What is the treatment for a male experiencing dysuria and itching while urinating?

Treatment for Male Dysuria and Urinary Itching

For a male experiencing dysuria and itching while urinating, empiric treatment should include antibiotics targeting both Neisseria gonorrhoeae and Chlamydia trachomatis, as these are the principal bacterial pathogens of clinical importance in men with urethritis.

Diagnostic Approach

Before initiating treatment, a proper diagnostic workup should include:

• Urethral discharge evaluation: Check for mucopurulent or purulent discharge
• Urinalysis: Look for pyuria (≥5 WBCs per high-power field) 1
• Gram stain of urethral secretions (if available): To distinguish gonococcal from nongonococcal urethritis
• Urine culture: To identify specific pathogens and guide targeted therapy

Treatment Algorithm

First-line Treatment

When diagnostic tools are unavailable or while awaiting results:

1. Treat for both gonococcal and nongonococcal urethritis simultaneously:
   • For gonococcal urethritis: Ceftriaxone 250 mg IM in a single dose
   • For nongonococcal urethritis: Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days 1

If Specific Diagnosis Is Available:

For Nongonococcal Urethritis (NGU):

• C. trachomatis is the most frequent cause (15-55% of cases) 1
• Treatment: Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days

For Gonococcal Urethritis:

• Treatment: Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose

For Urinary Tract Infection:

• If urinalysis suggests bacterial UTI rather than urethritis
• Treatment: Trimethoprim-sulfamethoxazole (TMP-SMX) for 7-14 days 2
  • Note: For men, 14 days is recommended when prostatitis cannot be excluded 1

Special Considerations

Differential Diagnosis

Consider other causes of dysuria and itching:

1. Lichen sclerosus: May present with urethral itching and dysuria, especially in uncircumcised men

   • Look for white patches on glans penis or foreskin
   • Treatment: Potent topical steroids; circumcision may be needed for persistent disease 1

2. Lower urinary tract symptoms (LUTS) due to BPH:

   • Common in older men
   • Evaluate for additional symptoms like weak stream, hesitancy
   • Consider α-blocker therapy if confirmed 1

3. Trichomoniasis or HSV infection:

   • Consider when standard treatment fails
   • Special diagnostic tests required 1

Follow-up

• Patients should be evaluated 7-14 days after treatment initiation
• If symptoms persist despite appropriate therapy, consider:
  • Poor compliance
  • Reinfection
  • Resistant organisms
  • Alternative diagnoses (prostatitis, urethral stricture)

Partner Management

• Sexual partners within the previous 60 days should be evaluated and treated
• Abstinence from sexual intercourse until both patient and partners are cured

Prevention

• Consistent and correct use of condoms
• Reducing number of sexual partners
• Regular screening for STIs in sexually active individuals

Common Pitfalls to Avoid

1. Treating for UTI only without considering STIs in sexually active men
2. Failing to test for both gonorrhea and chlamydia
3. Inadequate duration of therapy, especially when prostatitis cannot be excluded
4. Not addressing partner treatment, leading to reinfection

Remember that urethritis symptoms (dysuria and itching) in men are most commonly caused by sexually transmitted infections, particularly in younger men, while older men are more likely to experience these symptoms due to urinary tract infections related to prostatic hyperplasia 3, 4.