Urethritis: causes, symptoms and when it is an STI

Urethritis is inflammation of the urethra, the tube you urinate through. In the Netherlands chlamydia is the best known cause, and it sits in virtually every STI panel. Yet in a sizeable share of men with an inflamed urethra, the lab finds neither chlamydia nor gonorrhoea (Jordan, 2020).

That is the scenario this article is about.

You have symptoms, you get checked, and the result says nothing found. What strikes us is that almost no Dutch page explains what is left after that. Which is exactly the moment you want an answer.

Below you will read what urethritis is, which causes play a role, which of them a standard panel structurally misses, and what a sensible next step looks like. We sell STI tests, so let us be blunt: one of the causes in this story is not in our panel. We would rather tell you that ourselves.

What exactly is urethritis?

Urethritis means inflammation of the urethra. You usually notice it as a burning or painful feeling when you urinate, as discharge, or as both. It describes what is inflamed. It says nothing about the cause.

That distinction is the heart of this page.

Doctors often split urethritis into two groups. Gonococcal urethritis is caused by the gonorrhoea bacterium. Everything else is called non-gonococcal urethritis, or NGU. That second group is the larger one, and the messier one: it holds several possible causes, and sometimes none that the lab can pin down.

The Dutch GP standard on the STI consultation uses the same split in primary care. Thuisarts.nl, the patient platform of the Dutch College of General Practitioners, describes the symptoms in plain language.

How do you recognise urethritis?

The classic combination is burning urination plus discharge from the urethra. In men that discharge is often visible, sometimes only before the first urination of the day. In women the symptoms blend more easily into what looks like a bladder infection. Itching in the urethra and needing to go more often are common additions.

Here is what makes it tricky. The symptoms are not specific.

Burning urination fits a bladder infection just as well, or soap irritation, or a yeast infection. The difference is often where it sits. Symptoms coming from the urethra itself point more towards urethritis. Symptoms that feel like urgency and lower abdominal pain fit the bladder better. That is a rule of thumb, not a diagnosis. We wrote a separate piece on it: a burning feeling when urinating.

Some people notice nothing at all. Chlamydia often runs silently, which is exactly why it passes on so easily.

Is urethritis always an STI?

No. Urethritis often comes from an STI, but certainly not always. Chlamydia and gonorrhoea are the best known causes and both are sexually transmitted. Alongside them sit bacteria that are not classed as STIs, and sometimes the cause is mechanical irritation or a catheter. Without a test you cannot tell those apart.

So the practical question is not whether it is an STI, but which cause it is and whether a test can find it. That varies per cause, and it is rarely spelled out clearly.

This table is the core of the article.

The bottom two rows are where most of the confusion starts. The separate articles in this cluster deal with those.

What if your STI test is negative and symptoms persist?

Then you have not landed in some rare exception. Research into non-gonococcal urethritis shows two things. Several causes are often involved at once. And in a share of men, no known cause is identified at all (Jordan, 2020). A negative result does not rule symptoms out.

There are roughly three explanations, and all of them are boring enough to be reassuring.

First: you tested too early. Every test needs a window before the cause becomes detectable. Test inside that window and the result can read negative while something is going on. How long that takes differs per infection, which we covered in which test you need when.

Second: the cause was not in the panel. Mycoplasma genitalium is the textbook example. It demonstrably causes urethritis, but in the Netherlands it is not part of a standard panel, ours included.

Third: there is no infection. Irritation, a skin condition or non-infectious inflammation give comparable symptoms. A test cannot show those, because there is nothing to show.

In all three cases the GP is the logical next stop, not another test order.

What role does mycoplasma genitalium play here?

Mycoplasma genitalium is a sexually transmitted bacterium that can cause urethritis. The 2021 European guideline describes it as an established cause, and advises matching treatment to resistance testing rather than giving the same antibiotic by default (Jensen, 2022).

That resistance point is not a footnote.

A global meta-analysis showed that resistance to macrolides, the antibiotic class azithromycin belongs to, has clearly increased in this bacterium over the years (Machalek, 2020). An updated review from 2025 saw that pattern continue (Chua, 2025). Which is precisely why untargeted testing and treating can backfire here.

We worked this out in a separate article on mycoplasma as an STI, and a second on treatment and resistance.

What about ureaplasma?

Ureaplasma sits differently. This bacterium is found in plenty of people without symptoms, as part of normal flora. A positive result therefore does not always mean you have something that needs treating. Commercial test pages often present it that way regardless.

In 2018 the European STI Guidelines Editorial Board published a position statement with exactly that question as its title: should we be testing for this at all? The tone is cautious. Routine testing for ureaplasma and Mycoplasma hominis in people without symptoms mostly produces confusion (Horner, 2018).

