Urethritis can be classified as gonococcal or nongonococcal urethritis (NGU). NGU is caused most commonly by Chlamydia trachomatis and Mycoplasma genitalium, however it is common to not find any cause. Herpes simplex virus (HSV), adenovirus and Trichomonas vaginalis are less common causes. Ureaplasma urealyticum is another cause which exists as normal urethral flora.
The main symptoms (if present) are:
a burning sensation when passing urine (dysuria)
a penile discharge or leakage (clear, white or yellow)
Sometimes there is no discharge, just pain. Most often the symptoms are trivial with chlamydia. Although a creamy pus-like discharge is typical of gonorrhoea (see FIG. 117.1), and a less obvious milkywhite or clear discharge typical of chlamydia (see FIG. 117.2), it is often difficult to differentiate the causes from the discharge. In some males the only complaint is spots on the underpants or dampness under the foreskin.
Gonococcal urethritis: typical purulent discharge
Chlamydia urethritis: the discharge is usually milky in colour but can also be yellow
Given the prevalence of chlamydia in the community, it is recommended to treat with azithromycin 1 g (o) stat while waiting for other test results.
If tests are negative and symptoms persist, consider referral for first-pass urine NAAT testing for Mycoplasma genitalium, HSV and adenovirus (if not available through general practice).
Consider seeking specialist advice before treating infection other than chlamydia/gonorrhoea.
Regardless of results, female partners are at greater risk of PID and require assessment.
Symptoms appear 1–2 weeks after intercourse, although the incubation period can be as long as 12 weeks or as short as 5 days (compared with incubation period of gonorrhoea—about 2–3 days).
50% of men and 75% of women are asymptomatic. Genital and anorectal infections are most common, with rare infections of the eye and oropharynx.
Infection in men can cause urethritis and lead to epididymo-orchitis. In women, infection can cause cervicitis with vaginal discharge and postcoital bleeding.
epididymo-orchitis and secondary reduced male fertility
pelvic inflammatory disease (PID)
tubal factor infertility and ectopic pregnancy
chronic pelvic pain
perinatal conjunctivitis or pneumonia
reactive arthritis +/- conjunctivitis (rare)
For uncomplicated genital or pharyngeal infection:
Sexual intercourse must be avoided until 7 days after both partners have received treatment. Reinfection rates are high so retest after 3 months.
Gonorrhoea is most common in MSM, Aboriginal and Torres Strait Islander people living in rural and remote areas, and travellers from endemic areas.
Gonorrhoea has a short incubation period of 2–3 days and symptoms usually appear 2–7 days after vaginal, anal or oral sex. The incubation period can be as long as 3 weeks.
Up to 80% of women and 10–15% of men have no genital symptoms and most people are asymptomatic in other sites, especially the pharynx, rectum and endocervix. Upper genital infection can lead to pelvic inflammatory disease in women. Gonococcal urethritis in men is characterised by a purulent urethral discharge.
Other manifestations of gonorrhoea
epididymo-orchitis and prostatitis (males)
urethral stricture is not uncommon in males
perinatal conjunctivitis or pneumonia
reactive arthritis +/- conjunctivitis (rare)
NAATs for gonorrhoea are highly sensitive, however false positives can occur at non-genital sites. Gonococcal culture is not as sensitive but has high specificity and allows for antibiotic susceptibility testing. If an NAAT is positive, a swab should be obtained (if not already collected) for culture to determine antibiotic susceptibility prior to commencing treatment.
Alternative treatments are not recommended because of high levels of resistance.
For uncomplicated genital, anorectal or pharyngeal infection:
Sexual intercourse must be avoided until 7 days after both partners have received treatment. Test of cure 2 weeks after treatment is advisable.
Mycoplasma genitalium should be considered in patients with persistent genital tract symptoms when chlamydia and gonorrhoea have been excluded. It has been recently identified as a cause of urethritis in men, proctitis, cervicitis and PID.
Testing has not been widely available, although access to commercial assays is increasing. NAAT can be performed on vaginal, cervical and rectal swabs or first-pass urine. Testing is only offered to asymptomatic patients if a symptomatic partner has tested positive.
Optimal treatment is still unclear with increasing macrolide resistance. Most people diagnosed will have been treated empirically with azithromycin 1 g (o) stat. This is likely to be effective in up to 60% of cases, however specialist advice is required if symptoms persist. Guidelines may soon change to recommend doxycyline as first-line treatment.
