NOTES ON GENITOURINARY TRACT INFECTIONS
Dr. Saleh Mohammad Shoaib, Assistant Surgeon, Fakirhat UHC, Bagerhat
DMC (K – 67), MD resident (Phase – A, Neurology, NINS), Mob: 01757370094
CONTENTS
1. ACUTE BACTERIAL PROSTATITIS
2. CHRONIC BACTERIAL PROSTATITIS
3. NONBACTERIAL CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN
SYNDROME
4. ACUTE EPIDIDYMITIS/EPIDIDYMO - ORCHITIS
5. CHRONIC NON - TUBERCULOUS EPIDIDYMITIS
6. TUBERCULOUS EPIDIDYMO - ORCHITIS
7. URETHRITIS WITH OR WITHOUT URETHRAL DISCHARGE
1. ACUTE BACTERIAL PROSTATITIS
BACTERIOLOGY
Common: Gram – negative rods, esp. E coli and Pseudomonas
Less common: Gram – positive organisms (e.g: Enterococci)
PATHOGENESIS
Common: Ascending infection through urethra and reflux of
infected urine into the prostatic ducts.
Rare: Lymphatic and hematogenous routes.
SYMPTOMS
• Perineal, sacral, or suprapubic pain
• Fever
• Irritative voiding complaints (frequency, urgency, nocturia etc.)
• Obstructive symptoms: if acutely inflamed prostate swells (may
lead to urinary retention)
SIGNS
• High fever
• Prostate on DRE: Warm, swollen, often exquisitely tender
[Caution! Do DRE gently, vigorous manipulations may result in
septicemia. Prostatic massage is contraindicated.]
LAB FINDINGS
CBC: WBC, left shift
7.1. GONOCOCCAL URETHRITIS AND CERVICITIS
7.2. CHLAMYDIAL URETHRITIS & CERVICITIS
8. URETHRAL SYNDROME
9. BONUS TOPIC: ISOLATED/PRIMARY ORCHITIS
10. GENITOURINARY DRUGS IN PREGNANCY
11. EXAMPLES OF PRESCRIBING FOR GENITOURINARY TRACT
INFECTION
ST
12. 1 LINE DRUG TREATMENT FOR DIFFERENT GENITOURINARY
TRACT INFECTIONS
Urinalysis: Pyuria, bacteriuria, and varying degrees of hematuria
Urine culture: growth of offending pathogen
IMAGING
Pelvic CT or transrectal USG: Do in non - responders to antibiotics
in 24 – 48 hours to identify prostatic abscess.
TREATMENT
• Hospitalization may be required.
• IV therapy: IV ampicillin plus gentamicin should be initiated
until organism sensitivities are available.
• Oral therapy: After the patient is afebrile for 24 – 48 hours, oral
antibiotics (e.g: fluoroquinolones) are used to complete 4 – 6
weeks of therapy.
• Alternative oral drug: Fosfomycin 3–g dose every 3 days for 21
days
• If urinary retention develops, an ‘in and out’ catheterization to
relieve the initial obstruction or short–term (12 hours) small
indwelling urinary catheter is appropriate.
 Expressed prostatic secretions or a post - prostatic massage
voided urine or both: WBC (> 5 – 10/HPF), bacterial growth in
culture*** (necessary to make the diagnosis).

• If sterile culture, suspect nonbacterial prostatitis, chronic pelvic

pain, or interstitial cystitis.

IMAGING

USG with Post – void residual urine (PVR): evaluate for urinary
retention. Other imaging not necessary.

DIFFERENTIAL DIAGNOSIS

Fig: Treatment of acute bacterial prostatitis Chronic urethritis, cystitis, nonbacterial prostatitis, chronic pelvic
pain, interstitial cystitis, anal disease.
PROGNOSIS
TREATMENT
• Good prognosis, as bacteria usually eradicated with appropriate
antibiotic therapy. • Hospitalize if febrile or systemically ill.

• Progression to chronic prostatitis rare.

2. CHRONIC BACTERIAL PROSTATITIS

• May evolve from acute bacterial prostatitis or recurrent UTI (>

50 % patients have no h/o acute infection).

BACTERIOLOGY

Common: Gram - negative rods

Fig: Treatment of chronic bacterial prostatitis
Uncommon: Enterococcus
rd
• IV therapy: Start IV Ampicillin + gentamicin or a 3 gen
PATHOGENESIS cephalosporin or a fluoroquinolone.

