What is the recommended approach for hematuria and dysuria in a young adult male without costovertebral angle (CVA) tenderness, fever, or abnormal vital signs?

From the Guidelines

For a young adult male presenting with hematuria and dysuria without costovertebral angle tenderness, fever, or abnormal vital signs, the recommended approach is to consider empiric treatment for uncomplicated urinary tract infection (UTI) while also evaluating for other potential causes of hematuria, as suggested by the American College of Radiology in 2020 1.

Initial Evaluation

The initial evaluation should include a thorough history, physical examination, urinalysis, and serologic testing. Given the patient's symptoms, a clean-catch midstream urine sample should be collected for urinalysis and culture to confirm infection and guide therapy if symptoms don't improve.

Treatment Considerations

First-line treatment for uncomplicated UTI could be trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg (one double-strength tablet) twice daily for 7 days. Alternative options include nitrofurantoin 100 mg twice daily for 5-7 days, fosfomycin 3 g single dose, or fluoroquinolones like ciprofloxacin 250 mg twice daily for 3 days, though these are generally reserved for when other options cannot be used due to resistance concerns.

Additional Recommendations

• The patient should increase fluid intake.
• Phenazopyridine 200 mg three times daily for 2 days can be taken to relieve urinary discomfort.
• If symptoms worsen, include fever, flank pain, or persist beyond 48-72 hours of treatment, prompt reevaluation is necessary.
• UTIs in males are less common than in females and may indicate anatomical abnormalities or prostatitis, so if this is recurrent, urological evaluation would be warranted to rule out underlying conditions, as highlighted in the guidelines for hematuria evaluation 1.

Consideration for Hematuria

Given the presence of hematuria, it's crucial to consider the potential for underlying urinary tract cancer, especially if the patient has risk factors such as smoking, occupational exposure to chemicals, or a history of urologic disease. The American College of Physicians suggests that clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria 1.

High-Value Care Advice

Following the high-value care advice from the American College of Physicians, clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults 1. Referral for further urologic evaluation should be considered based on the presence of gross hematuria, risk factors, and the absence of a demonstrable benign cause.

Given the most recent and highest quality evidence from 2020 1, the approach to a young adult male with hematuria and dysuria should prioritize both the treatment of potential UTI and the evaluation for other causes of hematuria, considering the patient's risk factors and the clinical presentation.

From the Research

Evaluation of Hematuria and Dysuria

The recommended approach for hematuria and dysuria in a young adult male without costovertebral angle (CVA) tenderness, fever, or abnormal vital signs involves a thorough evaluation, including:

• A comprehensive history to identify potential causes of dysuria, such as sexually transmitted infections, urinary tract infections, or noninfectious causes 2, 3, 4
• A focused physical examination to assess for signs of infection or other conditions that may be causing the symptoms 2, 3, 4
• Urinalysis, including urine dipstick and microscopic examination, to help determine the presence of infection and identify potential causes of hematuria 2, 3, 4, 5, 6

Diagnostic Considerations

The differential diagnoses for hematuria and dysuria in a young adult male include:

• Urinary tract infection, which is a common cause of dysuria and hematuria 2, 3, 4, 5
• Sexually transmitted infections, such as Chlamydia trachomatis, which can cause dysuria and hematuria in younger patients 4
• Renal calculus, genitourinary malignancy, and other conditions that may cause hematuria and dysuria 4, 5, 6
• Noninfectious causes of dysuria, such as bladder irritants, skin lesions, and chronic pain conditions 2, 3

Further Evaluation and Management

Further evaluation and management of hematuria and dysuria may involve:

• Urine culture to guide appropriate antibiotic use, especially for recurrent or suspected complicated urinary tract infections 2, 3
• Advanced imaging, such as CT/MRI with urographic phase, to investigate macrohematuria 5
• Cystoscopy to evaluate the urinary tract for potential causes of hematuria and dysuria 5
• Referral to a specialist, such as a urologist or nephrologist, for further evaluation and management of persistent or complex cases 6