A 19-year-old man comes to the student health center due to 2 days of burning pain during urination. He has also had itching of the urethral meatus but no urinary discharge, fever, chills, or rash. The patient has no chronic medical conditions and takes no medications. He had unprotected sexual intercourse with a new female partner a week ago. The patient has smoked a pack of cigarettes daily since age 14. He drinks alcohol on weekends and does not use illicit drugs. Vital signs are within normal limits. There is scant, watery urethral discharge at the urethral meatus. There are no genital ulcers, rashes, erythema, or inguinal lymphadenopathy. Urethral swab is performed, and Gram stain of the urethral fluid reveals many neutrophils but no organisms. Nucleic acid amplification tests of the urine are sent for Chlamydia trachomatis and Neisseria gonorrhoeae. The patient received treatment with a single dose of azithromycin but returns to the office 2 weeks later due to continued burning with urination. Since his previous visit, he has had no urethral discharge, fever, chills, scrotal pain, rash, or additional sexual encounters. Nucleic acid amplification testing from his prior visit was negative for Neisseria gonorrhoeae and Chlamydia trachomatis. Screening for syphilis with rapid plasma reagin and for HIV with fourth-generation HIV testing was also negative. No urethral discharge is present, and the remainder of the physical examination is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 19-year-old man comes to the student health center due to 2 days of burning pain during urination.  He has also had itching of the urethral meatus but no urinary discharge, fever, chills, or rash.  The patient has no chronic medical conditions and takes no medications.  He had unprotected sexual intercourse with a new female partner a week ago.  The patient has smoked a pack of cigarettes daily since age 14.  He drinks alcohol on weekends and does not use illicit drugs.  Vital signs are within normal limits.  There is scant, watery urethral discharge at the urethral meatus.  There are no genital ulcers, rashes, erythema, or inguinal lymphadenopathy.  Urethral swab is performed, and Gram stain of the urethral fluid reveals many neutrophils but no organisms.  Nucleic acid amplification tests of the urine are sent for Chlamydia trachomatis and Neisseria gonorrhoeae. The patient received treatment with a single dose of azithromycin but returns to the office 2 weeks later due to continued burning with urination.  Since his previous visit, he has had no urethral discharge, fever, chills, scrotal pain, rash, or additional sexual encounters.  Nucleic acid amplification testing from his prior visit was negative for Neisseria gonorrhoeae and Chlamydia trachomatis.  Screening for syphilis with rapid plasma reagin and for HIV with fourth-generation HIV testing was also negative.  No urethral discharge is present, and the remainder of the physical examination is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Patients with urethritis often have continued symptoms after initial treatment. This can be due to reinfection, medication noncompliance, or infection with an organism not sensitive to initial empiric treatment. The first diagnostic step is repeating the urethral fluid Gram stain to confirm ongoing urethritis (≥2 leukocytes/hpf). If positive, patients should undergo nucleic acid amplification (NAAT) testing of the urine for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis (if available). This patient has continued symptoms of nongonococcal urethritis (NGU) after treatment with azithromycin, no new sexual activity, and negative testing for C trachomatis and N gonorrhoeae, suggesting an infection with an azithromycin-insensitive organism. Most cases of NGU not effectively treated with azithromycin are due to C trachomatis resistance or M genitalium or T vaginalisinfection. Persistent C trachomatis is usually treated with doxycycline, M genitalium is treated with moxifloxacin, and T vaginalis is treated with metronidazole. (Choice A) Fluorescent treponemal antibody absorption testing can be used for syphilis screening. This patient with a negative rapid plasma reagin test and no symptoms of primary syphilis (eg, chancre, lymphadenopathy) does not need a second syphilis screening test. (Choice B) Genital herpes simplex virus infection can be confirmed by PCR, viral culture, or serologic testing. Genital herpes is typically associated with multiple vesicles on an erythematous base, not isolated dysuria and urethral discharge. (Choice D) A 6-week course of trimethoprim-sulfamethoxazole can be used to treat bacterial prostatitis. Chronic bacterial prostatitis usually causes >3 months of urinary tract symptoms (frequency, dysuria, urgency) and/or pain in the perineum. Acute bacterial prostatitis usually causes fevers, chills, cloudy urine, and voiding symptoms. This young, sexually active patient has had dysuria for a few weeks and scant urethral discharge. Urethritis is more likely; a diagnosis of chronic prostatitis would be premature. (Choice E) Ceftriaxone is the antibiotic of choice for gonococcal urethritis. This patient had negative testing for N gonorrhoeae, making gonococcal urethritis unlikely. Educational objective: Patients with nongonococcal urethritis frequently have continued symptoms after azithromycin therapy due to reinfection, resistance, or infection with an organism (eg, Mycoplasma genitalium) not susceptible to azithromycin. Patients should receive repeat urethral Gram stain and nucleic acid amplification testing of the urine for common urethritis organisms to identify the best next treatment.

A 19-Year-Old Man Comes to the Student Health Center Due