Common: Ascending infection through urethra and reflux of
infected urine into the prostatic ducts.
Rare: Lymphatic and hematogenous routes.
SYMPTOMS
• Oral therapy: After the patient is afebrile for 24 hours, oral
fluoroquinolones, trimethoprim-sulfamethoxazole, or an
extended-spectrum beta-lactamase antibiotic (based on culture
and sensitivity results of expressed prostatic secretion or post -
prostatic massage urine) are used to complete 4 – 6 weeks of
therapy.

• Irritative voiding symptoms • Symptomatic relief: Indomethacin, Ibuprofen, hot sitz baths,
alpha-blockers (e.g: tamsulosin).
• Perineal or suprapubic discomfort, often dull and poorly
localized PROGNOSIS

• Urethral pain • May be recurrent, can be difficult to cure, and often requires
repeated courses of therapeutic antibiotics.
• Obstructive urinary symptoms
TREATMENT OF RECURRENCE OF CHRONIC BACTERIAL
• Low back pain
PROSTATITIS
SIGNS
• 12 - week course of treatment.
• Physical examination often unremarkable

• Prostate may feel normal, boggy, or indurated.

LAB FINDINGS

৹
Urinalysis: normal (unless 2 cystitis).
3. NONBACTERIAL CHRONIC PROSTATITIS/CHRONIC
PELVIC PAIN SYNDROME
• Features similar to chronic bacterial prostatits.
• No h/o UTI.
• Psychosocial factors (depression, anxiety, catastrophizing, poor
social support, stress) are frequently associated.
• Cause unknown.
• Diagnosis of exclusion.
• Quality of life greatly decreased.
SYMPTOMS
• Identical to that of chronic bacterial prostatitis.
• Irritative voiding symptoms.
• Chronic pain in perineal, suprapubic, or pelvic region, also in
testes, groin, and low back.
• Pain during or after ejaculation: one of the most prominent and
bothersome symptoms in many patients.
LAB FINDINGS
Expressed prostatic secretions or a post - prostatic massage
voided urine or both: WBC but negative culture*** (essential to
excluded chronic bacterial prostatitis).
DIFFERENTIAL DIAGNOSIS
Chronic bacterial prostatitis, bladder cancer (must be excluded in
older men with irritative voiding symptoms and negative cultures!
Do urine cytology for malignant cell and cystoscopy).
TREATMENT
• Multimodal therapy according to presentation.
• Patients with voiding symptoms: alpha - blocker (e.g: tamsulosin,
alfuzosin, silodosin).
• Newly diagnosed, antimicrobial – naive patients: Use antibiotics.
• Psychosocial disorders: cognitive behavioral therapy,
antidepressants, anxiolytics, referral to psychiatrist if needed.
• Neuropathic pain: gabapentin, amitriptyline, neuromodulation,
acupuncture, referral to a pain management specialist if needed.
• Pelvic floor muscle dysfunction: diazepam, biofeedback
techniques, pelvic floor physical therapy (eg, kegel exercises),
pelvic shock wave lithotripsy, heat therapy.
• Sexual dysfunction with pain symptoms: sexual therapy,
phosphodiesterase - 5 inhibitors (eg, sildenafil, tadalafil,
vardenafil).
• Surgery: not recommended.
PROGNOSIS
• Annoying, recurrent symptoms are common, but serious
sequelae have not been identified.
4. ACUTE EPIDIDYMITIS/EPIDIDYMO - ORCHITIS
• Inflammation confined to the epididymis is epididymitis;
infection spreading to the testis is epididymo - orchitis.
1. SEXUALLY TRANSMITTED FORMS:
• Age: < 35 y old.
• Associated with: urethritis.
• Bacteriology: Chlamydia trachomatis or Neisseria gonorrhoeae.
MEN WHO PRACTICE INSERTIVE ANAL INTERCOURSE:
• May have acute epididymitis from sexually transmitted and
enteric organisms.
2. NON – SEXUALLY TRANSMITTED FORMS:
• Age: > 35 y old.
• Associated with: UTI and prostatitis.
• Bacteriology: enteric gram-negative rods.
ROUTE OF INFECTION
• Probably via the urethra to the ejaculatory duct and then down
the vas deferens to the epididymis.
• Amiodarone: has been associated with self-limited epididymitis,
which is a dose - dependent phenomenon.
SYMPTOMS
• Symptoms may follow chronic dysfunctional voiding, urinary
retention, sexual activity or trauma.
• Pain develops in the scrotum and may radiate along the
spermatic cord or to the flank.
