Urethral Discharge — বাংলা Clinical Note

Urethral discharge হলো মূত্রনালী বা urethra থেকে স্বাভাবিক প্রস্রাব/বীর্য ছাড়া অস্বাভাবিক তরল বের হওয়া—যেমন সাদা, হলুদ, সবুজ, ঘন পুঁজের মতো বা পাতলা মিউকাস discharge। এটি সাধারণত urethritis-এর লক্ষণ, এবং sexually transmitted infection বা STI—বিশেষ করে gonorrhea ও chlamydia—সবচেয়ে গুরুত্বপূর্ণ কারণ। CDC urethritis diagnosis-এ visible mucoid/mucopurulent/purulent discharge, first-void urine leukocyte esterase positive, বা urine sediment-এ ≥10 WBC/HPF-কে objective evidence হিসেবে নেয়।

1. Definition / সংজ্ঞা

Urethral discharge মানে urethral meatus বা penis-এর মাথার ছিদ্র দিয়ে অস্বাভাবিক secretion বের হওয়া। এটি নিজে রোগ নয়—বরং underlying infection/inflammation-এর sign।

Common clinical meaning:
Urethral discharge + dysuria/জ্বালা + urethral irritation = urethritis until proven otherwise.

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2. Etiology / Causes — কারণগুলো

1) Neisseria gonorrhoeae — Gonococcal urethritis

• খুব common STI cause।
• সাধারণত ঘন হলুদ/সবুজ পুঁজের মতো discharge, প্রস্রাবে জ্বালা, urgency থাকতে পারে।
• untreated থাকলে epididymitis, prostatitis, infertility risk, disseminated gonococcal infection হতে পারে।
• Gonorrhea-এর জন্য CDC first-line treatment হলো ceftriaxone IM single dose।

2) Chlamydia trachomatis — Non-gonococcal urethritis / NGU

• discharge অনেক সময় পাতলা/স্বচ্ছ/সাদা হতে পারে।
• অনেক রোগী asymptomatic।
• CDC অনুযায়ী NGU-এর গুরুত্বপূর্ণ cause; chlamydia-associated NGU untreated থাকলে epididymitis, prostatitis, reactive arthritis হতে পারে।

3) Mycoplasma genitalium

• persistent বা recurrent urethritis-এর বড় কারণ।
• initial antibiotic নেওয়ার পরও symptoms থাকলে ভাবতে হবে।
• CDC persistent/recurrent symptoms-এ M. genitalium testing recommend করে।

4) Trichomonas vaginalis

• heterosexual men-এ urethritis করতে পারে।
• partner-এর vaginal discharge/itching থাকলে suspicion বেশি।
• persistent/recurrent urethritis-এ অথবা high prevalence setting-এ test করা উচিত।

5) HSV / Herpes simplex virus

• সাধারণ discharge-এর চেয়ে genital ulcer, painful blister, meatitis, severe dysuria বেশি থাকে।
• CDC অনুযায়ী genital herpes treatment-এর mainstay হলো systemic antiviral; first episode-এ acyclovir/valacyclovir/famciclovir ব্যবহার হয়।

6) Adenovirus

• oral-genital contact-এর পরে dysuria, meatal inflammation, conjunctivitis সহ urethritis হতে পারে।

7) Enteric bacteria / UTI-related bacteria

• insertive anal intercourse, UTI, prostatitis, instrumentation/catheterization-এর পরে হতে পারে।
• urine culture দরকার হতে পারে।

8) Non-infective causes

• Chemical irritation: harsh soap, antiseptic, lubricant, spermicide
• Trauma: vigorous sex/masturbation, catheterization
• Chronic prostatitis/chronic pelvic pain syndrome
• Physiological prostatorrhea/spermatorrhea—যা STI নয়, কিন্তু discharge মনে হতে পারে

Clinical Features / Symptoms — লক্ষণগুলো

Urethral discharge-এর লক্ষণ

• Penis-এর মাথা দিয়ে সাদা/হলুদ/সবুজ/স্বচ্ছ তরল বের হওয়া
• সকালে ঘুম থেকে ওঠার পর discharge বেশি দেখা
• underwear-এ দাগ
• urethral opening লাল/ফোলা
• discharge চাপ দিলে বের হওয়া

