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Urethral Discharge No 628009 Initiating diagnostic measures and pharmacological treatment in a male with urethral discharge Developed in collaboration with an advisory committee consisting of Québec clinicians and experts. Validated by the Comité d’excellence clinique en usage optimal du médicament, des protocoles médicaux nationaux et ordonnances of the Institut national d’excellence en santé et en services sociaux (INESSS). CLINICAL SITUATION OR TARGET POPULATION Symptomatic male: A sexually active male with a mucoid, mucopurulent or purulent urethral discharge1 with or without urethral discomfort or burning on urination CONTRAINDICATIONS TO THE APPLICATION OF THIS PROTOCOL Symptomatic male: < 14 years of age Immunocompromised state2 Urological intervention in the past month (e.g., a prostate biopsy, a cystoscopy or a urinary catheter) The presence of a contraindication to the use of a recommended drug, with no appropriate alternative Three or more episodes of urethral discharge in the past 6 months INSTRUCTIONS 1. PRECAUTIONS For a victim of sexual assault, also follow the recommendations in the Guide d’intervention médicosociale. 2. HEALTH STATUS ASSESSMENT 2.1 Presence of signs and symptoms Look for and characterize the following: Mucoid, purulent or mucopurulent urethral discharge Urethral discomfort Burning on urination Look for the following: Suprapubic, testicular or perianal pain or pain during ejaculation Urinary frequency, vesical tenesmus, hematuria, nocturia or urgency Fever Signs and symptoms of a sexually transmitted and blood-borne infection (STBBI) at other sites of exposure (pharynx or rectum) 2.2 Medical history Date and results of last STBBI screening test STBBI history 1 Urethral discharge reported by the patient or observed by the health professional. 2 Examples of possible causes of an immunocompromised state (see Appendix V of the Guide québécois de dépistage des ITSS): congenital immune deficiency, leukemia, lymphoma, multiple myeloma, nonhematologic cancer, acquired immune deficiency (such as during HIV infection), hemodialysis, and the use of immunosuppressants. INESSS | Quebec’s medical protocol – Urethral discharge 1 2.3 Medication history Medication use Drug allergies 2.4 STBBI risk factors Inquire about STBBI risk factors and assess the indications for STBBI screening. Consult the tool ITSS à rechercher selon les facteurs de risque décelés. 3. PHYSICAL EXAMINATION 3.1 Overall health and vital signs Take temperature, if warranted. 3.2 Inspection of external genitalia Inspect the external genitalia, the urethral meatus and the perinanal region. Palpate the inguinal lymph nodes, the scrotum, the testicles and the epididymis. If the patient is not circumcised, pull back the prepuce to inspect the glans penis. The patient or the clinician will need to induce the urethral discharge to make it more visible. Look for: A mucoid, purulent or mucopurulent urethral discharge or urethral meatus erythema. Epididymal or testicular tenderness on palpation or palpable epididymal swelling. Scrotal erythema or edema or scrotal masses. Skin or anogenital lesions. Lymphadenopathy. 4. INVESTIGATION 4.1 Specimens and microbiological tests Obtain the following: A urine specimen to screen for C. trachomatis and N. gonorrhoeae by nucleic acid amplification testing (NAAT) AND A specimen of urethral secretions for an N. gonorrhoeae culture. If there are signs or symptoms of pharyngeal or rectal infection3, obtain a pharyngeal or rectal specimen (depending on the location of the symptoms) to screen for C. trachomatis and N. gonorrhoeae by NAAT and a specimen for an N. gonorrhoeae culture. In the case of pharyngeal or rectal exposure with no signs or symptoms at these sites, consult the tool Prélèvements et analyses recommandés en fonction de l’infection recherchée chez les personnes asymptomatiques (dépistage). If the patient has risk factors for other STBBIs: Determine the STBBIs to screen for in accordance with the tool ITSS à rechercher selon les facteurs de risque décelés. Obtain the specimen or specimens to screen for the other STBBIs to be checked for according to the tool Prélèvements et analyses recommandés en fonction de l’infection recherchée chez les personnes asymptomatiques (dépistage). 3 The presence of signs or symptoms of pharyngeal or rectal infection is not a contraindication to the application of this protocol, but rather a constraint or situation requiring a mandatory medical consultation (see Section 6). As indicated in Section 4.1, pharmacological treatment can be initiated, and the patient can then be referred to the responding physician. In such case, a pharyngeal or rectal specimen is considered a prereferral specimen. INESSS | Quebec’s medical protocol – Urethral discharge 2 4.2 Details concerning specimens Regardless of type of specimen, it is important to consult the laboratory at the facility concerned for details on the tests used locally (e.g., suitable specimen collection sites, the types of specimens accepted, the applicable specimen collection conditions, storage and transport). 