Treatment for Dysuria
Antibiotics are the first-line treatment for dysuria when caused by urinary tract infection, with nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole (when local resistance is <20%) being the preferred options. 1
Diagnostic Approach
Before initiating treatment, it's essential to determine the cause of dysuria:
Infectious causes (most common):
- Urinary tract infection (UTI)
- Urethritis
- Sexually transmitted infections
- Vaginitis
Non-infectious causes:
- Inflammatory conditions (dermatologic conditions, foreign body)
- Medication side effects
- Urethral anatomic abnormalities
- Interstitial cystitis/bladder pain syndrome
- Trauma
Key Diagnostic Elements
- Urinalysis: Essential for most patients to detect infection and confirm diagnosis 2
- Urine culture: Gold standard for UTI detection, especially when probability is moderate or unclear 1
- Symptom assessment: Frequency, urgency, and absence of vaginal discharge are most diagnostic for UTI 1
Treatment Algorithm
1. Uncomplicated UTI in Women
For women with dysuria who have no complicating features (such as pregnancy, immunosuppression, or anatomical abnormalities):
First-line antibiotics 1:
- Nitrofurantoin 100 mg twice daily for 5 days
- Fosfomycin 3 g single dose
- Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days (if local resistance <20%)
Avoid fluoroquinolones due to increasing resistance and potential side effects 1
2. Complicated UTI
For patients with complicating factors (male sex, pregnancy, presence of urologic obstruction, recent procedure) or systemic symptoms:
Recommended treatment 3:
- Amoxicillin plus an aminoglycoside
- Second-generation cephalosporin plus an aminoglycoside
- Intravenous third-generation cephalosporin
Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 3
Important: Any urological abnormality or underlying complicating factor must be managed 3
3. Catheter-Associated UTI
- Replace or remove the indwelling catheter before starting antimicrobial therapy 3
- Treat according to the recommendations for complicated UTI 3
4. Non-infectious Causes
- Vaginitis: Treat the underlying cause (antifungal for candidiasis, antibiotics for bacterial vaginosis) 2
- Interstitial cystitis: Consider pentosan polysulfate sodium, antihistamines, or tricyclic antidepressants 4
- Atrophic vaginitis: Topical estrogen therapy 2
Special Populations
Older Adults
- Antimicrobial treatment aligns with other patient groups, using the same antibiotics and treatment duration unless complicating factors are present 3
- Be aware that UTI may present differently in older women (atypical symptoms) 1
- Avoid treating asymptomatic bacteriuria in older adults 1
Children with Voiding Dysfunction
- Initial steps should involve education, timed voiding, adequate fluid intake, and management of constipation 3
- Correct toilet posture is important to enable relaxed voiding 3
- Biofeedback sessions may be beneficial for dysfunctional voiding 3
Important Considerations
- Antibiotic resistance: Increasing resistance to fluoroquinolones, beta-lactams, and TMP-SMX has been observed 1
- Asymptomatic bacteriuria: Common, particularly in older women, and should not be treated with antibiotics 1
- Recurrent symptoms: Warrant a thorough history, physical examination, urinalysis, and urine culture 2
- Urine culture interpretation: In symptomatic women, even growth as low as 10² colony-forming units/mL could reflect infection 1
Common Pitfalls to Avoid
Overtreatment of asymptomatic bacteriuria: This contributes to antibiotic resistance and provides no clinical benefit 1
Inadequate follow-up: If treatment fails and the patient is not satisfied, they should be referred to a specialist 3
Ignoring non-infectious causes: Not all dysuria is caused by infection; consider inflammatory and non-inflammatory causes 2
Empiric treatment without proper diagnosis: While empiric treatment is appropriate for uncomplicated cases, more complex presentations require proper diagnostic evaluation 2