Clinical Opal - ‘It’s a bit embarrassing, doctor’
Tyler is a cis male 22 year old university student who presents to you late one afternoon. He is new to the practice. He starts the consultation off by saying ‘It’s a bit embarrassing, doctor’, and awkwardly proceeds to describe penile discharge and painful urination for the past couple of days.
On further questioning, Tyler discloses an episode of unprotected vaginal sex with a cis female ten days previously. He has never had a male partner. He says that over the past 48 hours he has had a small amount of clear discharge and is ‘pissing razor blades’. He denies any other genital or systemic symptoms.
Tyler is otherwise well with no significant PMHx and takes no regular medications.
On examination, he has a milky penile discharge. Examination is otherwise normal.
What is the most likely diagnosis and what investigations would you order at this point?
Tyler is presenting with urethritis, the most likely cause being non-gonococcal urethritis (NGU).
While the urethral discharge of gonorrhoea is usually copious and purulent, the discharge of NGU is typically scant (and very commonly is asymptomatic). Common aetiologies of NGU include Chlamydia trachomatis and Mycoplasma genitalium, and less commonly HSV and Trichomonas vaginalis. Up to 50% of cases will have no microbiological cause identified.
The Australian STI Management Guidelines for Use in Primary Care recommend testing for the following infections in the setting of a patient presenting with the clinical syndrome of penile urethritis:
- First pass urine (FPU) for nucleic acid amplification test (NAAT): C. trachomatis, M. genitalium and Neisseria gonorrhoea. A urethral swab can be collected for NAAT if urine cannot be obtained.
- Urethral swab for gonorrhoea culture and antibiotic sensitivity. Culture and susceptibility testing is important for N. gonorrhoeae because antimicrobial resistance is emerging and most nucleic acid amplification tests do not detect antimicrobial resistance.
Therapeutic guidelines recommend not testing for Ureaplasma urealyticum or Mycoplasma hominis when investigating urethritis.
Note, testing guidelines differ for men who have sex with men (MSM).
If test results are negative and symptoms persist, consider testing of FPU for HSV, adenovirus and trichomonas.
For more, enrol in the STI & HIV Care in General Practice course.
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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