That is an awkward message for a testing provider to write down. It is also the honest one.

More on that in ureaplasma urealyticum and mycoplasma hominis.

What should you do about urethritis?

The first step is finding out what it is. With symptoms that fit urethritis, a targeted test for chlamydia and gonorrhoea is the usual start. Those two are found most often. Both have a clear treatment route. If symptoms persist after a negative result, that belongs in a conversation with a doctor.

What we can do is the first part: a test for chlamydia, gonorrhoea and trichomonas, without an appointment and without anything reaching your GP records.

What we cannot do is prescribe an antibiotic or judge whether a non-infectious cause is at play. That is GP work, and with persistent symptoms it really is the right place.

In the questions we get, we've noticed one pattern above all: after a negative result people mostly want another test. A conversation with the GP tends to be worth more at that point.

Using leftover antibiotics from the cupboard is a bad idea here. With mycoplasma that is one of the ways resistance develops.

How do you get rid of urethritis?

When a bacterial cause has been identified, urethritis is generally treated with antibiotics, and which one depends on the cause. For chlamydia and gonorrhoea the treatment routes are well established. For mycoplasma genitalium resistance plays a bigger role. Where the cause is non-infectious, an antibiotic does not help.

Prescribing that treatment is your GP or the sexual health clinic, not us.

Worth knowing: with a confirmed STI, partner notification is part of the picture, otherwise the infection travels back and forth. We wrote about that in notifying your partner. And if the result is positive, tested positive, what now explains what happens next.

One more practical point. Symptoms that linger after correct treatment do not automatically mean the treatment failed. The lining needs time to recover. If it keeps going, have it reassessed.

Urethritis in women

In women urethritis is more often mistaken for a bladder infection. The symptoms overlap heavily: burning urination, going more often, sometimes a nagging feeling low down. The difference is usually that a bladder infection shows a bacterium on urine culture, and STI-related urethritis does not.

That difference has practical consequences.

Picture two women aged 30 sent home on a Friday evening with the same 5 day course for a bladder infection. For one, symptoms are gone within a week. For the other they half settle, then return two weeks later.

That second pattern, a course that only partly works, is exactly the moment to think about a different cause. Especially if a new partner has recently come into the picture.

Discharge muddies the picture further, because it fits bacterial vaginosis or candida just as well. In discharge: when does it point to an STI we set those side by side. The split with the bladder we covered in STI or bladder infection.

How long does urethritis last?

Where a bacterial cause has been identified, symptoms usually settle within a few days to a week after the right treatment starts. That is an average, not a promise. Some people keep an irritable feeling on urination for a while afterwards, without an infection still being there.

What you mostly want to avoid is stopping a course halfway.

With mycoplasma that is one of the routes resistance develops along, and then a second treatment gets harder than the first. If it persists after a completed course, a reassessment is more useful than repeating the same one.

Further reading in this cluster

If your symptoms are male-specific, start with urethritis in men. To understand why a standard panel misses mycoplasma, read mycoplasma genitalium.

If you got a positive ureaplasma result from another provider, ureaplasma urealyticum is the piece you want. For the broader overview of which STI does what: the lesser known STIs.

References

• Jordan SJ, et al. Aetiology and prevalence of mixed-infections and mono-infections in non-gonococcal urethritis in men: a case-control study. Sexually Transmitted Infections, 2020. PMID 31515293.
• Jensen JS, et al. 2021 European guideline on the management of Mycoplasma genitalium infections. Journal of the European Academy of Dermatology and Venereology, 2022. PMID 35182080.
• Machalek DA, et al. Prevalence of mutations associated with resistance to macrolides and fluoroquinolones in Mycoplasma genitalium: a systematic review and meta-analysis. The Lancet Infectious Diseases, 2020. PMID 32622378.
• Chua TP, et al. Evolving patterns of macrolide and fluoroquinolone resistance in Mycoplasma genitalium: an updated systematic review and meta-analysis. The Lancet Microbe, 2025. PMID 40147462.
• Horner P, et al. Should we be testing for urogenital Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum in men and women? A position statement from the European STI Guidelines Editorial Board. Journal of the European Academy of Dermatology and Venereology, 2018. PMID 29924422.
• NHG-Standaard Het soa-consult, Dutch College of General Practitioners. Accessed July 2026.
• Thuisarts.nl, Pain when urinating. Accessed July 2026.
• RIVM, Sexually transmitted infections in the Netherlands, annual report. Accessed July 2026.

Every test result includes a professional assessment from a BIG-registered doctor. For treatment decisions, discuss your results with your GP.