Urinary symptoms

• প্রস্রাবে জ্বালা বা burning micturition
• প্রস্রাবের সময় ব্যথা
• urinary frequency/urgency
• incomplete emptying feeling

Genital symptoms

• penis/urethra-তে চুলকানি বা irritation
• testicular pain/swelling — epididymitis suspect
• perineal pain, pelvic pain, ejaculation pain — prostatitis/chronic pelvic pain consider
• genital ulcer/blister — herpes/syphilis consider
• inguinal lymph node enlargement

Systemic/red flag symptoms

• fever, severe testicular pain, scrotal swelling
• joint pain, rash, conjunctivitis — reactive arthritis/disseminated gonorrhea consider
• severe lower abdominal pain in female partner — PID risk

CDC NGU clinical presentation হিসেবে urethral discharge, irritation, dysuria, meatal pruritus উল্লেখ করে।

4. Clinical Diagnosis & Investigations — Specific Workup

A) Clinical diagnosis

Examine:

• urethral meatus: discharge, redness, ulcer, vesicle
• gently milk urethra if discharge not visible
• genital ulcer/blister
• testis/epididymis tenderness
• inguinal lymph node
• prostate exam only if prostatitis suspected

B) Essential investigations

1) First-void urine NAAT

Best practical test for:

• N. gonorrhoeae
• C. trachomatis

CDC recommends suspected/confirmed NGU cases be tested for chlamydia and gonorrhea using NAAT.

2) Urethral swab microscopy / Gram stain

Findings:

• intracellular gram-negative diplococci → gonorrhea highly likely
• WBC present but no diplococci → NGU likely
• ≥2 WBC/oil immersion field in high-prevalence STI clinics or ≥5 WBC/HPF in lower-prevalence settings can support urethritis diagnosis।

3) First-void urine routine/microscopy

• leukocyte esterase positive
• ≥10 WBC/HPF supports urethritis
• nitrite/bacteria → UTI possibility

4) Urine culture & sensitivity

Do if:

• UTI suspected
• recurrent symptoms
• fever/flank pain
• treatment failure
• elderly/diabetic/catheter/instrumentation history

5) M. genitalium NAAT

Do if:

• persistent/recurrent urethritis after standard therapy
• no re-exposure but symptoms persist
  CDC recommends M. genitalium testing in persistent/recurrent symptoms after empiric treatment।

6) Trichomonas test

Do if:

• partner infected
• recurrent/persistent urethritis
• local prevalence high
• heterosexual exposure with partner symptoms

7) STI screening

Must consider:

• HIV Ag/Ab
• VDRL/RPR + TPHA/TPPA for syphilis
• HBsAg, anti-HCV depending risk
• HSV PCR if ulcer/blister present

CDC NGU management explicitly advises HIV and syphilis testing.

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5. Differential Diagnosis

• Gonorrhea
• Chlamydia
• Mycoplasma genitalium
• Trichomoniasis
• Genital herpes
• UTI
• Acute/chronic prostatitis
• Epididymitis
• Balanitis/candidiasis
• Syphilitic chancre with secondary discharge/irritation
• Chemical urethritis
• Trauma/instrumentation
• Physiological seminal/prostatic fluid discharge

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6. Complications — রোগ জটিলতা

Male complications

• Epididymitis: testicular pain/swelling; untreated হলে fertility affect করতে পারে।
• Prostatitis: pelvic/perineal pain, painful ejaculation, urinary symptoms।
• Reactive arthritis: urethritis + arthritis + conjunctivitis pattern হতে পারে, especially chlamydia-associated।
• Urethral stricture: recurrent inflammation/scarring হলে urine stream narrow হতে পারে।
• Infertility/subfertility: repeated epididymo-orchitis/prostatic involvement হলে risk।
• Disseminated gonococcal infection: fever, rash, migratory polyarthralgia, septic arthritis—rare but serious।
  CDC chlamydia-associated NGU complications হিসেবে epididymitis, prostatitis ও reactive arthritis উল্লেখ করেছে।