• Scrotal swelling and tenderness are usually apparent.
• Associated symptoms of urethritis (pain at the tip of the penis
and urethral discharge) or cystitis (irritative voiding symptoms)
may occur.
• Severe cases may develop systemic symptoms such as fever.
SIGNS
• Early in the course, the epididymis may be distinguishable from
the testis; however, later the two may appear as one enlarged,
tender mass.
• A reactive hydrocele may develop.
• The prostate may be tender on rectal examination.
LAB FINDINGS
CBC: WBC, left shift.
Sexually transmitted variety:
Urethral discharge: Gram staining: may be diagnostic of gram
negative intracellular diplococci (N. gonorrhoeae).
White cells without visible organisms on urethral smear represent
nongonococcal urethritis (C. trachomatis most likely pathogen).
Non - sexually transmitted variety:
Urinalysis: pyuria, bacteriuria, and varying degrees of hematuria.
Urine culture: growth of offending pathogen.
IMAGING
Scrotal USG: aids in diagnosis. Detects hydrocele, abscess.
DIFFERENTIAL DIAGNOSIS
Tumors: generally cause painless enlargement of the testis.
Urinalysis negative. Examination reveals normal epididymis. Do
scrotal USG.
Testicular torsion: usually occurs in pre - pubertal males, also in
young adults. Acute onset of symptoms and a negative urinalysis
favor testicular torsion or torsion of one of the testicular or
epididymal appendages. Prehn sign (elevation of the scrotum
improves pain from epididymitis) may be helpful but is not
reliable. If any clinical doubt about diagnosis, MUST exclude
testicular torsion by surgical testicular exploration.
Distal ureteral stone: often presents with referred pain into the
ipsilateral groin and scrotum. Scrotum not tender. Scrotal USG
normal.
TREATMENT
Acute phase: Drink plenty of fluid, bed rest, ice, analgesia and
scrotal elevation/support.
Fig: Treatment of acute epididymitis
Sexually transmitted variety (< 35 y old): IM Ceftriaxone 250 mg
stat plus oral Doxycycline 100 mg twice daily for 10 – 14 days.
Any sexual partners from the preceding 60 days must be evaluated
and treated as well.
Men who practice insertive anal intercourse: IM Ceftriaxone 250
mg stat plus an oral fluoroquinolone (eg, ciproflxacin 500 mg twice
daily, Levofloxacin 500 mg daily) for 10 – 14 days to cover sexually
transmitted and enteric organisms.
Non - sexually transmitted variety (> 35 y old): Oral
fluoroquinolone for 10 – 14 days, at which time evaluation of the
urinary tract is warranted to identify underlying disease.
Symptoms and signs of epididymitis that do not subside within 3
days require re - evaluation of the diagnosis and therapy.
PROGNOSIS
• Prompt treatment: usually favorable outcome.
• If significant scrotal swelling has developed, this may take 4
weeks to resolve.
• Delayed/inadequate treatment: Complications: epididymo -
orchitis, decreased fertility, or abscess formation (Drain urgently!)
5. CHRONIC NON - TUBERCULOUS EPIDIDYMITIS
• Usually follows failed resolution of acute epididymitis.
SYMPTOMS
• Intermittent episodes of scrotal discomfort
SIGNS
• Epididymis: thickened, tender.
TREATMENT
• Oral fluoroquinolones or Doxycycline plus anti - inflammatory
agents for 4 – 6 weeks.
• Epididymectomy/orchidectomy: Consider if no resolution (some
patients still suffer from pain after surgery).
6. TUBERCULOUS EPIDIDYMO - ORCHITIS
• Chronic form usually begins insidiously.
CLINICAL FEATURES
• Typically, there is a firm, uncomfortable discrete swelling of the
lower pole of the epididymis.
• The disease progresses until the whole epididymis is firm and
craggy behind a normal - feeling testis.
• There is a lax secondary hydrocele in 30% of cases, and a
characteristic beading of the vas may be apparent as a result of
subepithelial tubercles.
• The seminal vesicles feel indurated and swollen.
• In neglected cases, a tuberculous ‘cold’ abscess forms, which
may discharge.
• The body of the testis may be uninvolved for years but the
contralateral epididymis often becomes diseased.
rd
