What treatment is recommended for a 32-year-old patient experiencing dysuria (painful urination)?

From the Guidelines

For a 32-year-old female patient with burning during urination, I recommend empiric treatment for uncomplicated urinary tract infection (UTI) with nitrofurantoin (Macrobid) 100mg twice daily for 5 days, or trimethoprim-sulfamethoxazole (Bactrim DS) one tablet twice daily for 3 days if not contraindicated, as suggested by the most recent guidelines 1. Before starting treatment, obtain a urine sample for urinalysis and culture to confirm the diagnosis and identify the causative organism.

• Encourage increased fluid intake to help flush out the bacteria and reduce the risk of recurrent UTI, as advised by the European Association of Urology guidelines 1.
• Complete the full antibiotic course even if symptoms improve to ensure that the infection is fully cleared. If the patient has fever, flank pain, nausea/vomiting, or pregnancy, more urgent evaluation is needed as these suggest possible pyelonephritis or complicated UTI.
• Consider testing for chlamydia and gonorrhea if the patient has risk factors or if the UTI treatment fails, as dysuria can also be caused by sexually transmitted infections. The burning sensation occurs because bacterial infection causes inflammation of the urethral and bladder mucosa, which becomes irritated during urination. According to the European Association of Urology guidelines 1, diagnosing recurrent UTI via a urine culture is strongly recommended, and patients should be advised to increase their fluid intake to reduce the risk of recurrent UTI. Additionally, the guidelines suggest using methenamine hippurate to reduce recurrent UTI episodes in women without abnormalities of the urinary tract 1. However, for this patient, the initial treatment should focus on empiric antibiotic therapy, and further evaluation and management can be considered if symptoms persist or recur.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination

The patient's symptoms of burning when urinating suggest a possible urinary tract infection (UTI).

• The drug label indicates that trimethoprim-sulfamethoxazole is used to treat UTIs caused by susceptible strains of certain bacteria, such as Escherichia coli and Klebsiella species.
• It is recommended to treat initial episodes of uncomplicated UTIs with a single effective antibacterial agent. Based on this information, trimethoprim-sulfamethoxazole may be considered as a treatment option for this patient, but only if the infection is proven or strongly suspected to be caused by susceptible bacteria 2.

From the Research

Treatment Options for Dysuria

The patient's symptoms of burning during urination can be treated with various options, including:

• Antibiotics, such as nitrofurantoin, fosfomycin, trimethoprim, or trimethoprim/sulfamethoxazole, which are commonly used to treat urinary tract infections (UTIs) 3, 4
• Symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and delayed antibiotics may be considered for patients with uncomplicated UTIs 3
• Increased fluids, intake of cranberry products, and methenamine hippurate can help prevent recurrent infections 3
• Antibiotic prophylaxis is also effective in preventing recurrence but has a risk of adverse effects and antimicrobial resistance 3

Diagnostic Evaluation

Before providing treatment, a diagnostic evaluation should be performed to determine the cause of dysuria, including:

• Urinalysis to check for infection and confirm a suspected diagnosis 5, 6, 7
• Urine culture to guide appropriate antibiotic use, especially for recurrent or suspected complicated UTIs 5, 6, 3
• Vaginal discharge should be investigated, and other causes of dysuria, including cervicitis, should be considered 5
• Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis 5

Considerations for Women

For women with dysuria, the following considerations should be taken into account:

• A self-diagnosis of a UTI with typical symptoms (e.g., frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain) is accurate enough to diagnose an uncomplicated UTI without further testing 3
• Vaginal discharge decreases the likelihood of UTI, and other causes of dysuria, including cervicitis, should be investigated 5
• Women with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation should have urine culture and susceptibility testing to make a definitive diagnosis and guide antibiotic selection 3