Partner/female complications

• PID
• chronic pelvic pain
• ectopic pregnancy
• infertility
• pregnancy complication
• neonatal conjunctivitis/pneumonia if untreated chlamydia/gonorrhea in pregnancy

Public health complications

• HIV transmission/acquisition risk increase
• partner reinfection
• antibiotic resistance, especially gonorrhea

7. Treatment Management — Guideline-based

General rule

Sample collect → same-day empiric treatment if discharge is present and follow-up uncertain. WHO syndromic guidance supports confirmed urethral discharge cases being treated for both N. gonorrhoeae and C. trachomatis to ensure same-day treatment.

Empiric adult regimen for typical male urethral discharge

If gonorrhea/chlamydia not yet excluded:

• Ceftriaxone 500 mg IM single dose
  • if body weight ≥150 kg: 1 g IM single dose
• PLUS
• Doxycycline 100 mg PO twice daily for 7 days if chlamydia not excluded

CDC uncomplicated urethral gonorrhea regimen is ceftriaxone 500 mg IM once, and doxycycline 100 mg twice daily for 7 days if chlamydia has not been excluded.  

1) Ceftriaxone

• Generic name: Ceftriaxone sodium
• Therapeutic category: Antibiotic
• Pharmacological class: 3rd-generation cephalosporin
• কেন used হয়: Suspected/confirmed gonorrhea urethritis বা thick purulent urethral discharge-এর first-line drug।
• Adult dose:
  • Ceftriaxone 500 mg IM stat / single dose
  • Body weight ≥150 kg হলে 1 g IM single dose
  • Chlamydia exclude না হলে সাথে Doxycycline 100 mg BD × 7 days দিতে হয়। CDC uncomplicated gonorrhea-তে এই ceftriaxone regimen recommend করে।
• Duration: Single dose
• Side effects: Injection site pain, diarrhea, nausea, rash, allergy/anaphylaxis, rare C. difficile diarrhea
• Drug interaction / caution:
  • Severe penicillin/cephalosporin allergy থাকলে caution
  • Warfarin-এর সাথে INR/bleeding risk বাড়তে পারে
  • Calcium-containing IV fluid-এর সাথে same line avoid
• Bangladesh available brand examples:
  • Enocef IM Injection 500 mg/vial
  • Eracef IM Injection 250 mg, 500 mg, 1 g/vial
  • Xone-3 500 mg/vial
    MedEx Bangladesh ceftriaxone brand list-এ 500 mg vial এবং Eracef 250 mg/500 mg/1 g preparations দেখা যায়।

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2) Doxycycline

• Generic name: Doxycycline hydrochloride
• Therapeutic category: Antibiotic
• Pharmacological class: Tetracycline
• কেন used হয়: Chlamydia trachomatis ও non-gonococcal urethritis / NGU treatment; gonorrhea treatment-এর সাথে add হয় যদি chlamydia exclude না করা থাকে।
• Adult dose:
  • Doxycycline 100 mg orally twice daily × 7 days
• Duration: 7 days
• Side effects: Gastritis, nausea, vomiting, esophagitis, photosensitivity, diarrhea
• Drug interaction / caution:
  • Milk, calcium, iron, zinc, antacid-এর সাথে absorption কমে—২–৪ ঘণ্টা gap
  • Warfarin effect বাড়তে পারে
  • Pregnancy এবং usually <8 years children-এ avoid
  • Full glass water দিয়ে খেতে হবে; খাওয়ার পর সাথে সাথে শোয়া যাবে না
• Bangladesh available brand examples:
  • Doxicap 100 mg
  • Doxicline 100 mg
  • Doxico 100 mg
  • Doxicon 100 mg
  • Doxylin 100 mg
    MedEx doxycycline page-এ uncomplicated genital chlamydia/NGU dose হিসেবে 100 mg twice daily regimen উল্লেখ আছে এবং Doxicap/Doxicline/Doxico/Doxicon 100 mg brands listed আছে।

