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Clinical Review ABC of sexually transmitted infections

Main presentations of sexually transmitted infections in men

BMJ 2004; 328 doi: (Published 20 May 2004) Cite this as: BMJ 2004;328:1251
  1. John Richens, lecturer in sexually transmitted diseases (
  1. Royal Free and University College Medical School, London


    Some sexually transmitted infections, such as gonorrhoea and chlamydial infection, have different presentations in the two sexes because of differences in genital anatomy. This chapter focuses on infections of the male urethra, epididymis, testis, and prostate. Anal and oral symptoms are also covered because these are encountered more often among men, especially men who have sex with men.

    Urethral discharge and dysuria

    Spontaneous discharge of fluid from the urethral meatus, usually most noticeable after holding urine overnight and often accompanied by burning discomfort during urination (dysuria), strongly indicates a sexually acquired urethral infection.

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    Management of urethritis

    Symptomatic gonorrhoea usually develops within a few days of exposure. Chlamydial infections take slightly longer. Mild infections may cause urethral discomfort and dysuria without discharge and may be confused with cystitis.

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    Causes of urethritis in men

    In clinics with laboratory facilities, the usual approach is to test for gonorrhoea and chlamydial infection. The first step is microscopy of a urethral smear. Optimal results for this are obtained from patients who have held their urine for four hours or more.

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    Gonococcal urethral discharge

    Urethritis is confirmed if the urethral smear shows five or more polymorphs per high power field. If the smear shows Gram negative intracellular diplococci, the patient is treated for gonorrhoea and chlamydia to cover the possibility of a mixed infection. Meanwhile, confirmatory tests for gonorrhoea and chlamydia are carried out (see

    World Health Organization flow chart for managing urethral discharge

    Patients without evidence of gonorrhoea receive doxycycline (100 mg twice daily for one week), erythromycin (500 mg twice daily for two weeks), or azithromycin (1 g single dose), which are active against chlamydial infection and most other pathogens associated with non-gonococcal urethritis. Doxycycline …

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