Nongonococcal Urethritis (NGU) (Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum): Diagnosis, Treatment, and STI Counseling

👤 Patient Case:

A 23-year-old male presents with mucoid urethral discharge and mild dysuria for 4 days. He denies systemic symptoms. No history of condom use with a recent new sexual partner. Gram stain is negative for gonococci, but shows WBCs >5/HPF. No intracellular diplococci seen.

🌡️ Clinical Presentation:

1. Gonorrhea (หนองในแท้)

Purulent urethral discharge (thick, yellow-green)
Dysuria (burning sensation during urination)
Incubation: 2–7 days
May be asymptomatic in some men

2. Nongonococcal Urethritis (NGU; หนองในเทียม)

Mucoid or watery urethral discharge
Mild dysuria
Incubation: ~1–3 weeks
Common organisms: Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum

🔍 Investigations (must be done before diagnosis)

Urinalysis (UA):→ WBCs >10/HPF, negative nitrites → Suggests urethritis, not UTI.
Urine Gram Stain (UGram):→ WBCs present, no visible organisms (no Gram-negative diplococci)
NAAT (Nucleic Acid Amplification Test):→ Confirms Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum
STI panel (HIV, Syphilis, Hepatitis B/C):→ Rule out co-infections

🧩 Patient Problem List

Nongonococcal urethritis
Likely Chlamydia trachomatis infection
Recent unprotected sexual contact
Elevated urinary WBCs
Negative Gram stain for gonococcus

📌 Final Diagnosis

Nongonococcal urethritis (NGU) — likely Chlamydia trachomatis, pending NAAT

🏥 Management Plan

Management Setting: Outpatient Department (OPD)

No systemic signs, no complications → OPD is appropriate.

💊 Treatment

Problem 1: Nongonococcal Urethritis

Definitive Treatment→ Empirical coverage for Chlamydia and Mycoplasma:

Doxycycline (100 mg) PO bid × 7 daysor (if doxycycline contraindicated)
Azithromycin (1 g) PO single dose

If persistent symptoms (or positive M. genitalium):

Moxifloxacin (400 mg) PO qd × 7–10 days

Supportive Treatment

Paracetamol (500 mg) PO q6h PRN for discomfort
Encourage hydration and rest

🧠 Patient Education

Abstain from sex for at least 7 days and until partner(s) are treated
Notify and treat sexual partners from past 60 days
Reinforce safe sex practices (condoms)
Watch for complications: epididymitis, prostatitis, reactive arthritis