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3) Azithromycin

• Generic name: Azithromycin dihydrate
• Therapeutic category: Antibiotic
• Pharmacological class: Macrolide / azalide
• কেন used হয়: Doxycycline contraindicated হলে chlamydia/NGU alternative; কিছু ক্ষেত্রে pregnancy chlamydia-তে ব্যবহার হয়। Routine gonorrhea treatment-এ ceftriaxone-এর বিকল্প নয়।
• Adult dose:
  • Alternative NGU/chlamydia: Azithromycin 1 g orally single dose
  • Alternative extended option: 500 mg day 1, then 250 mg daily day 2–5
• Duration: Single dose অথবা 5 days regimen
• Side effects: Nausea, vomiting, abdominal pain, diarrhea, QT prolongation, rare hepatitis
• Drug interaction / caution:
  • QT-prolonging drugs, antiarrhythmics, digoxin, warfarin-এর সাথে caution
  • Severe liver disease-এ caution
• Bangladesh available brand examples:
  • Ranzith 500 mg tablet
  • Razithro 500 mg tablet
  • Rema-Zith 500 mg tablet
  • Respazit 250 mg capsule / 500 mg tablet
  • Azithromycin 500 mg tablet
    MedEx Bangladesh azithromycin brand page-এ Ranzith, Razithro, Rema-Zith, Respazit 250/500 mg preparations listed আছে।

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4) Cefixime

• Generic name: Cefixime trihydrate
• Therapeutic category: Antibiotic
• Pharmacological class: Oral 3rd-generation cephalosporin
• কেন used হয়: Ceftriaxone injection unavailable/not feasible হলে uncomplicated urogenital gonorrhea-তে alternative; তবে pharyngeal gonorrhea-তে reliable নয়।
• Adult dose:
  • Cefixime 800 mg orally single dose
  • অর্থাৎ 400 mg capsule হলে সাধারণত 2 capsule stat
  • Chlamydia exclude না হলে সাথে doxycycline 100 mg BD × 7 days
• Duration: Single dose
• Side effects: Diarrhea, nausea, abdominal pain, rash, allergy
• Drug interaction / caution:
  • Cephalosporin allergy
  • Warfarin-এর সাথে INR বাড়তে পারে
• Bangladesh available brand examples:
  • Cefixim 400 mg capsule
  • Cefixime-A 400 mg capsule
  • Ofex 400 mg capsule
  • Trifix 400 mg capsule
  • Triocim 400 mg capsule
    MedEx Bangladesh cefixime brand list-এ Cefixim/Cefixime-A/Ofex/Trifix/Triocim 400 mg preparations listed আছে।

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5) Metronidazole

• Generic name: Metronidazole
• Therapeutic category: Antiprotozoal + antibacterial
• Pharmacological class: Nitroimidazole
• কেন used হয়: Trichomonas vaginalis suspected/confirmed হলে; recurrent urethritis + female partner trichomoniasis থাকলে consider।
• Adult male dose:
  • Metronidazole 2 g orally single dose
    CDC trichomoniasis guideline summary-তে men-এর জন্য metronidazole 2 g orally single dose উল্লেখ আছে।
• Duration: Single dose
• Side effects: Metallic taste, nausea, vomiting, abdominal pain, headache, dark urine; prolonged use-এ neuropathy
• Drug interaction / caution:
  • Alcohol avoid during treatment এবং অন্তত 48–72 hours after
  • Warfarin effect/INR বাড়ায়
  • Disulfiram-এর সাথে avoid
  • Lithium toxicity risk বাড়তে পারে
• Bangladesh available brand examples:
  • Flagyl 400 mg tablet
  • G-Metronidazole 400 mg tablet
  • Flamyd 200 mg/5 ml suspension
    MedEx Bangladesh metronidazole page-এ Flagyl 400 mg, G-Metronidazole 400 mg এবং Flamyd suspension preparations listed আছে।