5. THERAPEUTIC APPROACH IN THE PRESENCE OF A MUCOID, PURULENT OR MUCOPURLENT URETHRAL DISCHARGE 5.1 Treatment indication If there is a mucoid, purulent or mucopurlent urethral discharge, initiate pharmacological treatment without waiting for the microbiological test results. Details: Initiate pharmacological treatment even if there are signs or symptoms at other sites of exposure (pharynx or rectum) and then refer the patient to the responding physician. 5.2 Preventive interventions, pharmacological treatment and follow-up Consult the optimal usage guide STBBI – Syndromic approach (urethritis) 6. FOLLOW-UP Inquire about adverse effects and monitor the patient for potential interactions with other drugs or substances. Check if the signs and symptoms persist beyond 7 days after the start of treatment. Order a test of cure in accordance with the recommendations in the optimal usage guide STBBI – Uncomplicated Chlamydia trachomatis or Neisseria gonorrhoeae infection. INESSS | Quebec’s medical protocol – Urethral discharge 3 7. SITUATIONS NECESSITING A SUPPLEMENTARY INVESTIGATION At the time of the evaluation Fever Suprapubic, testicular or perianal pain or pain during ejaculation The following signs noted during the physical examination: epididymal or testicular tenderness on palpation, palpable epididymal swelling, erythema or edema of the scrotum, scrotal masses, skin lesions, anogenital lesions, lymphadenopathy Signs or symptoms at other sites of exposure Signs or symptoms suggestive of a urinary tract infection: urinary frequency, vesical tenesmus, hematuria, nocturia and urgency The following table contains a summary of the specimens to be collected (prereferral specimens) before referring a male in one or more situations requiring, at the time of the evaluation, a mandatory medical consultation with the responding physician based on the existence of certain conditions. CONDITIONS SPECIMENS TO BE OBTAINED BEFORE REFERRING THE PATIENT TO THE (MORE THAN ONE CONDITION MAY APPLY) RESPONDING PHYSICIAN Risk factors for C. trachomatis or N. • Urine specimen to screen for C. trachomatis and N. gonorrhoeae by NAAT AND gonorrhoeae infection AND urethral discharge • Specimen of urethral secretions for an N. gonorrhoeae culture Risk factors for C. trachomatis or N. Pharyngeal or rectal specimen (depending on the location of the symptoms) to screen for gonorrhoeae infection AND signs or symptoms C. trachomatis and N. gonorrhoeae by NAAT and a specimen for an N. gonorrhoeae culture of pharyngeal or rectal infection Risk factors for C. trachomatis or N. Consult the tool Prélèvements et analyses recommandés en fonction de l’infection recherchée gonorrhoeae infection AND pharyngeal or rectal chez les personnes asymptomatiques (dépistage) exposure with no signs or symptoms at these sites Signs or symptoms suggestive of a urinary tract Urine specimen for urinalysis and urine culture infection (urinary frequency, vesical tenesmus, hematuria, nocturia and urgency) • Specimen for a viral identification test for the herpes simplex virus (HSV)5 AND Anogenital ulceration4 • Syphilis serology During or after treatment: Intolerance to the medication Persistence of signs or symptoms 7 days after the start of treatment Signs or symptoms of urethritis that reappear within the 6 weeks following the start of treatment after having first resolved Microbiological test results: Positive screening test results for other STBBIs Screening test results for C. trachomatis and N. gonorrhoeae: - Negative (C. trachomatis and N. gonorrhoeae not present): refer patient to the responding physician only if he is still symptomatic when the result is received; - Positive at other sites (pharynx or rectum): if the nurse does not have the right to prescribe for the purpose of applying the Protocole national pour le traitement d'une infection à C. trachomatis ou à N. gonorrhoeae chez une personne asymptomatique, refer the patient to the responding physician; - Positive for C. trachomatis with an LGV genotype. Test of cure positive for C. trachomatis or N. gonorrhoeae 4 If anogenital ulceration and STBBI risk factors, request on the requisition that tests be performed to screen for the LGV (lymphogranuloma venereum) genotype if the urine (or rectal, if applicable) NAAT results are positive for C. trachomatis. 5 Unless the patient had a viral identification test (culture or NAAT) result that was positive for HSV in the past. Obtaining a specimen
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