Anorectal syndromes (proctitis)
Proctitis is characterised by anal discharge, pain and bowel symptoms including tenesmus and constipation. The most common causes are HSV, N. gonorrhoea and C. trachomatis (particularly lymphogranuloma venerum, LGV, strains). Other causes include M. genitalium and non-STI causes such as inflammatory bowel disease.
It is important to perform an examination and collect swabs at the time. Request NAAT for HSV and C. trachomatis and culture and NAAT for N. gonorrhoea. LGV should be tested in the event of a positive chlamydia test, which requires the same treatment as symptomatic anorectal chlamydia infection.
Treatment should be empirical, taking into account the clinical picture and likelihood of particular STIs in the patient. Consider a combination of ceftriaxone 500 mg (IM) stat and doxycyline 100 mg (o) BD for 14–21 days, +/- antiviral therapy.7
Epididymo-orchitis is covered in more detail in CHAPTER 111. Consider chlamydia and gonorrhoea in all sexually active men, especially men aged <35 years.
Vaginal discharge is presented in more detail in CHAPTER 106. The most common cause of vaginal discharge in women of reproductive age is normal physiological discharge. It should be noted that vaginal thrush and bacterial vaginosis are not considered STIs, but can be associated with sex. The pathogens to consider are:
Candida albicans → vaginal thrush
Gardnerella vaginalis → bacterial vaginosis
Trichomonas vaginalis (more common in Aboriginal and Torres Strait Islander women, older women and women living in rural and remote areas)
Herpes simplex virus may cause vaginal discharge if HSV cervicitis is present.
Cervicitis is often a forerunner to PID. The likely organisms are C. trachomatis or N. gonorrhoeae. Others causes include M. genitalium, T. vaginalis and HSV. If there is cervicitis only (mucopus at the cervix without uterine pain or tenderness) treat with azithromycin (o) 1 g stat.
Pelvic inflammatory disease
PID is covered in more detail in CHAPTER 103. It is not always an STI. The intra-uterine device is a possible cause. Often multiple pathogens are involved in the infection and 70% of cases have an unidentified cause.
Common pathogens are N. gonorrhoeae, C. trachomatis and M. genitalium. Swabs from the cervical os frequently underestimate the organisms involved and thus treatment needs to be directed to all possible pathogens.
Therapy for PID is deliberately vigorous because the major aim is to prevent infertility and the consequent need for assisted reproductive treatment (ART) in the long term. The detailed treatment is outlined in CHAPTER 102.
Mild to moderate infection:
ceftriaxone 500 mg IM (in 2 mL of 1% lignocaine) or IV (as single dose)
azithromycin 1 g as single dose
metronidazole 400 mg BD for 14 days
doxycycline 100 mg BD for 14 days
Severe PID: hospitalise for IV therapy
Most genital ulcers are herpes—any small genital ulcer that is superficially ulcerated, scabbed, red-edged, multiple and painful is invariably herpes. Consider herpes zoster if unilateral genital ulcers are present.
STI causes of anogenital ulcers include:
Herpes simplex virus (HSV 1, HSV 2)
Treponema pallidum (primary chancre)
Haemophilus ducreyi (chancroid)
Klebsiella granulomatis (donovanosis)
Genital ulcers due to primary syphilis and donovanosis are usually painless. Chancroid and donovanosis are rare, almost always imported infections and require specialist input if suspected. Collect a swab of the base of the ulcer or deroofed vesicle and send for NAAT testing, which is available for most causative organisms.
The incubation period varies from 2–12 days. A microbiological diagnosis is recommended as clinical diagnosis can be unreliable.
HSV 2 is associated with genital lesions and HSV 1 with oral lesions. HSV 1 is an increasingly common cause of a first episode of genital herpes, although recurrent genital herpes is usually caused by HSV 2.7 Studies suggest that about 12% of Australian adults are infected with HSV 2 and 76% with HSV 1.8 The majority of patients remain undiagnosed, with mild or asymptomatic recurrences. Once infected with HSV, the virus achieves latency in the nerve roots and is usually a lifelong infection.
With the first attack there is a tingling or burning feeling in the genital area. A crop of small vesicles then appears; these burst after 24 hours to leave small, red, painful ulcers. The ulcers form scabs and heal after a few days. The glands in the groin can become swollen and tender, and the patient might feel unwell and have a fever.
The first attack lasts about 2 weeks if untreated.
The virus usually affects the shaft of the penis, but can involve the glans and coronal sulcus, and the anus (see FIG. 117.3). Other presenting symptoms include painful splitting of the skin, erythema with tingling/itch, urethritis and proctitis.
