Fact sheet 2- Dysuria and urethral discharge in males

Risk assessment and symptoms

Ask a few direct questions in a sensitive manner in private to
check if any other symptoms or a risk history are present as
this may guide testing, treatment and management.
1. Past history - Check medical records and ask about any
past history of STI
2. Sexual history - Include the follow questions:
Regular partner and/or casual sexual partners

Treat for chlamydia and gonorrhoea

Repeat Treatment

Do not wait for test results - treat with:

Azithromycin 1g orally as single dose

Azithromycin 1g as a single dose

AND

AND

Ceftriaxone 500mg IMI as a single dose AND

Tinidazole 2g orally as a single dose
Treat contacts with the same treatment as above3

Amoxycillin 3g AND Probenecid 1g as a single dose3

Replace Amoxycillin and Probenecid with Ceftriaxone
500mg IMI if infection was acquired outside the region3.

Contact tracing and follow up

New partners in the last 6 months

Complete the STI case management form

If their partner has other sexual partners

Test and treat contacts as soon as possible for both

chlamydia and gonorrhoea as above

3. Symptoms - Check for:

Advise to abstain from sex until contact(s) are treated

Burning, stinging or pain on passing urine

Discharge from the penis or anus
Testicular pain or swelling
Genital sores or rashes
If sores are present check protocols for genital ulcers and
discuss with a medical officer or KPHU

Take blood as above if not done at the initial visit

Enter on recall system for a follow up STI check (PCR

and blood tests) in 3 months time

Condom use

Urethritis
If a male has the following symptoms test and treat during
initial consult:

Burning, stinging or pain on passing urine and/or

Urethral discharge

Recurrent or persistent urethritis

If symptoms recur or do not resolve with treatment consider
re-infection, resistant gonorrhoea or another cause of
urethritis.
Re-infection is likely

if discharge is present ALSO take:

External urethral swab for MCS to check for

gonococcal antibiotic sensitivities

Note- The swab should be taken before passing urine and

can be self collected
Blood tests

Syphilis serology, HIV Ab, Hep B cAb sAb sAg2

Hep C Ab if indicated (eg: history of injecting drug use

or unsafe tattooing, body piercing, incarceration etc)

Check if any other blood tests are due

Discuss with a doctor (MO).

Torsion excluded- epididymitis likely
Risk assessment and tests as for urethritis

Initiate treatment
Azithromycin 1g as a single dose
AND

Ceftriaxone 500mg as a single dose3

Second day
Doxycycline 100mg bd for 10 days OR repeat Azithromycin
1g in 7 days if adherence to doxycycline is unlikely

Contact(s) should be treated to cover chlamydia and

gonnorhoea

New partner since treatment was given

Follow up in 7 days to check response to treatment,

contact(s) have been treated and to provide ongoing
management as appropriate.

Test again (as above) if it is more than one month since

the previous test. Take another urethral swab for MCS if
discharge is present. Repeat treatment for urethritis as above
and test and treat contacts.

AND

Exclude torsion of the testes (medical emergency).

Presents with pain and swelling of the testis

Contact trace and follow up as for urethritis.

First void urine for chlamydia and gonorrhoea PCR

Epididymo-orchitis

Symptoms resolved quickly with treatment but have

recurred and contact(s) were not treated at the same
time

Take the following tests with consent

If no response to this treatment, discuss with KPHU or a

sexual health physician

1 Check general fact sheet for how to collect specimens

Resistant gonorrhoea or another cause is likely

2 Hep B testing is not needed if Hep B immune (cAb positive and sAg negative) or if
adequately vaccinated.

3 Do not give Amoxycillin or Ceftriaxone to people allergic to penicillin discuss with

MO. Alternative treatment for gonorrhoea is Ciprofloxacin 500mg as a single dose or

No or little response of symptoms to initial treatment

Contact(s) were treated at the same time
No new partners since treatment given.

Azithromycin 2g as a divided dose

Test again (as above) if it is more than one month since

the previous test. Take another urethral swab for MCS if
discharge is present.
VC - Last Modified: October 4, 2010 8:50 AM

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Flow chart 2- Dysuria and urethral discharge in males

Presents with:
- Urethral discharge and/ or dysuria- (stinging/burning or pain on passing urine)
Ask about

Presents with:

AND
/OR

Testicular pain or swelling

- Sexual history and risk assessment

- Check for other symptoms

Testing:

Talk to a medical officer:

1) First void urine (FVU) for chlamydia, gonorrhoea and trichomonas PCR1 AND

Exclude torsion of the testes

(medical emergency)

2) If urethral discharge present - Urethral swab (external) MCS2

Plus

TEST

Obtain informed consent and take blood for:

Torsion excluded:

3) HIV, syphilis, Hep B3 (Hep C if indicated)

- Test as for urethritis

- Treat for epididymo-orchitis

4) Throat and/or rectal swabs for chlamydia and gonorrhoea (PCR and MCS)
if indicated4

Treatment for epididymo-orchitis- check allergies2

Treatment for urethritis- check allergies before treatment5

Initial treatment

1) Azithromycin 1g as a single dose

1) Azithromycin 1g as a single dose

AND

AND

2) Amoxycillin 3g and Probenecid 1g as a single dose

Or Ceftriaxone 500mg IM if infection acquired outside the region3

2) Ceftriaxone 500mg IMI stat

Ongoing Treatment
3) Doxycycline 100mg bd for 14 days OR repeat Azithromycin
1g in 7 days if adherence to doxycycline is unlikely

Contact tracing and follow up

- Test and treat contacts for both chlamydia and gonorrhoea as soon as possible
- Enter on recall system for a repeat STI check in 3 months

Represents with recurrent or persistent dysuria and /or discharge?

3
YES
Symptoms- should resolve quickly with appropriate antibiotics.
If symptoms recur assess if re-infection or another cause is likely - refer to symptomatic male factsheet

Resistant gonorrhoea or another cause

- Test as above if more than 1 month since the previous test
- Take another urethral swab for MCS if discharge is present
Re-infection
- Test as above if more than 1
month since the previous test
- Repeat treatment as above
- Test and treat contacts

Treat with:
1) Azithromycin 1g orally,
2) Ceftriaxone 500mg IMI stat
AND
3) Tinidazole 2g orally
- Treat contacts with above5

Footnotes
1
Always take FVU on any male the presents with symptoms.
2
If discharge present, then take urethral swab BEFORE Urine sample - the client can self collect urethral swab.
3
Hep B testing is not necessary if immune or history of vaccination
4
Refer to WA Guidelines for managing Sexually Transmitted Infections. http://silverbook.health.wa.gov.au
5
Do NOT give Amoxycillin or Ceftriaxone to people allergic to penicillin discuss with a MO. Alternative treatment for gonorrhoea is Ciprofloxacin 500mg as a single
dose or Azithrromycin 2g as a divided dose
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley Vc - Last Updated: 24Sep10