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6) Moxifloxacin

• Generic name: Moxifloxacin hydrochloride
• Therapeutic category: Antibiotic
• Pharmacological class: Fluoroquinolone
• কেন used হয়: Persistent/recurrent urethritis-এ Mycoplasma genitalium suspected/confirmed হলে, especially macrolide-resistant case। Routine first-line urethral discharge drug নয়।
• Adult dose:
  • Usually staged regimen:
    • Doxycycline 100 mg BD × 7 days, then
    • Moxifloxacin 400 mg once daily × 7 days
      CDC M. genitalium guideline-এ moxifloxacin 400 mg orally once daily for 7 days regimen উল্লেখ আছে।
• Duration: 7 days after doxycycline lead-in
• Side effects: Nausea, diarrhea, dizziness, QT prolongation, tendonitis/tendon rupture, neuropathy, dysglycemia, CNS effects
• Drug interaction / caution:
  • Antacid, iron, zinc, calcium absorption কমায়—gap দিতে হবে
  • QT-prolonging drugs-এর সাথে avoid/caution
  • Warfarin interaction
  • Pregnancy, tendon disease, aortic aneurysm risk, arrhythmia থাকলে caution
• Bangladesh available brand examples:
  • Maxiflox 400 mg
  • Maximox 400 mg
  • Moxana 400 mg
  • Moxibac 400 mg
  • Moxif 400 mg
  • Moxifix 400 mg
  • Moxilocin 400 mg
  • Moxquin 400 mg
  • Odycin 400 mg
  • Optimox 400 mg
    MedEx Bangladesh moxifloxacin brand list-এ এই 400 mg tablet brands listed আছে।

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7) Acyclovir

• Generic name: Acyclovir / Aciclovir
• Therapeutic category: Antiviral
• Pharmacological class: Guanosine nucleoside analogue antiviral
• কেন used হয়: Urethral discharge-এর সাথে painful genital ulcer/blister, severe dysuria, meatitis থাকলে HSV urethritis/genital herpes suspect করে ব্যবহার।
• Adult dose, first episode genital herpes:
  • Acyclovir 400 mg orally three times daily × 7–10 days
    WHO genital HSV guideline-এ first clinical episode-এর জন্য aciclovir 400 mg orally thrice daily for 10 days option উল্লেখ আছে।
• Duration: 7–10 days
• Side effects: Nausea, headache, diarrhea; dehydration/renal disease থাকলে renal toxicity risk
• Drug interaction / caution:
  • Renal impairment হলে dose adjust
  • Nephrotoxic drugs, probenecid-এর সাথে caution
• Bangladesh available brand examples:
  • Clovir 400 mg tablet
  • Novirax 200 mg / 400 mg tablet
  • Simplovir 200 mg / 400 mg tablet; 200 mg/5 ml suspension
  • Viroxi 200 mg tablet
  • Virux 200 mg/5 ml suspension
    MedEx Bangladesh acyclovir oral brand list-এ Clovir, Novirax, Simplovir, Viroxi, Virux preparations listed আছে।

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8) Gentamicin

• Generic name: Gentamicin sulfate
• Therapeutic category: Antibiotic
• Pharmacological class: Aminoglycoside
• কেন used হয়: Severe cephalosporin allergy হলে gonorrhea treatment-এর alternative regimen-এ specialist supervision-এ ব্যবহার করা যায়; routine first-line নয়।
• Adult alternative dose:
  • Gentamicin 240 mg IM single dose + Azithromycin 2 g orally single dose
• Duration: Single dose
• Side effects: Nephrotoxicity, ototoxicity, vertigo, dizziness, neuromuscular blockade rare
• Drug interaction / caution:
  • Renal disease হলে avoid/caution
  • Loop diuretics, amphotericin B, vancomycin, other nephrotoxic drugs-এর সাথে toxicity risk
  • Hearing problem/vestibular disease থাকলে caution
• Bangladesh available brand examples:
  • Egen 80 mg/2 ml
  • G-Gentamicin 40 mg/2 ml, 80 mg/2 ml
  • Gentasol 80 mg/2 ml
    MedEx Bangladesh gentamicin injection list-এ Egen, G-Gentamicin, Gentasol preparations listed আছে।

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Overview / Summary

Urethral discharge-এর empiric core treatment সাধারণত gonorrhea + chlamydia coverage দেয়: ceftriaxone IM single dose + doxycycline 7 days। Persistent/recurrent হলে M. genitalium, trichomonas, HSV, reinfection, partner untreated—এসব evaluate করতে হবে।

