What are the treatment options for dysuria (painful urination)?

From the Guidelines

For patients experiencing dysuria, I recommend initiating treatment with a short-course of antibiotics, such as 5-7 days of fluoroquinolones or trimethoprim/sulfamethoxazole, as this has been shown to be effective in managing complicated urinary tract infections (UTIs) and pyelonephritis, according to a recent study published in 2023 1.

Initial Management

• Start with over-the-counter pain relievers like ibuprofen (Advil, Motrin) at 200-400mg every 6-8 hours or acetaminophen (Tylenol) at 500-1000mg every 6 hours to reduce discomfort.
• Phenazopyridine (AZO, Pyridium) at 100-200mg three times daily for 2 days can specifically target urinary tract pain by numbing the urinary tract lining, but be aware it turns urine orange-red.
• Drink plenty of water (at least 8 glasses daily) to dilute urine and reduce irritation.

Antibiotic Treatment

• If symptoms persist beyond 2-3 days, develop fever, or include blood in urine, see a healthcare provider immediately as painful urination often indicates an infection requiring antibiotics.
• A study published in 2018 1 suggests that in patients with recurrent lower urinary tract infections (rUTI), a pretreatment urine culture should be obtained when an acute UTI is suspected, and consideration of antibiotic resistance patterns in the patient and the community (local antibiograms) as well as patient allergies, side effects, and cost is important.
• The use of short-duration antibiotic courses, such as 5-7 days, has been shown to be effective in managing complicated UTIs and pyelonephritis, with similar clinical success as long-duration therapy (10-14 days), even in patients with bacteremia 1.

Special Considerations

• Avoid classifying patients with rUTI as “complicated” unless they have congenital or acquired structural and/or functional abnormalities of the urinary tract and/or immune suppression or pregnancy, as this often leads to the use of broad-spectrum antibiotics with long durations of treatment 1.
• Reserve the classification of complicated UTI for those with specific underlying conditions, and use nitrofurantoin when possible as a first-line agent for re-treatment since resistance is low and, if present, decays quickly 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim oral suspension and other antibacterial drugs, sulfamethoxazole and trimethoprim oral suspension should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy 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 treatment option for dysuria (painful urination) is antibacterial therapy with a single effective agent, such as trimethoprim/sulfamethoxazole, for urinary tract infections caused by susceptible bacteria, including:

• Escherichia coli
• Klebsiella species
• Enterobacter species
• Morganella morganii
• Proteus mirabilis
• Proteus vulgaris 2

From the Research

Treatment Options for Dysuria (Painful Urination)

The treatment options for dysuria, a common symptom of urinary tract infections (UTIs), depend on the type and severity of the infection.

• First-line antibiotics for acute uncomplicated UTIs include:
  • Nitrofurantoin for 5 days 3, 4, 5, 6
  • Fosfomycin in a single dose 3, 4, 5, 6
  • Trimethoprim/sulfamethoxazole for 3 days 3, 5, 6
• For men with lower UTI symptoms, first-line antibiotics include:
  • Trimethoprim 3
  • Trimethoprim/sulfamethoxazole 3
  • Nitrofurantoin for 7 days 3
• Symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics may be considered for women 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

Treatment of UTIs Caused by Resistant Bacteria

For UTIs caused by antibiotic-resistant bacteria, treatment options include:

• Oral cephalosporins such as cephalexin or cefixime 4
• Fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 4
• Nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam, and carbapenems for UTIs due to AmpC-β-lactamase-producing Enterobacteriales 4
• Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, and aminoglycosides 4

Special Considerations

• Women with diabetes without voiding abnormalities presenting with acute cystitis should be treated similarly to women without diabetes 5
• Immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone 5, 6
• Urine cultures are recommended in women with suspected pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after completing treatment, and women who present with atypical symptoms 3, 6