Gonorrheal urethritis (Neisseria gonorrhoeae), initially a sexually transmitted infection of the urethral mucosa, becomes symptomatic after the gonococci penetrate perimucosal tissues. Crypts and glands of the penile urethra ﬁll with leukocytes and organisms. Chronic gonorrheal urethritis results from retention of gonococci in the urethral glands (Littré) and their intermittent discharge from these glands (carrier stage). The incubation period of gonorrhea is 3 to 5 days. In mild infections, the urethral discharge may be scant and often mistaken for nonspeciﬁc urethritis.
Abundant purulent discharge and balanoposthitis (with preexisting phimosis) are typical of severe infections. In severe cases, the corpus spongiosum may become involved, resulting in painful erections. With extension of the infection into the posterior urethra, urinary frequency and dysuria occur. Infection of the prostate is usually asymptomatic, unless a prostatic abscess is present. Gonorrhea may spread through the spermatic cord to the vas deferens (vasitis) and epididymis, resulting in epididymitis. Gonococcal endocarditis resulting from septicemia has been observed historically. The diagnosis is conﬁrmed with bacterial cultures or urine DNA testing. If denudation of the epithelium in the urethra or vas deferens occurs from treatment, urethral strictures and infertility due to reproductive tract obstruction may develop. Risk factors for contracting the infection include having multiple sexual partners, a partner with a past history of any sexually transmitted diseases, and unprotected sex. Antibiotics are curative. The term nongonorrheal urethritis or nonspeciﬁc urethritis refers to urethritis due to sexually transmitted diseases other than gonorrhea. This form of urethritis is more common than gonorrheal urethritis, with approximately 89 million new cases diagnosed annually worldwide versus 62 million new cases of gonorrhea. The clinical presentation can be identical to that of gonorrhea and concurrent infections with several different organisms can occur. Responsible organisms are most commonly Chlamydia trachomatis, the mycoplasma species Ureaplasma urealyticum and Mycoplasma genitalium, and herpes simplex type II virus. Nonspeciﬁc urethritis, when associated with conjunctivitis and arthritis, is referred to as Reiter syndrome and may be a consequence of sexually transmitted infections by nongonorrheal organisms. Urethral strictures can present with urethritis-like symptoms, and in rare instances the underlying cause may be a papilloma, polyp, or cyst of the urethra. Bacterial nongonorrheal urethritis is routinely cured with antibiotics.
Trichomonas vaginalis is a sexually transmitted, microscopic parasite that causes trichomoniasis. This is a relatively common form of nongonorrheal urethritis with an estimated 8 million new cases annually in the United States. Trichomonads are usually found in the urethral exudate or urethral urine and are recognized microscopically by their active motility and propelling ﬂagella. Patients may be asymptomatic or have a slight thin, milky white urethral discharge in the morning. Itching, dysuria, and possibly urinary urgency may be present. It is curable with antibiotics.