• In 2/3 s of cases there is evidence of renal TB or previous
disease. Otherwise, patients typically appear healthy.
LAB TESTS
• Urine and semen should be examined repeatedly for tubercle
bacilli in all patients with chronic epididymo-orchitis.
IMAGING
• Chest X - ray should be performed, as should imaging of the
upper urinary tract.
• Scrotal USG will demonstrate a thickened epididymis.
TREATMENT
৹
• 2 TB epididymitis may resolve when the primary focus is
treated.
• Treat with anti – TB drugs, though it is less effective in genital TB
than in urinary TB.
• A course of anti - TB chemotherapy should be completed even if
there is no evidence of disease elsewhere.
• If resolution does not occur within 2 months, epididymectomy or
orchidectomy is advisable.
7. URETHRITIS WITH OR WITHOUT URETHRAL
DISCHARGE
ETIOLOGY
Commonest: Neisseria gonorrhoeae, Chlamydia trachomatis.
Others: Mycoplasma genitalium, Ureaplasma urealyticum,
Trichomonas vaginalis.
Non - infectious cause: Reactive arthritis with associated
urethritis.
7.1. GONOCOCCAL URETHRITIS AND CERVICITIS
CLINICAL FEATURES
MEN
• Initial symptoms: Dysuria, serous/milky urethral discharge.
• 1 - 3 days later, the urethral pain is more pronounced and the
discharge becomes yellow, creamy, and profuse, sometimes
blood-tinged.
• The disorder may regress and become chronic or progress to
involve the prostate, epididymis, and periurethral glands with
painful inflammation.
• Chronic infection leads to prostatitis and urethral strictures.
• Asymptomatic infection common, occurs in both sexes.
WOMEN
• Often becomes symptomatic during menses.
• Symptoms: Dysuria, urinary frequency, urgency, purulent
urethral discharge.
• Vaginitis and cervicitis with inflammation of Bartholin glands are
common.
• Infection may be asymptomatic, with only slightly increased
vaginal discharge and moderate cervicitis on examination.
DIAGNOSIS
• Nucleic acid amplification test (NAAT): excellent sensitivity and
specificity.
• In women with suspected cervicitis, take endocervical or vaginal
st
swabs and/or 1 catch morning urine specimen.
st
• In men with urethral infection, take 1 catch morning urine
specimen.
• Gram stain of urethral discharge in men, especially during the
st
1 week after onset, shows gram - negative diplococci in poly -
morphonuclear leukocytes. Gram stain is less often positive in
women.
• Cultures: should be obtained in treatment failure to detect
resistance.
DIFFERENTIAL DIAGNOSIS
• Non - gonococcal urethritis (e,g: Chlamydia), Gardnerella
vaginalis, Trichomonas, Candida, and other pathogens associated
with STDs and PID, arthritis, proctitis, and skin lesions.
• Reactive arthritis (urethritis, conjunctivitis, arthritis) may mimic
gonorrhea or coexist with it.
PREVENTION
• Education.
• Mechanical/chemical prophylaxis: Condom.
• Partner notification and referral of contacts.
• Early treatment of contacts.
• Treatment of sex partners by patient - delivered partner therapy.
TREATMENT
• Treat before antimicrobial susceptibilities are known.
• Resistance noted to: penicillin, tetracycline, ciprofloxacin,
azithromycin, Ceftriaxone.
• Test and treat pt. and sex partners for HIV infection and syphilis.
Regimen: Inj. Ceftriaxone 250 mg IM stat plus Azithromycin 1000
mg PO single dose.
Alternative: Cefixime 400 mg PO single dose plus Azithromycin
1000 mg PO single dose.
• Doxycycline 100 mg PO twice daily for 7 days can substitute
azithromycin if needed.
• Fluoroquinolones: not recommended. High rates of resistance.
7.2. CHLAMYDIAL URETHRITIS & CERVICITIS
• Important cause of postgonococcal urethritis.
• Co - infection with gonococci and chlamydiae is common.
• Post - gonococcal (i.e: Chlamydial) urethritis may persist after
successful treatment of the gonococcal component.
• Infection with organisms not readily cultured by ordinary
methods (such as Chlamydia and certain anaerobes)
• Intermittent or low-count bacteriuria
• Reaction to toiletries or disinfectants
• Symptoms related to sexual intercourse
• Post – menopausal atrophic vaginitis