Actionable Plan / Steps

1. First-void urine NAAT for gonorrhea + chlamydia।
2. Sample নেওয়ার পর empiric treatment start।
3. Partner treatment না হলে reinfection হবে।
4. Treatment চলাকালীন sex avoid।
5. Persistent symptoms হলে M. genitalium/T. vaginalis test করুন।

Reference List

1. CDC. Sexually Transmitted Infections Treatment Guidelines: Gonorrhea, Urethritis, M. genitalium, Trichomoniasis.
2. WHO. Guidelines for the management of symptomatic sexually transmitted infections, 2021.
3. MedEx Bangladesh drug brand database for ceftriaxone, doxycycline, azithromycin, cefixime, metronidazole, moxifloxacin, acyclovir, gentamicin.

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8. Pharmacological Drug List with Dose, Purpose, Side Effect, Interaction & Bangladesh Brands

Note: নিচের dose adult uncomplicated urethritis/STI context-এর জন্য। Pregnancy, renal/hepatic disease, allergy, children, severe infection, epididymo-orchitis, prostatitis বা PID হলে regimen আলাদা হতে পারে। Bangladesh brand list exhaustive নয়; MedEx-listed commonly available examples দেওয়া হলো।

Drug	Details
1. Generic name: Ceftriaxone	Therapeutic category: Antibiotic. Pharmacological class: 3rd-generation cephalosporin, beta-lactam. Why used: Gonorrhea coverage; purulent urethral discharge/gonococcal urethritis suspected হলে first-line. Dose: 500 mg IM single dose if <150 kg; 1 g IM single dose if ≥150 kg. Add doxycycline if chlamydia not excluded. Duration: single dose. Common side effects: injection-site pain, diarrhea, rash, nausea; rare anaphylaxis, biliary sludge, C. difficile diarrhea. Interactions/cautions: severe beta-lactam allergy; warfarin may increase bleeding/INR; IV calcium caution especially neonates. Bangladesh available brands: Ceftrix 500 mg vial, Dicephin 500 mg/1 g vial, Exephin 500 mg/1 g vial, G-Ceftriax 500 mg/1 g vial, Eracef 500 mg/1 g vial, Trizon 500 mg vial, Traxon 500 mg/1 g vial.
2. Generic name: Doxycycline	Therapeutic category: Antibiotic. Pharmacological class: Tetracycline. Why used: Chlamydia/NGU first-line; ceftriaxone-এর সাথে add করা হয় যদি chlamydia excluded না থাকে. Dose: 100 mg PO twice daily for 7 days. Duration: 7 days. Common side effects: nausea, vomiting, epigastric pain, esophagitis, photosensitivity. Interactions/cautions: milk/calcium/iron/zinc/antacid absorption কমায়—2–4 hours gap; warfarin effect ↑; avoid pregnancy and usually children <8 years. Full glass water দিয়ে খেতে হবে, খাওয়ার পর 30 min শোয়া যাবে না। Bangladesh available brands: Doxicap 100 mg, Doxicline 100 mg, Doxico 100 mg, Doxicon 100 mg.
3. Generic name: Azithromycin	Therapeutic category: Antibiotic. Pharmacological class: Macrolide/azalide. Why used: Doxycycline contraindicated হলে NGU/chlamydia alternative; M. genitalium macrolide-sensitive হলে extended regimen; pregnancy chlamydia ক্ষেত্রে option. Dose for NGU alternative: 1 g PO single dose OR 500 mg once then 250 mg daily for 4 days. Important: Routine gonorrhea treatmentে ceftriaxone-এর বদলে নয়; resistance concern আছে। Side effects: nausea, diarrhea, abdominal pain; rare QT prolongation, arrhythmia, cholestatic hepatitis. Interactions/cautions: QT-prolonging drugs, antiarrhythmics, warfarin, digoxin; severe liver disease caution. Bangladesh available brands: Ezith 250 mg/500 mg, Favozyth 500 mg, Fizyth 500 mg, G-Azithromycin 500 mg, Hyzith 500 mg, Zithrox 500 mg, Azimex 500 mg.
