Urethral discharge

I would like to congratulate Rebick and colleagues1 on their article on the treatment of urethral infections. In their elegant work, the authors describe the tests available for specific diagnosis of various causes of urethritis in men and conclude by analyzing the guidelines on medical treatment, stressing the high risk of relapse or reinfection and consequent recommendations for posttreatment tests.

Recommendations for follow-up cultures or tests of cure are essential in order to show possible recurring infections or re-infection, thus minimizing any late complications related to infection. As emphasized by Rebick and colleagues1 in case of failure of treatment, the patient should be referred to a specialist in sexually transmitted diseases for proper management of the infection.

To emphasize the need for correct management of urethral reinfections or the recurrence of previously treated urethritis, I would like to stress some points. First, many infections (and reinfections) of the urethra are asymptomatic, making the diagnosis of failure of treatment very difficult.

Second, failure of medical treatment may be due not only to inadequate therapy or resistance to antibiotics,2 but also to patient behaviour. Often when patients are instructed to abstain from sexual intercourse for at least 1 week after therapy is initiated and prompt treatment of partners is also recommended, many studies have shown that about 30% of cases are positive at rescreening and, in more than 60% of these, repeat infections occur (originating from re-exposure to an untreated or inadequately treated partner).3

Third, one of the most frequent and dramatic late complications of urethritis is inflammatory stricture of the urethra, which usually starts with meatal stenosis, later progressively involving the anterior and posterior urethra and often requiring long-term management. Optical urethrotomy, as described by Sachse in 1974, is still the initial treatment for the majority of men. Unfortunately, this treatment alone is associated with a significantly high recurrence rate, which may reach 50%.4

Management of recurrent stenoses is a complex dilemma for urologists.5 Given the expanding number of endoscopic techniques available, the choice of the best surgical option is often difficult, and urethral reconstruction has become an increasingly specialized urologic procedure. Because of the cost and invasiveness of some treatments (e.g., urethroplasty with buccal mucosa grafts), many urologists have limited experience performing more complicated repairs.

In addition, the very definition of success is hampered by nonstandardized follow-up methods, making understanding the outcome of some of these interventions difficult.6

Proper medical management of urethral infection is essential, in view of the possible late complications of untreated urethritis. Urethral discharge must never be underestimated.