Discharge from penis and dysuria (pain passing urine)
  • Urethral discharge is almost always caused by STI
  • Dysuria (pain on passing urine) is most likely due to an STI in young men and often in older men — especially if a recent new partner
  • Could be gonorrhoea, chlamydia, trichomonas or less commonly mycoplasma genitalium, herpes or other viral infections

Ask

  • How long has he had problem, has he had it before
  • Is there pain when passing urine, discharge from penis
  • Is scrotum painful or swollen
  • Other STI symptoms
    • Sores, blisters, lumps, rashes in genitals
    • Swollen lymph nodes, sore throat, rash, hair loss
  • About sexual partners — any from geographical area with penicillin resistant gonorrhoea

Check

  • Full STI check — with attention to
    • Skin and mouth sores, inflammation
    • Lymph nodes in neck, armpits, groin
    • Genitals, and anal area — for sores, blisters, lumps, painful or swollen scrotum

Do

  • Treat for both gonorrhoea and chlamydia. Presentations are very similar — syndromic management
    • Do not wait for laboratory or POC Test results if not immediately available
  • If man and all partners in last 3 months from geographical area with penicillin SENSITIVE gonorrhoea
    • Give azithromycin oral — adult 1g, single dose
    • AND amoxicillin oral — adult 3g, single dose
    • AND probenecid oral — adult 1g, single dose
  • If man and/or any partner in last 3 months from geographical area with penicillin RESISTANT gonorrhoea OR partners unknown
    • Give azithromycin oral — adult 1g, single dose
    • AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
    • If allergy to penicillin — medical consult
  • Contact tracing
  • STI and safer sex education

Follow-up

  • If positive test result — re-test in 3 months — Standard STI check
    • Can take up to a month for NAAT tests to become negative after successful treatment

Follow-up if ongoing symptoms

  • Check STI test results and contact tracing. If full STI check not done — collect remaining samples including urine for trichomonas
  • ALSO do U/A and send urine for MC&S
  • Medical consult about NAAT for mycoplasma genitalium

Possible causes of ongoing symptoms

  • Symptoms caused by another STI — medical consult. May need to
    • Give doxycycline oral — adult 100mg, twice a day (bd) for 7 days
    • If trichomonas result unknown — ALSO give metronidazole oral — adult 2g, single dose
    • If allergy — medical consult
  • Persistent or recurrent gonorrhoea or chlamydia. If positive for gonorrhoea and or chlamydia
    • Was all first round of treatment taken. If not — repeat
    • Did sexual partners all get treated
  • If reinfection (symptoms got better and then came back) likely — repeat STI check and treatment for man and partners
  • If resistance (never got better at all) likely, ie gonorrhoea may be penicillin resistant
    • Check test results for antibiotic sensitivities
    • Repeat STI check — make sure MC&S for gonorrhoea included
    • If amoxicillin given for initial treatment — now give azithromycin oral — adult 1g, single dose
    • AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
    • If allergy — medical consult

Symptoms not caused by STI — there are other causes of discharge or urine symptoms

  • Check urine MC&S results. If positive — medical consult
  •  If persisting symptoms despite all of the above — medical consult