CLINICAL FEATURES TREATMENT

• Urethral/cervical discharge: less painful, less purulent, and
watery compared with gonococcal infection.
• Women infected with chlamydiae may be asymptomatic or may
have features of cervicitis, salpingitis, or PID.
• Antibiotics if suspected infection
• Vaginal estrogen cream in post – menopausal women
9. BONUS TOPIC: ISOLATED/PRIMARY ORCHITIS

• Long - term sequelae: ectopic pregnancy, infertility. MUMPS ORCHITIS

• Assume a patient with clinical signs and symptoms of urethritis • Most common orchitis.
or cervicitis to have chlamydial infection until proven otherwise.
• Develops in 20 – 30% of post - pubertal patients with a mumps
LAB FINDINGS virus infection.

• NAAT in urine or vaginal swabs: Diagnostic. • Usually develops as the parotid swelling is waning.

• A NAAT negative for chlamydia reliably excludes the diagnosis of • Serum IgM supports the diagnosis.
chlamydial urethritis or cervicitis. No therapy needed.
• Complication: testicular atrophy > may cause infertility if
SCREENING bilateral. Partial testicular atrophy is associated with persistent
testicular pain.
Do active screening in:
SYPHILITIC ORCHITIS
• Women: pregnant, sexually active < 25 y age, anyone with risk
factors for STD • Uncommon.

• Men: Risk factors for STD i.e. HIV-positive men or men who have • Presentations:
sex with men.
1. Bilateral orchitis: feature of congenital syphilis
TREATMENT
2. Interstitial fibrosis: Causes painless destruction of the testis
• Non – pregnant/Male: Any one of
3. Gumma of testis: unilateral slowly growing painless swelling.
1. Azithromycin: Single oral 1 - g dose or May be difficult to distinguish from neoplasm without surgical
exploration.
2. Doxycycline: 100 mg PO twice daily for 7 days or
Diagnosis: confirmed by serology.
3. Levofloxacin: 500 mg PO once daily for 7 days

• Pregnant: Azithromycin Single oral 1 - g dose (preferred and

safe, Doxicycline and fluoroquinolones contraindicated in
pregnancy).
10. GENITOURINARY DRUGS IN PREGNANCY
• Presumptive therapy: sexual contacts of documented cases.
Safe in pregnancy
Exclude HIV and syphilis.
• Penicillins
• Cephalosporins
8. URETHRAL SYNDROME • Nitrofurantoin (Avoid at
term.  risk of neonatal
• Some patients, usually female, have symptoms suggestive of jaundice if used within 30
urethritis and cystitis but no bacteria are cultured from the urine. days of delivery).
• Fosfomycin
POSSIBLE EXPLANATIONS • Trimethoprim (safe after
1st trimester).
Unsafe in pregnancy
st
• Sulfonamides (1 trimester:
rd
teratogenic. 3 trimester: may
interfere with bilirubin binding >
neonatal jaundice and
kernicterus)
• Fluoroquinolones (potential
teratogenic effects on fetal
cartilage and bone)
• Doxicycline
 11. EXAMPLES OF PRESCRIBING FOR GENITOURINARY TRACT INFECTIONS

Example 1 – Acute bacterial prostatitis: A 57 y old male presented Hospitalize if necessary.

with abrupt onset of fever, frequency of micturition, urgency, dysuria
and suprapubic pain. There is extreme tenderness on prostate
palpation during DRE.
Management
Ask necessary questions and give advice***
Identify underlying risk factors and causes and treat any remediable
cause***

