Review – Infections Management of Urethritis: Is It Still the Time for Empirical Antibiotic Treatments? Riccardo Bartoletti a, *, Florian M.E. Wagenlehner b , Truls Erik Bjerklund Johansen c,d , Bela Ko ¨ves e , Tommaso Cai f , Zafer Tandogdu g , Gernot Bonkat h a Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy; b Clinic und Polyclinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany; c Dept. of Urology, Oslo University Hospital, Oslo, Norway; d Institute of Clinical Medicine, University of Oslo, Oslo, Norway; e Department of Urology, South-Pest Teaching Hospital, Budapest, Hungary; f Department of Urology, Santa Chiara Regional Hospital, Trento, Italy; g Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK; h Alta Uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry (COB), University of Basel, Basel, Switzerland E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 18 ) X X X – X X X ava ilable at www.sciencedirect.com journa l homepage: www.europea nurology.com/eufocus Article info Article history: Accepted October 5, 2018 Associate Editor: Christian Gratzke Keywords: Urethritis Urethral inflammation Gonococcal urethritis Nongonococcal urethritis Nucleic acid amplification test Empirical treatment Abstract Context: Urethritis prevalence in Europe changed in the last years due to both the increase of migratory streams from North Africa and the more frequent exposition of males to relevant risk factors. Owing to these reasons, urethritis treatment should be optimized by accurate microbiological investigations to avoid the risk of persistence, recurrence, or reinfection. Objective: The aim of this systematic review is to optimize the treatments for urethritis and investigate the applicability of nucleic acid amplification test (NAAT) as the primary microbiological investigation. Evidence acquisition: A literature search in Medline, Cochrane, and Google Scholar databases was conducted up to June 2018. Subject headings were selected as follows: Urethritis OR gonococcal urethritis OR non-gonococcal urethritis AND Antibiotics OR Recurrence. A total of 528 abstracts were identified and selected. Finally, 12 full-text articles were selected for a qualitative synthesis. The Preferred Reported Items for Systematic Reviews and Meta-Analyses statement was used to perform an accurate research checklist and report. Evidence synthesis: Empirical treatments are no more recommended, although a broad spectrum of antibiotic therapy may be initiated while awaiting the results from patho- gens’ microbiological characterization. First-line treatment for gonococcal urethritis consists of a single dose of ceftriaxone/azithromycin combined therapy. Specific thera- pies should be initiated for nongonococcal urethritis according to each single pathogen involved in the infection process. Owing to this reason, NAAT is mandatory in the clinical approach to the disease, although the Gram stain of urethral discharge or smear remains applicable for some less frequent nongonococcal urethritis. Moreover, the urethritis “modern view” also includes noninfectious etiologies that occurred after traumas or injection of irritating compounds. Sexual abstinence of at least 7 d should be observed from the start of treatment to avoid reinfection, while sexual partners should evenly be treated. Conclusions: The treatment of urethritis implies accurate determination of pathogens involved in the infection process by NAAT with subsequent appropriate antibiotic therapy, thus avoiding the risk of antibiotic resistance and overuse of antibiotics * Corresponding author. University Urology Unit, Cisanello Hospital Blg. 30, Via Paradisa 4, 56124 Pisa, Italy. Tel.: +39 3483630658. E-mail addresses: riccardo.bartoletti@hotmail.com, riccardo.bartoletti@unipi.it (R. Bartoletti). EUF-619; No. of Pages 7 Please cite this article in press as: Bartoletti R, et al. Management of Urethritis: Is It Still the Time for Empirical Antibiotic Treatments?. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2018.10.006 https://doi.org/10.1016/j.euf.2018.10.006 2405-4569/© 2018 Published by Elsevier B.V. on behalf of European Association of Urology.