4. Generic name: Cefixime	Therapeutic category: Antibiotic. Pharmacological class: Oral 3rd-generation cephalosporin. Why used: Ceftriaxone injection unavailable/not feasible হলে uncomplicated urogenital gonorrhea alternative. Dose: 800 mg PO single dose. If chlamydia not excluded, add doxycycline 100 mg PO twice daily 7 days. Limitation: Pharyngeal gonorrhea-তে reliable alternative নয়. Side effects: diarrhea, nausea, rash, abdominal pain; rare allergy/C. difficile. Interactions/cautions: cephalosporin allergy; warfarin INR ↑; probenecid level ↑. Bangladesh available brands: G-Cefixime 400 mg capsule, Fixpro 400 mg, Cefixim 400 mg, Cefixime-A 400 mg, Cefim-3 DS 400 mg, Cefimax 400 mg.
5. Generic name: Metronidazole	Therapeutic category: Antiprotozoal/antibacterial. Pharmacological class: Nitroimidazole. Why used: Trichomonas vaginalis suspected/confirmed হলে; recurrent urethritis + infected female partner থাকলে consider. Dose in men: 2 g PO single dose. Recurrent/persistent case: specialist-guided regimen, often 500 mg PO twice daily for 7 days depending scenario. Side effects: metallic taste, nausea, vomiting, abdominal pain, dark urine; long useে neuropathy. Interactions/cautions: alcohol avoid during and 48–72 h after; warfarin INR ↑; lithium toxicity risk; disulfiram avoid. Bangladesh available brands: Flagyl 400 mg, G-Metronidazole 400 mg, Jetrazole 400 mg, Kemet 400 mg, Kilpro 400 mg, Klion 400 mg, Flamyd suspension 200 mg/5 ml.
6. Generic name: Moxifloxacin	Therapeutic category: Antibiotic. Pharmacological class: Fluoroquinolone. Why used: Persistent/recurrent urethritis where M. genitalium detected/suspected after testing; not routine first-line empiric drug. Dose: doxycycline 100 mg twice daily 7 days, then moxifloxacin 400 mg PO once daily 7 days. Side effects: nausea, diarrhea, dizziness, QT prolongation, dysglycemia, tendinitis/tendon rupture, peripheral neuropathy, CNS effects. Interactions/cautions: antacid/iron/zinc/calcium reduce absorption; QT drugs; warfarin; avoid pregnancy; tendon disease, aortic aneurysm risk, arrhythmia caution. Bangladesh available brands: Maxiflox 400 mg, Maximox 400 mg, Moxana 400 mg, Moxibac 400 mg, Moxif 400 mg, Moxifix 400 mg, Moxilocin 400 mg, Moxquin 400 mg, Odycin 400 mg, Optimox 400 mg.
7. Generic name: Acyclovir	Therapeutic category: Antiviral. Pharmacological class: Guanosine nucleoside analogue. Why used: HSV urethritis/genital herpes—painful ulcer/blister, meatitis, severe dysuria থাকলে। Dose first episode: 400 mg PO three times daily for 7–10 days. Side effects: nausea, headache, diarrhea; high dose/IV/dehydrationে renal toxicity. Interactions/cautions: nephrotoxic drugs, probenecid; renal impairmentে dose adjust. Bangladesh available brands: Virux 200 mg/400 mg oral, Viroxi 200 mg, Virux 500 mg/vial injection, Virunil 250/500 mg/vial.
8. Generic name: Gentamicin	Therapeutic category: Antibiotic. Pharmacological class: Aminoglycoside. Why used: Severe cephalosporin allergy হলে CDC alternative regimen-এ specialist-supervised option: gentamicin 240 mg IM single dose + azithromycin 2 g PO single dose. Side effects: nephrotoxicity, ototoxicity, dizziness/vertigo, neuromuscular blockade rare. Interactions/cautions: renal disease, loop diuretics, other nephrotoxic drugs, aminoglycoside allergy. Bangladesh available brands: Egen 80 mg/2 ml, G-Gentamicin 80 mg/2 ml, Gentasol 80 mg/2 ml, Gentin 80 mg/2 ml, Intamycin 80 mg/2 ml.

