What is the most common cause of dysuria (painful urination) in males?

Most Common Cause of Dysuria in Males

The most common cause of dysuria in males is urethritis due to Chlamydia trachomatis infection. 1

Epidemiology and Pathophysiology

Urethritis is the primary illness resulting from chlamydial infections in men, with dysuria being one of the cardinal symptoms. While urethral infections with Chlamydia trachomatis can present with symptoms similar to gonorrhea (urethral discharge and dysuria), chlamydial symptoms are often milder or even absent compared to gonorrheal urethritis 1.

The prevalence varies by age group:

• In sexually active men under 35 years of age, chlamydia is the predominant cause of dysuria 1, 2
• In men over 35 years of age, coliform bacteria (particularly E. coli) become more common causes of dysuria 2

Clinical Presentation

Chlamydial urethritis typically presents with:

• Dysuria (burning or pain during urination)
• Urethral discharge (though often less pronounced than with gonorrhea)
• Symptoms may be mild or even absent in many cases 1

Differential Diagnosis

Other important causes of dysuria in men include:

1. Bacterial causes:

   • Neisseria gonorrhoeae (especially in younger, sexually active men)
   • Escherichia coli and other Enterobacteriaceae (more common in older men)
   • Ureaplasma urealyticum and Mycoplasma genitalium

2. Non-infectious causes:

   • Benign prostatic hyperplasia with inflammation (more common in men >50)
   • Urinary tract stones/calculi
   • Urethral stricture
   • Trauma or irritation
   • Medication side effects

Diagnostic Approach

For men presenting with dysuria, the following diagnostic steps are recommended:

1. Urethral evaluation:

   • Gram-stained smear of urethral exudate to detect urethritis (>5 polymorphonuclear leukocytes per oil immersion field) 1
   • Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis (either urethral swab or first-void urine) 1

2. Urinalysis:

   • Examination of first-void urine for leukocytes if urethral Gram stain is negative
   • Culture and Gram stain of urine specimen 1

3. Additional testing:

   • Syphilis serology and HIV testing should be considered 1

Treatment Considerations

For confirmed or suspected chlamydial urethritis:

• Doxycycline 100 mg twice daily for 7 days is the first-line treatment
• Azithromycin 1 g as a single dose is an alternative
• Treatment of sexual partners is essential to prevent reinfection

Special Considerations

• Age-based approach: In men under 35, focus on sexually transmitted infections; in men over 35, consider both STIs and urinary tract infections caused by enteric bacteria 2
• Recurrent symptoms: Warrant further investigation for anatomical abnormalities or resistant organisms
• Complications: Epididymitis is a potential complication of untreated chlamydial urethritis in men 1

Prevention

• Regular screening for sexually active men with multiple partners
• Consistent condom use
• Partner notification and treatment for those diagnosed with chlamydial infection

Understanding the age-related shift in etiology of dysuria in men is crucial for appropriate empiric treatment while awaiting culture results.