Ep 125: A 19-Year-Old Man with Dysuria

This case presents a 19-year-old man with new onset dysuria and purulent urethritis. The discussion focuses on likely diagnoses and appropriate therapy.

Transcript

[upbeat intro music]

[Dr. Handy] Hi, everyone. Welcome

back to Harrison's Podclass.

We're your co-hosts. I'm Dr. Cathy Handy.

[Dr. Wiener] And I'm Dr. Charlie

Wiener, and we're joining

you from the Johns Hopkins

School of Medicine.

[music continues]

[Dr. Handy] Welcome to episode 125:

a 19-year-old man with dysuria.

[Dr. Wiener] Cathy, 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.

[Dr. Handy] Okay, so we have a young man

with symptomatic urethritis.

What's the question?

[Dr. Wiener] 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 gonorrhoeae;

and option E. is Trichomonas vaginalis.

[Dr. Handy] All right, common

causes of urethral discomfort

and discharge in men include

Chlamydia trachomatis,

Neisseria gonorrhoeae,

Mycoplasma genitalium,

which it didn't mention,

ureaplasma, urealyticum,

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 ureaplasmas,

but fewer studies than in the past

have implicated them as a pathogen.

[Dr. Wiener] So the only

organism that we mentioned

that is not a common cause

of male urethritis is Gardnerella, right?

[Dr. Handy] Yeah, so answer

B. Gardnerella vaginalis,

is a usual cause of

bacterial vaginosis in women.

It's not a pathogen in men.

[Dr. Wiener] Okay, well let's

talk more about our patient.

You mentioned distinguishing between

gonococcal and non-gonococcal urethritis.

How do we make that distinction?

[Dr. Handy] 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.

[Dr. Wiener] Okay, we're

going to get to treatment

in a minute, but any additional

workup on our patient?

[Dr. Handy] 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 N-A-A-T or NAAT,

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 voided for the prior two hours.

This is highly sensitive and

specific for the diagnosis

of gonococcal or chlamydial

urethritis in men.

[Dr. Wiener] Okay, back to our patient.

This patient's Gram stain does show

greater than five polies

per high-power field

and no intracellular diplococci.

[Dr. Handy] Okay, so our patient

has non-gonococcal urethritis.

[Dr. Wiener] 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.

[Dr. Handy] 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

have fully ruled out gonococcus,

then ceftriaxone can also be considered.

[Dr. Wiener] Just for completeness,

what about the other antibiotics?

[Dr. Handy] Fluconazole is

used for fungal infections,

notably Candida.

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.

[Dr. Wiener] He should also

contact his recent partners, right?

[Dr. Handy] 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.

[Dr. Wiener] Okay, so the

teaching point 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.

[Dr. Handy] 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 Harrison's.

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.

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