Is gonorrhea the most common cause of urethritis in males?

[gregoryhouse]

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I remember reading this in a UWorld question. I had an NBME today and I'm really bothered by what the right answer to this question is.

It was about a 20 year old male with dysuria. Sexually active non-consistent condom use. UA was normal. Then it asked the most common organism.

I picked gonorrhea because I remember reading that gonococcal is the most common cause of urethritis in males, but I feel like this question should have at least mentioned something about a gram stain to differentiate it from chlamydia.

I looked up on uptodate and it doesn't confirm whether gonorrhea is the most common cause or not. I know chlamydia is the most common STD but it seems it only causes urethritis in men a small proportion of the time. It does say dysuria without purulence raises higher suspicion for chlamydia but says that can't be used definitively as symptoms often overlap.

So what do you guys think is the answer? Chlamydia or gonorrhea?

 

[OnePunchBiopsy]

Chlamydia is most common according to UWORLD for Step 2 CK. Just had a question on this.

In terms of symptoms though, in the real world, chlamydia in males can present with dysuria, or it can be asymptomatic. A male patient with Gonorrhea will have lots of purulent urethral discharge, to the point of staining their underwear.

 

[gregoryhouse]

Chlamydia is most common according to UWORLD for Step 2 CK. Just had a question on this.

In terms of symptoms though, in the real world, chlamydia in males can present with dysuria, or it can be asymptomatic. A male patient with Gonorrhea will have lots of purulent urethral discharge, to the point of staining their underwear.

I just went back and looked right now. UWorld definitely states gonorrhea is the most common cause of urethritis in men. Question ID is 2236. So unless UWorld made a mistake, I'd really like to hear peoples opinions on how they would answer the question. I guess you could argue lack of purulence would make chlamydia more likely but that seems like a unfair question as purulence is not necessarily going to be in every gonococcal case and if it is indeed the most common cause then I still feel gonorrhea is the best answer.

 

[Taddy Mason]

I just went back and looked right now. UWorld definitely states gonorrhea is the most common cause of urethritis in men. Question ID is 2236. So unless UWorld made a mistake, I'd really like to hear peoples opinions on how they would answer the question. I guess you could argue lack of purulence would make chlamydia more likely but that seems like a unfair question as purulence is not necessarily going to be in every gonococcal case and if it is indeed the most common cause then I still feel gonorrhea is the best answer.

Everything I was taught 2nd year, and all the practice questions I did for that scenario were always gonnorhea. But, there's always the caveat of treating both together because they supposedly commonly occur together. IMHO it's a bs question and I wouldn't lose sleep over it.

 

[gregoryhouse]

Everything I was taught 2nd year, and all the practice questions I did for that scenario were always gonnorhea. But, there's always the caveat of treating both together because they supposedly commonly occur together. IMHO it's a bs question and I wouldn't lose sleep over it.

Yea I agree its a BS question.

I took my CK on monday before I took my family medicine shelf which was today, so I was kind of looking at this shelf exam to give me reassurance and so I'm most likely being hypercritical of all the questions.

The good news is after today I dont have to worry about this BS til Step 3 and that test is just about passing. I just wish they would hurry up and release my CK scores so I could truly relax.

 

[PhillyMed777]

Yea I agree its a BS question.

I took my CK on monday before I took my family medicine shelf which was today, so I was kind of looking at this shelf exam to give me reassurance and so I'm most likely being hypercritical of all the questions.

The good news is after today I dont have to worry about this BS til Step 3 and that test is just about passing. I just wish they would hurry up and release my CK scores so I could truly relax.

I feel you man. Every step of the way is tricky, if you are trying to do well.
hang in there.

 

[Psai]

Yeah the answer is chlamydia when it comes to uworld. In real life you test for both and treat for both with ceftriaxone 250 mg im and azithro 1 gram (for the clam) po

 

[badasshairday]

Probably. And Tinder is the most common cause of gonnococcus.

 

[shoal]

in my antedotal experience chlamydia always comes back positive on the naat. havent seen too many positive gonnorheas. always treat both. ceftriaxone plus doxy is best choice per cdc

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[tux4]

Chlamydia is 3x more reported than gonorrhea in the general population. Also Uworld isn't the be all end all for information. Individuals write the questions and then sometimes cite really random pubmed articles to back it up.


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[badasshairday]

Turns out it doesn't matter because you treat for both anyways. Am I right? I am a few years out from treating std stuff at this point. More into angiography and intervention these days.

 

[TheFutureFatMan]

Probably. And Tinder is the most common cause of gonnococcus.

The GYN I work for said to give you an internet high five.

 

[TheFutureFatMan]

Turns out it doesn't matter because you treat for both anyways. Am I right? I am a few years out from treating std stuff at this point. More into angiography and intervention these days.

Gyn I work for also said yes you TX for both because a. symptoms can be similar and b. when you culture you often find them together, especially in city clinics.

 

[DocWinter]

Chlamydia is by far #1 most common.

I would key in on the purulence and coloration. NG should be green/yellow and probably more copious than chlamydia. Also chlamydia will not gram stain on typical agars.

 

[Teddy.KGB]

Just to be safe, I always assume that my sex partners have chlamydia... that way I don't have to tell them about my chlamydia.

 

[afraidoffailure]

I remember reading this in a UWorld question. I had an NBME today and I'm really bothered by what the right answer to this question is.

It was about a 20 year old male with dysuria. Sexually active non-consistent condom use. UA was normal. Then it asked the most common organism.

I picked gonorrhea because I remember reading that gonococcal is the most common cause of urethritis in males, but I feel like this question should have at least mentioned something about a gram stain to differentiate it from chlamydia.

I looked up on uptodate and it doesn't confirm whether gonorrhea is the most common cause or not. I know chlamydia is the most common STD but it seems it only causes urethritis in men a small proportion of the time. It does say dysuria without purulence raises higher suspicion for chlamydia but says that can't be used definitively as symptoms often overlap.

So what do you guys think is the answer? Chlamydia or gonorrhea?

Yeah, definitely chlamydia is the most likely. Especially if there's no report of discharge from the urethra or WBCs in the UA. I'm a community health provider at a men's STD clinic in an urban area, and that question sets off chlamydia bells for me. And to your point about a gram stain - there's nothing to stain if there isn't any discharge, and dysuria without discharge in males (especially MSW males) typically points to chlamydia and not gonorrhea (in my experience).

Also true that you typically just treat for both to be sure, but if you're working in a free clinic with limited resources, what we'd do in this case is wait for the urine results to come back before providing treatment, unless WBCs were elevated in the UA.

 

[WilliamofOckham]

Standardized tests want you to answer "chlamydia."

 

[Donald Juan]

Board questions: + discharge = gonococcal, - discharge = chlamydia

Real life: treat for both, get a culture + sensitivity in case the patient shows back up without improvement in 2 weeks.

 

[Crayola227]

Yeah, definitely chlamydia is the most likely. Especially if there's no report of discharge from the urethra or WBCs in the UA. I'm a community health provider at a men's STD clinic in an urban area, and that question sets off chlamydia bells for me. And to your point about a gram stain - there's nothing to stain if there isn't any discharge, and dysuria without discharge in males (especially MSW males) typically points to chlamydia and not gonorrhea (in my experience).

Also true that you typically just treat for both to be sure, but if you're working in a free clinic with limited resources, what we'd do in this case is wait for the urine results to come back before providing treatment, unless WBCs were elevated in the UA.

aren't chlamydia intracellular dwelling and therefore cannot be seen on a gram stain?

I thought all the testing for it these days was PCR