What is the best course of treatment for a patient with persistent dysuria and a negative urinalysis (UA) result?

Management of Persistent Dysuria with Negative Urinalysis

For patients with persistent dysuria and negative urinalysis, a thorough evaluation for non-infectious causes is necessary, including consideration of interstitial cystitis, urethral syndrome, or sexually transmitted infections that require specific testing beyond standard urinalysis.

Diagnostic Approach

When faced with dysuria and a negative urinalysis, consider the following:

1. Rule out sexually transmitted infections:

   • Obtain urethral and vaginal smears/cultures to identify potential pathogens 1
   • Consider testing for Mycoplasma genitalium if initial STI testing is negative but symptoms persist 1

2. Evaluate for non-infectious causes:

   • Noninfectious inflammation (dermatologic conditions, foreign body)
   • Anatomic abnormalities (urethral stricture, pelvic organ prolapse)
   • Interstitial cystitis/bladder pain syndrome
   • Medication-induced dysuria
   • Hypoestrogenism in postmenopausal women 2, 3

3. Consider specialized testing:

   • Cystoscopy if hematuria is present or if symptoms persist despite treatment 4
   • Urodynamic studies if neurogenic bladder is suspected 4

Treatment Algorithm

Step 1: For women with persistent dysuria and negative UA

• If vaginal discharge is present → Evaluate for vaginitis 3
• If no vaginal discharge → Consider urethral syndrome or interstitial cystitis

Step 2: For men with persistent dysuria and negative UA

• Consider prostatitis or urethritis
• Evaluate for urethral stricture or benign prostatic hyperplasia 4

Step 3: For all patients with persistent symptoms

• Avoid empiric antibiotics when urinalysis and cultures are negative 2
• Treating asymptomatic bacteriuria increases the risk of symptomatic infection, bacterial resistance, and healthcare costs 2

Special Considerations

• Avoid unnecessary antibiotics: The AUA guidelines emphasize antimicrobial stewardship to prevent resistance development 4
• Reconsider diagnosis: Persistent symptoms after initial evaluation require further workup for both infectious and non-infectious causes 1
• Virtual care limitations: Evaluation of dysuria through virtual encounters without laboratory testing may increase recurrent symptoms and unnecessary antibiotic courses 1

Common Pitfalls to Avoid

1. Assuming all dysuria is due to UTI: Only 46% of women with dysuria have significant bacteriuria 5
2. Overlooking STIs: In STD clinic settings, symptoms of UTI and STIs can overlap considerably 6
3. Repeated empiric antibiotics: This practice can lead to antimicrobial resistance without addressing the underlying cause 4, 2
4. Inadequate follow-up: Patients with persistent symptoms need reevaluation rather than repeated empiric treatment 3

Remember that dysuria without bacteriuria may represent the "urethral syndrome" and requires careful evaluation beyond simply repeating urinalysis or empirically prescribing antibiotics.