**3. History and physical examination**

Chlamydial urethritis is asymptomatic in 75% of women and nearly 50% of men [11]. As men are more likely to be symptomatic than women, the diagnosis rate is reported to be higher in males [9]. The factors that determine whether the infection will be symptomatic or not remain unclear. The more common serovar E is known to cause more asymptomatic infections than other less common serotypes. For this reason, it is not uncommon for diagnosis and treatment to be delayed and the infection to persist for months or years. These patients are reservoirs for the disease [11]. In chronic chlamydial infection, RBs do not transform into EBs. When the environmental conditions change, *Chlamydia* can resume its life cycle [22].

Most patients are young and have history of unprotected sexual intercourse, previous urethritis, and antibiotic use. Transmission occurs through direct tissue contact during

vaginal, anal, or oral intercourse. Symptoms begin 1–3 weeks after transmission [10] and generally include burning, urethral discharge, urethral itching, frequent urination, urgency, and/or lower abdominal and groin pain. The most common symptom of chlamydial urethritis is painful urination. More rarely, it may cause fever, testicular pain and tenderness, sore throat, and rectal pain and discharge. These must be differentiated from other infectious processes such as epididymitis, pharyngitis, and prostatitis [15].

Ideally, genital examination should be performed 2 h after last urination to detect urethral discharge. If discharge is not seen in the urethra, the clinician can attempt to express it by placing the thumb on the ventral root and the other four fingers on the dorsal surface of the penis and applying gentle pressure toward the urethral meatus. Although it is difficult to make a differential diagnosis based on clinical examination of discharge, a gray-white mucoid or clear discharge is more common in nongonococcal urethritis, whereas purulent discharge is typically seen in gonococcal infections. However, generalization is not reliable. Discharge may be seen continuously or only when the penis is milked, in the morning, or the form of underwear staining [15].

In addition, scrotum and testicle examination is performed to assess for epididymitis and orchitis. If prostatitis is suspected, rectal examination should be performed [7]. As it can also cause ulcers and lymphadenitis and coexist with other sexually transmitted diseases, the skin, pharynx, lymph nodes, and neurological system should also be evaluated in addition to the genital area in men with urethritis [23].

Urethritis is usually diagnosed based on history and physical examination, but laboratory tests should be used to confirm the diagnosis and identify the causative pathogen.
