopy if this is not available on-site.

    A chlamydia and gonorrhoea NAAT test should be requested on a first void urine specimen.

    A full STI screen should be offered, with explanation of the window periods.

  • 3. Microscopy of the Gram stained urethral smear shows >=5 PMNLs per microscopic field. No intracellular or extracellular Gram-negative diplococcic are seen. What is your diagnosis and immediate management?

    Correct answer: The diagnosis is non-gonococcal urethritis (NGU). The most likely cause is C. trachomatis. First-line treatment is Azithromycin 1g in a single oral dose. Treatment should not be delayed until the NAAT results are available.

  • 4. What further management or follow-up is required?

    Correct answer: Complete abstinence from sexual intercourse should be advised. Partner notification is required with a ‘look back’ period of 4 weeks. Sexual partners should be offered screening and epidemiological treatment. Follow-up (either in person or via telephone) is recommended 2 weeks after treatment to ensure adherence to treatment, abstinence from sex, and resolution of symptoms. Further STI testing may be indicated out with the window period, e.g. for HIV and syphilis. A test of cure is not usually indicated. Follow-up is often undertaken by a sexual health advisor.

    This consultation gives an opportunity for brief intervention for alcohol misuse which may lead to behavioural change. A discussion about risk reduction and safer sex could also be of benefit.

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