What is the recommended evaluation and treatment approach for a patient presenting with dysuria (painful urination)?

Evaluation and Treatment of Dysuria in Adults

The recommended evaluation of dysuria should include urinalysis and urine culture before initiating treatment, with first-line therapy being nitrofurantoin 100mg twice daily for 5 days or trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days for uncomplicated urinary tract infections. 1, 2

Initial Evaluation

History and Physical Examination

• Focus on key symptoms:
  • Presence of urinary frequency, urgency, suprapubic pain
  • Vaginal discharge or irritation (decreases likelihood of UTI)
  • Hematuria
  • Fever, flank pain (suggests pyelonephritis)
  • Sexual activity history (strongest predictor of recurrent UTIs)
  • Recent antibiotic use
  • Previous UTI history

Laboratory Testing

1. Urinalysis - Essential first step 1, 3

   • Significant pyuria: ≥10 WBC/mm³ on enhanced urinalysis or ≥5 WBC per high power field
   • Positive leukocyte esterase and nitrite suggest UTI
   • Clear urine on inspection with negative dipstick has 95-98% negative predictive value for UTI

2. Urine Culture - Should be obtained before starting antibiotics 1, 4

   • Positive culture: >10,000 CFU/mL of a uropathogen
   • Not necessary for uncomplicated UTI in healthy outpatients
   • Essential for:
     • Recurrent UTIs
     • Treatment failures
     • Complicated UTIs
     • Patients with risk factors for resistant organisms

Additional Testing (When Indicated)

• Vaginal/urethral swabs if STI suspected
• Cystoscopy for recurrent UTIs, hematuria, or suspected anatomic abnormality 1
• Upper tract imaging for:
  • Febrile UTI not responding to antibiotics
  • Recurrent UTIs
  • Suspected urinary stones or anatomical abnormalities 1

Treatment Approach

Uncomplicated UTI in Women

First-line options: 2, 5

• Nitrofurantoin 100mg twice daily for 5 days
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (if local resistance <20%)
• Fosfomycin 3g single dose

Second-line options:

• Cephalosporins (e.g., cefpodoxime 100mg twice daily for 3-7 days)
• Fluoroquinolones should be reserved as last resort due to increasing resistance and adverse effects 2

Complicated UTI

• Broader spectrum antibiotics initially
• Adjust based on culture results
• Consider IV therapy for systemic symptoms
• Longer treatment duration (7-14 days)
• Address underlying anatomical or functional abnormalities 1

Special Populations

Pregnant women:

• Nitrofurantoin, fosfomycin, or cephalexins
• Avoid trimethoprim-sulfamethoxazole in first and third trimesters 2

Elderly patients:

• Consider functional status and comorbidities
• Adjust antibiotic choice based on renal function
• Avoid nitrofurantoin if creatinine clearance <30 mL/min 2

Patients with neurogenic bladder: 1

• Obtain urinalysis and urine culture when symptomatic
• Do not treat asymptomatic bacteriuria
• Consider upper tract imaging for febrile UTIs

Management of Recurrent UTIs

Preventive strategies: 1, 2

• Vaginal estrogen for postmenopausal women
• Low-dose antibiotic prophylaxis (post-coital or daily)
  • Trimethoprim-sulfamethoxazole 40mg/200mg once daily or three times weekly
  • Nitrofurantoin 50-100mg daily
  • Cephalexin 125-250mg daily
  • Fosfomycin 3g every 10 days
• Non-antibiotic options:
  • Cranberry products (minimum 36mg/day proanthocyanidin A)
  • Intravaginal probiotics
  • Methenamine hippurate

Follow-up

• Routine post-treatment urinalysis or cultures not indicated for asymptomatic patients 2
• For persistent symptoms:
  • Obtain repeat urine culture with susceptibility testing
  • Consider 7-day course with different antibiotic class
  • Evaluate for underlying causes (stones, anatomical abnormalities)

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria (except in pregnancy or before urologic procedures) 1, 2
2. Using fluoroquinolones as first-line therapy 2
3. Not obtaining cultures for recurrent or complicated UTIs 1, 4
4. Prolonged antibiotic therapy without clear indication 2
5. Failing to consider non-infectious causes of dysuria (interstitial cystitis, bladder irritants, hypoestrogenism) 3
6. Not evaluating for underlying structural abnormalities in recurrent UTIs 2

By following this systematic approach to evaluation and treatment, clinicians can effectively manage dysuria while practicing appropriate antibiotic stewardship.