What is the initial workup and care for a patient presenting with dysuria (painful urination)?

From the Guidelines

The initial workup for a patient with dysuria should include a thorough history, physical examination, urinalysis, and urine culture, as dysuria is a highly specific symptom for urinary tract infection (UTI) with more than 90% accuracy in young women, as noted in the 2019 guideline by the American Urological Association 1. When evaluating a patient with dysuria, it is essential to consider the symptom duration, associated symptoms such as frequency, urgency, and hematuria, as well as sexual history and previous UTIs.

• A physical examination should focus on abdominal, genital, and pelvic areas to identify tenderness or discharge.
• For uncomplicated UTIs in women, empiric antibiotic therapy can be started with nitrofurantoin 100mg twice daily for 5 days, trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days, or fosfomycin 3g single dose.
• Men with dysuria should generally undergo more extensive evaluation before treatment, as outlined in the 2013 evaluation and treatment of lower urinary tract symptoms in older men 1. Patients should increase fluid intake and can use phenazopyridine 200mg three times daily for 2 days for symptom relief, though it may discolor urine orange-red.
• If fever, flank pain, or systemic symptoms are present, the patient should be evaluated for pyelonephritis or other complications.
• In sexually active patients, consider testing for sexually transmitted infections, and
• pregnant women, immunocompromised patients, and those with recurrent UTIs may require different management approaches, as dysuria commonly results from bacterial infection of the urinary tract, with E. coli being the most frequent pathogen, though inflammation from other causes can produce similar symptoms. The most recent and highest quality study, the 2019 guideline by the American Urological Association 1, provides the best evidence for the initial workup and care of patients with dysuria.

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 initial workup and care for a patient presenting with dysuria (painful urination) should include:

• Identifying the causative organism(s) of the urinary tract infection
• Selecting an appropriate antibacterial agent, such as trimethoprim-sulfamethoxazole, based on susceptibility patterns and local epidemiology
• Treating the infection with a single effective antibacterial agent for uncomplicated cases 2 Key considerations include:
• Urinary tract infection diagnosis and treatment
• Antibacterial therapy selection based on susceptibility patterns
• Local epidemiology and resistance patterns

From the Research

Initial Workup for Dysuria

• The initial workup for a patient presenting with dysuria (painful urination) typically involves a history, brief physical examination, and urinalysis 3.
• A presumptive diagnosis can be made when a patient has clinical symptoms and some combination of pyuria, hematuria, or bacteriuria 3.
• Urine cultures are unnecessary in uncomplicated urinary tract infections and add substantially to the cost of therapy 3.

Differential Diagnosis

• Dysuria can be caused by urinary tract infection, but can also be due to sexually transmitted infection, bladder irritants, skin lesions, and some chronic pain conditions 4.
• A history is most often useful for finding signs of sexually transmitted infection, complicated infections, lower urinary symptoms in males, and noninfectious causes 4.
• Vaginal discharge decreases the likelihood of urinary tract infection, and other causes of dysuria, including cervicitis, should be investigated 4.

Treatment

• Appropriate therapy requires selection of a drug and determination of the length of treatment 3.
• A minor infection should be treated with easy, safe, cost-effective therapy 3.
• Drug choices for short-course therapy include representatives from the penicillin, sulfa, and quinolone families 3.
• Single-dose therapy with trimethoprim-sulfamethoxazole is effective, easily administered, inexpensive, and free from significant side effects for acute, uncomplicated urinary tract infection 5.

Cost-Effectiveness

• Urine culture at the same time as empirical antibiotics is the most cost-effective strategy and maximizes symptom-free days, except when antibiotic resistance is very low or very high 6.
• Empirical antibiotics first should only be considered if the expected antibiotic resistance is very low 6.
• If antibiotic resistance is expected to be very high, symptomatic treatment is the best strategy and minimizes antibiotic use 6.
• A decision aid based on clinical items can reduce unnecessary antibiotic prescriptions for acute cystitis by 30% compared with usual physician care 7.