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9. Follow-up & Partner Management

• Sex abstinence: treatment complete না হওয়া, symptoms resolve না হওয়া, এবং partner treated না হওয়া পর্যন্ত sex avoid। CDC NGU guidance: 7-day regimen complete ও symptoms resolved না হওয়া পর্যন্ত, অথবা single-dose therapy-এর পর 7 দিন পর্যন্ত abstain।
• Last 60 days sexual partners: evaluation, testing, presumptive treatment।
• Gonorrhea/chlamydia/trichomonas confirmed হলে: 3 months পরে repeat testing, reinfection common।
• Symptoms persist করলে: adherence, re-exposure, reinfection, M. genitalium, T. vaginalis, prostatitis, epididymitis reassess।

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10. Prevention — কীভাবে প্রতিরোধ করবেন

• Condom consistent and correct use
• Multiple/new partner হলে regular STI screening
• Symptom থাকলে sex বন্ধ রেখে test + treatment
• Partner treatment ছাড়া শুধু patient treatment করলে reinfection হবে
• Self-medication বা incomplete antibiotic course avoid
• Genital ulcer/discharge হলে HIV, syphilis, hepatitis screening
• High-risk patient হলে HIV PrEP counselling consider
• HPV ও Hepatitis B vaccination status check
• Alcohol/drug-associated risky sex avoid
• Follow-up না করলে antibiotic resistance ও complication risk বাড়ে

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Overview / Summary

Urethral discharge সবচেয়ে বেশি STI-related urethritis-এর sign। সবচেয়ে গুরুত্বপূর্ণ cause হলো gonorrhea + chlamydia, তবে M. genitalium, trichomonas, HSV, adenovirus, UTI/prostatitis-ও বিবেচনায় রাখতে হবে। Typical empiric adult treatment: ceftriaxone IM single dose + doxycycline 7 days, যদি gonorrhea/chlamydia exclude করা না থাকে। Persistent/recurrent case-এ partner reinfection, adherence, M. genitalium ও trichomonas evaluate করতে হবে।

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Actionable Plan / Steps

1. First-void urine NAAT: gonorrhea + chlamydia।
2. Urethral swab Gram stain if available।
3. HIV + syphilis serology routinely।
4. Visible discharge থাকলে sample নেওয়ার পর same-day empiric treatment।
5. Partner treatment: last 60 days।
6. Sex avoid until patient + partner treated and symptoms resolved।
7. 3 months পরে repeat test if STI confirmed।
8. Persistent symptoms হলে M. genitalium/T. vaginalis testing এবং urology/STI specialist referral।

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Reference List

Textbook

1. Harrison’s Principles of Internal Medicine, 21st ed. Sexually Transmitted Infections; Gonococcal and Chlamydial Infections sections.
2. Davidson’s Principles and Practice of Medicine, 24th ed. Infectious Diseases; Genitourinary infections/STI sections.
3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Infectious diseases and inflammation principles.

Guidelines

1. CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. DOI: 10.15585/mmwr.rr7004a1.
2. WHO. Guidelines for the management of symptomatic sexually transmitted infections. 2021.
3. CDC Gonococcal Infections Among Adolescents and Adults; Urethritis and Cervicitis; Mycoplasma genitalium; Trichomoniasis; Genital Herpes guideline pages.

Peer-reviewed / DOI

1. Hazra A, Collison MW, Davis AM. CDC Sexually Transmitted Infections Treatment Guidelines, 2021. JAMA. 2022;327(9):870–871. DOI: 10.1001/jama.2022.1246.
2. Chernesky M, et al. Self-collected meatal swabs vs urine specimens for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men. J Med Microbiol. 2017;66:134–136. DOI: 10.1099/jmm.0.000428.
3. Dize L, et al. Performance of self-collected penile-meatal swabs for detection of C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium by NAAT. Diagn Microbiol Infect Dis. 2016;86:131–135. DOI: 10.1016/j.diagmicrobio.2016.07.018.

Md.Rafiqul Islam Lipu.Date:-25-05-2026 Monday Time:-8-59-39 Pm