Usual sites of vesicles/ulcers in males
Vesicles develop around the opening of and just inside the vagina, and can involve the cervix and anus (see FIG. 117.4). Passing urine might be difficult. The cervix may be the only site of lesions and these cases may be asymptomatic or present with symptoms of cervicitis including vaginal discharge. The problem could be a simple tingling around the saddle area or a scratch-like lesion on epithelium.
Usual sites of vesicles/ulcers in females
In both sexes, it can affect the buttocks and thighs. A serious but uncommon complication, especially in females, is the inability to pass urine.
Take a swab from a deroofed vesicle for NAAT testing. Serological tests for HSV are not recommended.
HSV can be caught by direct contact through vaginal, anal or oral sex. Transmission of HSV 1 is usually by contact with saliva and HSV 2 is usually by sexual contact. It can appear spontaneously in people in stable relationships or years after cessation of sexual relationships. 50% of first presentations are not true primary infections.
Most HSV transmissions occur within the first few months of a relationship with asymptomatic viral shredding as the main mechanism. Combined condom use and antiviral therapy reduces the risk of transmission.
It is unlikely for HSV 1 to recur in the genital area. Recurrences of HSV 2 may produce prodromal symptoms prior to an outbreak, including burning, tingling or neuralgia. Fortunately, episodes become milder and less frequent over time and many will stop eventually. Emotional stress is a common trigger.
Treatment (antimicrobial therapy)
Pain relief can be provided in some patients with topical lignocaine 2% gel but caution is needed since it may cause sensitisation with prolonged use.
Oral treatment—first episode
For the first episode of primary genital herpes:
Episodic genital herpes (within 24 hours)
Very frequent recurrences (six or more attacks annually) benefit from continuous low-dose therapy for 6 months (e.g. valaciclovir 500 mg (o) once daily). Interrupt at 6 months to evaluate.
Supportive treatment (advice to the patient)
Rest and relax as much as possible. Warm salt baths can be soothing.
Icepacks or hot compresses can help.
Painkillers such as paracetamol or ibuprofen may give relief.
If urination is painful, pass urine under water in a warm bath.
Wear loose clothing and cotton underwear.
‘A chat beats medicine for herpes’. Since genital herpes is distressing and recurrent, patients are prone to feel stressed and depressed, and can be assisted by appropriate counselling and support. Sexual abstinence should be practised while lesions are active.
In Australia, syphilis, which has re-emerged, usually presents either as a primary lesion or through chance finding on positive serology testing (latent syphilis).
It is important to be alert to the various manifestations of secondary syphilis (refer to CHAPTER 122). The classification and clinical features of syphilis are presented in TABLE 117.4 (see also CHAPTER 29).
Table 117.4Classification and clinical features of syphilis |Favorite Table|Download (.pdf) Table 117.4 Classification and clinical features of syphilis
|Type ||Time period ||Infectivity ||Clinical features |
|Acquired || || || |
|Early (within first 2 years of infection) || || || |
| ||10–90 days, average 21 ||Infectious || |
| ||2–24 weeks after chancre (average 6) ||Infectious || |
Coarse non-itchy maculopapular rash (usually trunk, palms and soles)
Constitutional symptoms (may be mild)
Mucous membrane lesions
| ||Months to 2 years ||Infectious ||No clinical features but positive serology |
|Late (after the second year of infection) || || || |
| ||2 years plus ||Non-infectious ||Risk to unborn fetus |
| || ||Non-infectious || |
Late benign: gummas
|Congenital || || || |
|Early ||Within first 2 years of life ||Infectious || |
Stillbirth or failure to thrive
Nasal infection: ‘snuffles’
Skin and mucous membrane lesions
|Late ||After second year of life ||Non-infectious || |
Stigmata (e.g. Hutchinson teeth)
Table 117.5STIs: Twelve golden rules of management (Sexual Health Society of Victoria) |Favorite Table|Download (.pdf) Table 117.5 STIs: Twelve golden rules of management (Sexual Health Society of Victoria)
|1 ||An STI can only be diagnosed if the possibility is considered. |
|2 ||An adequate sexual history is paramount. |
|3 ||A proper history and careful examination must precede laboratory investigations. |
|4 ||Remember the sexual partner(s)! |
|5 ||reatment consists of the appropriate antibiotic in correct dosage for an adequate period of time. |
|6 ||A patient concerned about STIs is probably an at-risk patient. |
|7 ||Counselling and education are fundamental to STI management. |
|8 ||Penicillin will not cure NGU. |
|9 ||Not all vaginal discharges are thrush. |
|10 ||Multiple, painful genital ulcers are most often due to herpes simplex. |
|11 ||Prompt, accurate treatment of PID is necessary to preserve fertility. |
|12 ||Remember the three Cs—Consent, Confidentiality and Counselling—of HIV antibody testing. |
The management of syphilis has become quite complex and referral of the patient to a specialist facility for diagnosis, treatment and follow-up is recommended.
