History: Ask about symptoms and sexual history, including timing of recent sexual contacts, partners and their genders, types of sexual contact and exposed sites, condom use, risk behaviours, previous STIs, and relevant partner blood-borne virus risks; also cover medical and surgical history, trauma, vaccination, medicines, allergies, and recreational drug use NICE CKS.
Examination: Examine in the morning or at least 2 hours after urination, check underwear for discharge, inspect the genital area and meatus (retracting the foreskin if present), and gently milk the urethra if discharge is not visible NICE CKS. Palpate for lymphadenopathy, masses, and tenderness, and consider digital rectal examination if prostatitis is suspected NICE CKS.
Tests: Send first-void urine for NAAT for Chlamydia trachomatis and gonorrhoea, checking local test availability; if gonorrhoea NAAT is unavailable, take a urethral swab for gonorrhoea culture NICE CKS. Check local availability of Mycoplasma genitalium testing, and consider urethral swab and/or first-void urine for trichomoniasis testing by culture and/or microscopy, depending on local availability NICE CKS. Offer HIV and syphilis screening, and consider hepatitis screening if risk is high NICE CKS. If UTI is suspected, send a mid-stream urine for culture and sensitivity NICE CKS. Urinary threads may indicate inflammation but are not sensitive or specific for urethritis NICE CKS.
Working diagnosis: Urethritis is supported by urethral discharge, first-void urine leukocyte esterase of 1+ or greater, or urinary threads NICE CKS. Offer referral to a GUM clinic or local specialist sexual health service when urethritis is suspected NICE CKS.