Ask necessary questions and give advice*** Take hot water bath (Take povisep mixed lukewarm water in a bucket.
Sit with perineum immersed for 15 – 30 minutes twice daily) – for
Identify underlying risk factors and causes and treat any remediable symptomatic relief
cause***
Drugs: 1. Inj. Traxon 1 g IV stat and BD plus Inj. Gentin 1.5 mg/kg IV
Hospitalize if required. stat and 8 hourly until afebrile for 24 – 48 hours, followed by Tab.
Levoxin 750 0 + 0 + 1 for 4 – 6 weeks
Non – hospitalized:
2. Cap. Reumacap SR 75 1 + 0 + 1 (after meals) – if pain
Diet: Plenty of fluid (>2 L/day).
3. Cap. Maxpro 40 1 + 0 + 0 (before meals) – if pain
Drugs: Tab. Ciprocin 500 1 + 0 + 1 for 4 to 6 weeks or
4. Tab. Uromax 0.4 0 + 1 + 0 – if obstructive symptoms
Tab. Levoxin 250/500 0 + 0 + 1 for 4 to 6 weeks or
Example 3 – Acute epididymitis (Sexually transmitted variety): A 25 y
Tab. Cotrim DS 1 + 0 + 1 for 4 to 6 weeks or old male having multiple sexual partners presents with right sided
scrotal pain radiating to flank. There is a tender mass above Rt. testis.
Fosamin 3 g – 1 packet with ½ glass water – one dose every 3 days for
Pt. is mildly pyrexic.
21 days.
Management
Hospitalized:
Hospitalize if necessary.
Diet: Plenty of fluid (>2 L/day).
Ask necessary questions and give advice***
Drugs: 1. Inf. 0.9% Normal saline as needed to rehydrate
Identify underlying risk factors and causes and treat any remediable
2. Inj. Anadol 100 mg 1 amp. IM 8 hrly and SOS
cause***
3. Inj. Emistat 8 mg 1 vial IV 8 hrly and SOS
Drink plenty of fluid, bed rest, ice, anti – pyretic, analgesia and scrotal
elevation/support.
4. Inj. Gentin 80 mg 1.5 mg/kg IV stat and 8 hrly until afebrile for 24 –
48 hrs (check renal function repeatedly!)
Sexual counselling.
5. Inj. Ceftron 1 g 1 vial IV stat and BD until afebrile for 24 - 48 hrs
Evaluate and treat any sexual partners from the preceding 60 days.
(max. 14 days) followed by one of
Drugs: 1. Inj. Exephin 250 mg IM stat
6. Tab. Ciprocin 500 1 + 0 + 1 for rest of 4 – 6 weeks or
2. Cap. Doxicap 100 1 + 0 + 1 for 10 – 14 days.
Tab. Levoxin 750 0 + 0 + 1 for rest of 4 – 6 weeks.
Example 4 – Acute epididymitis (Non – sexually transmitted variety):
(Give drug according to C/S)
A 46 y old male presents with left sided scrotal pain radiating to flank,
dysuria, urgency and frequency of micturition. There is a tender mass
[N.B: If urinary retention develops, do ‘in and out’ catheterization to
over Lt. testis. He has h/o UTI.
relieve the initial obstruction or use short–term (12 hours) small
indwelling urinary catheter.]
Management
Example 2 – Chronic bacterial prostatitis: A 65 y old male presented
Hospitalize if necessary.
with fever, dull perineal discomfort and obstructive bladder symptoms.
He has h/o UTI. On DRE, prostate feels indurated. Urine R/E – normal. Ask necessary questions and give advice***
Post - prostatic massage voided urine shows bacterial growth in
culture. Identify underlying risk factors and causes and treat any remediable
cause***
Management
Drink plenty of fluid, bed rest, ice, analgesia and scrotal elevation/ Example 8 – Chlamydial urethritis: A 33 y old sexually active female
support. presented with mildly painful, somewhat purulent urethral discharge.
A NAAT of urethral discharge confirms Chlamydia.
Drugs: 1. Tab. Levoxin 500 0 + 0 + 1 for 10 – 14 days.
Management
Example 5 – Chronic non - TB epididymitis: A 49 y old male was
previously diagnosed as a case of Non – sexually transmitted Exclude pregnancy first.
epididymitis and treated with oral Levofloxacin 250 mg daily for 7 days.
He was feeling well since then but few weeks later, he developed Treat sexual contacts.
intermittent episodes of scrotal discomfort. On palpation, Epididymis is
Exclude HIV and syphilis.
thickened and tender. TB is excluded.
Drugs: If not pregnant:
Management
Tab. Zimax 500 2 tab PO stat or
Ask necessary questions and give advice***
Cap. Doxicap 100 1 + 0 + 1 for 7 days or
Identify underlying risk factors and causes and treat any remediable
cause***
Tab. Levoxin 500 0 + 0 + 1 for 7 days
Drink plenty of fluid, bed rest, ice, analgesia and scrotal elevation/
If Pregnant: Tab. Zimax 500 2 tab PO stat
support if needed.

Drugs: 1. Tab. Levoxin 500 0 + 0 + 1 for 4 – 6 weeks or

Cap. Doxicap 100 1 + 0 + 1 for 4 – 6 weeks.