Recommended antimicrobial therapy
Early syphilis (primary, secondary or latent) of not more than two years duration:7
benzathine penicillin 1.8 g IM as single dose
procaine penicillin 1 g IM daily for 10 days
For patients hypersensitive to penicillin:
doxycycline 100 mg (o) 12 hourly for 14 days
sex should be avoided until ulcers are healed
sexual contacts in the past 3 months should have treatment
repeat serology at 3 months and then 3 monthly
Late latent syphilis: more than 2 years or indeterminate duration:
Sexual contacts in the past 6 months should have treatment. Neurosyphilis and cardiovascular and congenital syphilis are also treated with penicillin but require special regimens.
fixed drug eruptions, aphthous ulcers, trauma, carcinoma, Crohn disease
be aware of increased risk of HPV-related anorectal cancers in MSM.
Warts and Molluscum contagiosum have a distinctive appearance and are readily diagnosed by inspection (see FIG. 117.5). Removal for diagnosis is usually not required. Condylomata lata are multiple lesions that resemble warts superficially but are covered by abundant exudate. They occur in secondary syphilis and leutic screen is positive.
Molluscum contagiosum on and around the penis. They were on the buttocks of his female partner.
Warts may be removed by chemical or physical means, or by surgery. Treatment is cosmetic rather than curative and needs to be individualised. For small numbers of readily accessible warts the simplest treatment is:7
cryotherapy weekly until resolved
podophyllotoxin 0.5% paint or 0.15% cream:
Note: Paint is more suited for use on external keratinised skin. Cream is best used in perianal area, introital area and under the foreskin.
topical imiquimod 5% cream applied to each wart by the patient 3 times a week at bedtime (wash off after 6–10 hours) until the warts disappear (usually 8–16 weeks)
If warts are in the pubic region avoid shaving or waxing as this may facilitate local spread by autoinoculation of HPV into areas of microtrauma.
Treatment of Molluscum contagiosum3
These lesions often resolve spontaneously in immunocompetent patients. There are many treatment choices to provoke resolution. These include:
Cryotherapy is usually the treatment of choice. If lesions are widespread or severe, refer for expert advice. Other destructive methods such as piercing with a needle, application of phenol or diathermy are seldom performed due to issues of pain and potential scarring.
C. albicans is not considered an STI but can be associated with sex. Other non-STI itchy rashes on genitals include dermatitis and psoriasis.
Scabies: inspection on scraping and microscopy. Scabies is diagnosed by a very itchy, lumpy rash. It is rare to find the tiny mites, but it may be possible to find them in the burrows, which look like small wavy lines.
Pubic lice: inspection for moving lice and nits (eggs) on hair shaft.
C. albicans: swab for Candida culture.
permethrin 5% cream if >6 months of age. Apply to whole body from jawline down (include every flexure and area), leave overnight, then wash off.
benzyl benzoate 25% emulsion left for 24 hours before washing off. Repeat after 7 days.
Wash clothing and linen after treatment and hang in sun. Repeat treatment in 7 days.The whole family and close contacts must be treated, regardless of symptoms, which can take weeks to develop. Treatment of children younger than 6 months is covered in CHAPTER 120.
Note: Persistence of the itch after treatment is common, which can take 3 weeks or more to resolve. Also prescribe a moderately potent topical corticosteroid +/- an oral antihistamine for the itch.
permethrin 1% lotion: apply to pubic hair and surrounding area, leave for 20 minutes and then wash off
pyrethrins 0.165% with piperonyl butoxide 2% in foam base; apply as above
Shaving pubic hair is also effective. Bed clothes and underwear should be washed normally in hot water after treatment and hung in the sun to dry. Repeat the treatment after 7 days. Sometimes a third treatment is necessary. Sexual contacts and the family must be treated (young children can be infested from heavily infested parents). Where the lice or nits are attached to eyelashes, insecticides should not be used: apply white soft paraffin (e.g. Vaseline) liberally to the lashes bd for 8 days. Then remove the nits with forceps.