What is the treatment for dysuria in males?

Treatment of Dysuria in Males

Alpha-blockers are the first-line pharmacological treatment for dysuria in males with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). 1

Diagnostic Approach

Before initiating treatment, a proper evaluation is essential:

1. Initial Assessment:

   • Medical history focusing on symptom duration, severity, and associated symptoms
   • Physical examination including digital rectal examination to assess prostate size
   • International Prostate Symptom Score (IPSS) questionnaire
   • Urinalysis to rule out infection or hematuria 1

2. Additional Testing (if indicated):

   • PSA testing in men with at least 10-year life expectancy or when it may change management 1
   • Post-void residual measurement if incomplete emptying is suspected
   • Frequency-volume chart for 3 days if nocturia is a predominant symptom 1

Treatment Algorithm

First-Line Treatment:

1. Behavioral and Lifestyle Modifications:

   • Regulate fluid intake (especially in the evening)
   • Avoid bladder irritants (alcohol, caffeine, spicy foods)
   • Implement timed voiding
   • Avoid sedentary lifestyle 1

2. Pharmacological Treatment:

   • Alpha-blockers (terazosin, doxazosin, tamsulosin, alfuzosin, silodosin) for all men with moderate-to-severe LUTS
     • Rapid onset of action (2-4 weeks)
     • Improves symptoms and flow rate
     • Monitor for side effects: orthostatic hypotension, dizziness, retrograde ejaculation 1

Second-Line or Combination Therapy:

1. For enlarged prostate (>30cc) or PSA >1.5 ng/ml:

   • 5-alpha reductase inhibitors (finasteride, dutasteride)
     • Takes 3-6 months for full effect
     • Reduces prostate size and risk of disease progression
     • Side effects: sexual dysfunction, decreased libido 1
   • Combination therapy (alpha-blocker + 5-alpha reductase inhibitor) for better efficacy in men with enlarged prostates 1

2. For mixed storage and voiding symptoms:

   • Antimuscarinic agents (if storage symptoms predominate and PVR is low)
   • PDE5 inhibitors (especially if erectile dysfunction is present) 1

Treatment Failure:

If symptoms persist after 4-12 weeks of appropriate medical therapy:

• Reassess diagnosis and adherence
• Consider referral to urologist for specialized management and possible surgical intervention 1

Special Considerations

1. Acute urinary retention: Requires immediate catheterization 2

2. Dysuria with suspected infection:

   • Appropriate antibiotics based on culture and sensitivity
   • Complete the full course of antibiotics 3, 4

3. Monitoring:

   • Follow-up at 4-12 weeks after initiating treatment
   • Annual follow-up if symptoms are stable
   • Reassess IPSS score at each visit 1

Pitfalls and Caveats

1. Don't assume all dysuria in men is due to BPH:

   • Consider urinary tract infection, sexually transmitted infections (especially in younger men), urethritis, and bladder cancer 5, 6

2. Avoid antimuscarinic agents in men with elevated post-void residual (>200-300 mL) due to risk of urinary retention 2

3. Be cautious with alpha-blockers in men taking medications for erectile dysfunction due to risk of hypotension 1

4. Don't delay referral when red flag symptoms are present (hematuria, recurrent UTIs, bladder stones, renal insufficiency) 1

By following this evidence-based approach, most men with dysuria can be effectively managed, improving their symptoms and quality of life while preventing disease progression and complications.