What is the treatment for dysuria with a clear urinalysis (UA)?

From the Guidelines

For dysuria with a clear urinalysis, treatment should focus on symptomatic relief while investigating potential non-infectious causes. The absence of bacteria or white blood cells in the urinalysis indicates inflammation rather than infection may be causing symptoms, which is why anti-inflammatory approaches are more appropriate than antimicrobials in this scenario 1. Start with increased fluid intake to dilute urine and reduce irritation. Over-the-counter pain relievers like phenazopyridine (AZO) 100-200mg three times daily for 2-3 days can provide urinary tract pain relief, though patients should be warned about orange urine discoloration. Ibuprofen 400-600mg every 6-8 hours can help reduce inflammation and discomfort.

Some key considerations for treatment include:

• Increased fluid intake to reduce irritation
• Over-the-counter pain relievers for symptomatic relief
• Avoiding potential bladder irritants like caffeine, alcohol, spicy foods, and acidic beverages
• Further evaluation if symptoms persist beyond a few days to rule out other conditions

It's also important to note that empiric antibiotics should be avoided since the clear urinalysis suggests no bacterial infection 1. The diagnostic value of urinalysis for UTI is limited, and the positive predictive value of pyuria for diagnosing infection is exceedingly low, often indicating the presence of genitourinary inflammation due to many other possible noninfectious reasons 1. Urine cultures are reasonable for complicated cases and/or recurrent UTIs, particularly in suspected pyelonephritis, to guide targeted therapy.

From the FDA Drug Label

Phenazopyridine HCl is indicated for the symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or the passage of sounds or catheters The treatment for dysuria with a clear urinalysis (UA) may include phenazopyridine for symptomatic relief of pain, burning, and discomfort.

• The use of phenazopyridine should not delay definitive diagnosis and treatment of the causative condition.
• Phenazopyridine provides only symptomatic relief, and the underlying cause of the dysuria must be addressed. 2

From the Research

Treatment for Dysuria with Clear Urinalysis

• Dysuria, defined as pain, burning, or discomfort on urination, can be caused by various factors, including urinary tract infection, noninfectious inflammation, trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, or psychogenic disorders 3.
• A comprehensive history and physical examination can often reveal the cause of dysuria, and urinalysis may not be needed in healthier patients with uncomplicated medical histories and symptoms 3.
• However, in most patients, urinalysis can help determine the presence of infection and confirm a suspected diagnosis 3.

Evaluation and Differential Diagnosis

• History is most often useful for finding signs of sexually transmitted infection, complicated infections, lower urinary symptoms in males, and noninfectious causes 4.
• Most patients presenting with dysuria should have a urinalysis performed, and urine culture should be performed for infection to guide appropriate antibiotic use, especially for recurrent or suspected complicated urinary tract infection 4.
• Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis 4.

Noninfectious Causes of Dysuria

• Noninfectious inflammatory causes of dysuria include a foreign body in the urinary tract and dermatologic conditions 5.
• Noninflammatory causes of dysuria include medication use, urethral anatomic abnormalities, local trauma, and interstitial cystitis/bladder pain syndrome 5.

Urinalysis and Urine Culture

• Pyuria is the best determinate of bacteriuria requiring therapy, and values significant for infection differ depending on the method of analysis 6.
• In cases of uncomplicated symptomatic urinary tract infection, a positive value for nitrites and leukocyte esterase by urine dipstick can be treated without the need for a urine culture 6.
• Urine culture is of clear value only in patients with acute pyelonephritis or subclinical pyelonephritis 7.