Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 9: Genito-urinary diseases · Médecins Sans Frontières, Current online edition (updated August 2022)

MSF guidance on syndromic management of urethral discharge caused by gonorrhoea and chlamydia for field clinicians.

In one sentenceTreat urethral discharge empirically with azithromycin 1 g or doxycycline 100 mg twice daily for 7 days PLUS ceftriaxone 500 mg IM; always treat sexual partners.

Issuer: Médecins Sans Frontières
Edition: Current online edition (updated August 2022)
Audience: Field clinicians in resource-limited settings
Evidence: Expert consensus based on field experience
Reviewed: 21 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 21 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF guideline section addresses the clinical management of urethral discharge, seen almost exclusively in men and principally caused by Neisseria gonorrhoeae and Chlamydia trachomatis. The guidance emphasises syndromic treatment in resource-limited settings where laboratory confirmation is often unavailable.

When microscopy is available, treatment should be guided by the presence or absence of gonococci on urethral smear. In the absence of laboratory facilities, empiric treatment for both chlamydia and gonorrhoea is recommended. The guideline provides clear treatment algorithms using azithromycin or doxycycline for chlamydia plus ceftriaxone or cefixime for gonorrhoea.

Partner treatment is mandatory regardless of symptom status, and the guideline addresses management of treatment failure, including consideration of antimicrobial resistance and alternative diagnoses such as trichomoniasis.

Key points

For clinicians — doses and thresholds as stated in the guideline

Confirm abnormal discharge by clinical examination, gently milking the urethra if no discharge is visible; check specifically in patients with dysuria
When microscopy is available: treat for chlamydia alone if no gonococci seen; treat for both if gonococci present
When no laboratory available: treat empirically for both chlamydia AND gonorrhoea
Chlamydia treatment: azithromycin 1 g single dose PO OR doxycycline 100 mg twice daily PO for 7 days
Gonorrhoea treatment: ceftriaxone 500 mg single dose IM OR cefixime 400 mg single dose PO if ceftriaxone unavailable
If discharge persists after 7 days and effective treatment given, consider trichomoniasis (tinidazole or metronidazole 2 g single dose PO) or reinfection
Gonococcal resistance possible if suboptimal antibiotics (co-trimoxazole, kanamycin) were used; re-treat with recommended regimen
Sexual partners receive the same treatment as the patient whether or not symptoms are present

Treatment regimens for urethral discharge in men when no laboratory available

Table extracted from the guideline

Treatment for chlamydia		Treatment for gonorrhoea
azithromycin PO: 1 g single dose	PLUS	ceftriaxone IM: 500 mg single dose
OR		OR, if ceftriaxone not available
doxycycline PO: 100 mg 2 times daily for 7 days		cefixime PO: 400 mg single dose

Source: Médecins Sans Frontières, Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“When no laboratory is available, treat for chlamydia AND gonorrhoea.”

— Médecins Sans Frontières, Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines, Treatment of the patient section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal, I recognise that syndromic management of urethral discharge remains essential across much of Georgia where point-of-care diagnostics for chlamydia are unavailable in primary care settings. The recommendation to use ceftriaxone plus azithromycin or doxycycline aligns with international best practice and addresses the global threat of gonococcal antimicrobial resistance. For Georgian clinicians, I would stress the non-negotiable requirement to treat sexual partners regardless of symptoms, as partner management remains a weak point in our national STI control efforts. The main implementation challenge will be ensuring reliable availability of injectable ceftriaxone in rural ambulatories where oral cefixime may need to substitute, though this is explicitly recognised as acceptable in the guideline when the preferred agent is unavailable.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026

Applicability

Georgia and the South Caucasus

This guidance is highly relevant for Georgia and the South Caucasus where sexually transmitted infections remain a public health concern and laboratory capacity varies considerably between urban centres and rural settings. National programmes would need to consider local antimicrobial resistance patterns for gonorrhoea, ensure availability of first-line agents (particularly injectable ceftriaxone in primary care settings), and integrate partner notification and treatment into existing STI services. In endemic areas of the region, differential diagnosis should include lymphatic filariasis as noted in the guideline, though this is not currently a major concern in Georgia.

Questions this guideline answers

Quick answers

When should I treat for both gonorrhoea and chlamydia versus chlamydia alone?

If microscopy of a urethral smear shows no gonococci, treat for chlamydia alone. If gonococci are present or if no laboratory is available, treat for both chlamydia AND gonorrhoea with the combination regimen.

What should I do if urethral discharge persists 7 days after treatment?

First verify that the patient received an effective combination treatment. If suboptimal antibiotics were used, re-treat for gonorrhoea with the recommended regimen. If effective treatment was given, consider trichomoniasis (treat with tinidazole or metronidazole 2 g single dose) or reinfection.

Do I need to treat the sexual partner if they have no symptoms?

Yes. The sexual partner receives the same treatment as the patient whether or not symptoms are present, as asymptomatic carriage is common and facilitates ongoing transmission.

Can I use co-trimoxazole or kanamycin to treat gonorrhoea?

No. The guideline specifically identifies these as examples of treatments that may lead to gonococcal resistance. Use ceftriaxone 500 mg IM or cefixime 400 mg PO as recommended.

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Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines

What this guideline says

Key points

Treatment regimens for urethral discharge in men when no laboratory available

From the guideline