Is dysuria (painful urination) treated prophylactically in pregnancy?

Management of Dysuria in Pregnancy

Dysuria (painful urination) is not routinely treated prophylactically in pregnancy unless there is a history of recurrent urinary tract infections (UTIs). 1

Screening and Diagnosis Approach

• All pregnant women should be screened for asymptomatic bacteriuria (ASB) with urine culture at least once in early pregnancy (typically 12-16 weeks) 1, 2
• Diagnosis should be based on properly collected urine specimens with ASB defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥10^5 CFU/mL 1
• Screening for pyuria has low sensitivity (approximately 50%) for identifying bacteriuria in pregnant women 2

Treatment Guidelines

Asymptomatic Bacteriuria (ASB)

• Treat confirmed ASB in pregnancy with 4-7 days of antimicrobial treatment according to susceptibility testing 1
• Only treat true uropathogens (E. coli, Klebsiella) and not contaminants (Lactobacillus, S. epidermidis) 1
• Follow treatment with a test of cure after completion of therapy 1

Symptomatic UTI (Including Dysuria)

• Empiric treatment with antibiotics is recommended for symptomatic patients while awaiting culture results 1
• Adjust therapy based on culture results 1

Prophylactic Treatment

When Prophylaxis IS Indicated

Prophylactic antibiotics should only be considered in pregnant women with:

• History of recurrent UTIs 2, 3
• Previous pyelonephritis during current pregnancy 2

Prophylactic Options for Recurrent UTIs

For women with history of recurrent UTIs, the following prophylactic approaches may be used:

1. Post-coital antimicrobial prophylaxis 2, 3:

   • Single dose of cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) after intercourse 3
   • Highly effective in preventing recurrent UTIs during pregnancy 3

2. Continuous antimicrobial prophylaxis 2:

   • Daily antibiotic prophylaxis for 6-12 months in women with recurrent UTIs
   • Options include trimethoprim-sulfamethoxazole, nitrofurantoin, cephalexin, or quinolones 2

Important Considerations

• Overtreatment with antibiotics during pregnancy can lead to unnecessary antibiotic exposure, side effects, and antimicrobial resistance 1
• Before initiating any antimicrobial prophylaxis, eradication of previous UTI should be confirmed by negative urine culture 1-2 weeks after treatment 2
• Prophylaxis should be considered only after counseling and behavioral modification have been attempted 2

Pitfalls to Avoid

1. Treating without confirmation: Do not treat dysuria prophylactically without documented history of recurrent UTIs or previous pyelonephritis 2, 1

2. Misinterpreting urine cultures: Distinguish between true uropathogens and contaminants to avoid unnecessary treatment 1

3. Inadequate follow-up: Failure to confirm clearance of bacteriuria after treatment is a common concern in managing UTIs in pregnancy 1

4. Inappropriate antibiotic selection: Choose antibiotics with established safety profiles in pregnancy (nitrofurantoin, cephalexin) 3

The evidence strongly supports that prophylactic treatment for dysuria in pregnancy should be reserved only for women with documented history of recurrent UTIs or previous pyelonephritis, not as a routine practice for all pregnant women experiencing dysuria.