2. Tab. Cortan 20 1 + 0 + 0 (after meals) for 14 days

then ½ + 0 + 0 (after meals) for next 14 days.

Example 6 – Chronic TB epididymitis: A 63 y old male had pulmonary

TB 8 y back and had Category – 1 anti – TB therapy for 6 months. Now,
he complains of Rt. hemiscrotal swelling. O/E, Rt. epididymis is firm
and craggy. Urine microscopy reveals AFB. Scrotal USG: thickened Rt.
epididymis. A diagnosis of TB epididymitis is made.

Management

Drugs: Re – treatment (4 – FDC plus Levofloxacin for 6 months)

Example 7 – Gonococcal urethritis: A 36 y old sexually active female

presented with dysuria, urinary frequency, urgency and purulent
urethral discharge. Gram stain of urethral discharge shows gram
negative diplococci in PMN.

Management

Partner notification and referral of contacts.

Early treatment of contacts.

Treatment of sex partners by patient - delivered partner therapy.

Test and treat pt. and sex partners for HIV infection and syphilis.

Drugs: 1. Inj. Ceftron 250 mg IM stat (or Tab. Cef – 3 DS 400 mg 1 tab
stat) plus

2. Tab. Zimax 500 2 tab PO stat (or Cap. Doxicap 100 1 + 0 + 1 for 7
days)
 12. 1ST LINE DRUG TREATMENT FOR DIFFERENT GENITOURINARY TRACT INFECTIONS
*Choose any 1 from drug treatment column until otherwise stated, drugs are oral until otherwise stated.
Name of the condition
Acute bacterial prostatitis
Chronic bacterial prostatitis
Acute epididymitis (+ orchitis)
A. Sexually transmitted
variety (< 35 y old)
B. Men who practice
insertive anal intercourse
C. Non - sexually transmitted
variety (> 35 y old)
Chronic non - tuberculous
epididymitis
Tuberculous epididymo -
orchitis
Gonococcal urethritis
Chlamydial urethritis
Non – pregnant
female/Male
Pregnant
DS = double strength, IM = intramuscular, IV = Intravenous, PO = per oral, BD = twice daily, OD = once daily
Drug treatment* Duration Comments
IV Ceftriaxone 1 g BD PLUS Gentamicin IV : up to 24 – 48 Perineal, sacral, or suprapubic pain, fever,
1.5 mg/kg 8 hourly FOLLOWED BY hours after fever frequency, urgency. Obstructive features if
Co – trimoxazole 960 mg (DS) BD subsides, then oral = inflamed prostate swells (> urinary retention),
Ciprofloxacin 500 mg BD total 4 – 6 weeks DRE: Prostate: Warm, swollen, often
Fosfomycin 3 – g every 3 days for 21 exquisitely tender [Caution! Do DRE gently,
days vigorous manipulations may result in
septicemia. Prostatic massage is
contraindicated.]
IV Ceftriaxone 1 g BD plus Gentamicin IV: up to 24 – 48 Treat recurrence for minimum 12 weeks
1.5 mg/kg 8 hourly FOLLOWED BY hours after fever
subsides
Levofloxacin 750 mg OD 28 days
Ciprofloxacin 500 mg BD 1 – 3 months
IM Ceftriaxone 250 mg stat PLUS 10 – 14 days
Doxycycline 100 mg BD
IM Ceftriaxone 250 mg stat PLUS 10 – 14 days
Levofloxacin 500 mg daily
Levofloxacin 500 mg daily 10 – 14 days
Levofloxacin 500 mg daily 4 – 6 weeks Use concomitant anti – inflammatory agents
Doxycycline 100 mg BD
৹
Anti – TB drugs According to TB 2৹ TB epididymitis may resolve when the 1
protocol (Min. 6 focus is treated.
months)
IM Ceftriaxone 250 mg PLUS Both single dose Doxycycline 100 mg BD for 7 days can
Azithromycin 1000 mg substitute azithromycin
Alternative: Cefixime 400 mg PLUS Both single dose
Azithromycin 1000 mg
Azithromycin 1000 mg Single dose
Doxycycline 100 mg BD 7 days
Levofloxacin 500 mg OD 7 days
Azithromycin 1000 mg Single dose Doxicycline and fluoroquinolones
contraindicated in pregnancy