What are the management options for urethral burning in an 84-year-old male with a negative Urinalysis (UA) and urine culture?

From the Guidelines

For an 84-year-old male experiencing urethral burning with negative urinalysis and urine culture, I recommend starting with a thorough evaluation to rule out urethral stricture, as it is a possible cause of symptoms, and considering urethro-cystoscopy, retrograde urethrography (RUG), or ultrasound urethrography for diagnosis, as suggested by the American Urological Association guideline 1. Given the patient's age and symptoms, it is essential to consider urethral stricture in the differential diagnosis, as it can present with decreased urinary stream, incomplete emptying, dysuria, and rising post-void residual (PVR) 1. The negative urinalysis and urine culture suggest that the cause of urethral burning may be non-infectious, and further evaluation is necessary to determine the underlying cause.

Some possible management options for urethral burning in this patient include:

• Increased hydration to help flush out any potential irritants
• Avoiding caffeine, alcohol, spicy foods, and acidic beverages that may exacerbate symptoms
• Over-the-counter phenazopyridine (Pyridium) 100-200mg three times daily for 2-3 days to provide symptomatic relief of urinary burning, although it should be used cautiously in the elderly and discontinued if symptoms resolve
• Warm sitz baths for 10-15 minutes twice daily to help alleviate discomfort
• Referral to a urologist for further evaluation and management, including possible urethro-cystoscopy, RUG, or ultrasound urethrography to diagnose urethral stricture, as recommended by the American Urological Association guideline 1.

It is crucial to note that urethral burning in elderly men without evidence of infection may indicate underlying conditions like interstitial cystitis, bladder outlet obstruction, or urethral stricture, and prompt referral to a urologist is warranted if symptoms persist despite initial interventions or if there are concerning features like hematuria or significant urinary obstruction 1.

From the FDA Drug Label

Phenazopyridine HCl is indicated for the symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or the passage of sounds or catheters The use of Phenazopyridine HCl for relief of symptoms should not delay definitive diagnosis and treatment of causative conditions. Because it provides only symptomatic relief, prompt appropriate treatment of the cause of pain must be instituted and Phenazopyridine HCl should be discontinued when symptoms are controlled

The management options for urethral burning in an 84-year-old male with a negative Urinalysis (UA) and urine culture may include:

• Symptomatic relief with phenazopyridine (PO) for up to 2 days, as it can help relieve pain and discomfort 2.
• Definitive diagnosis and treatment of the underlying cause of urethral burning, which is not specified in the provided information.
• Discontinuation of phenazopyridine when symptoms are controlled. It is essential to note that the use of phenazopyridine should not delay the diagnosis and treatment of the underlying cause of urethral burning.

From the Research

Management Options for Urethral Burning

Given the negative Urinalysis (UA) and urine culture results, the management options for urethral burning in an 84-year-old male can be considered as follows:

• The patient's symptoms may not be related to a urinary tract infection (UTI), as a negative UA reliably excludes a catheter-associated UTI 3.
• The possibility of benign prostatic hyperplasia (BPH) should be considered, and a digital rectal examination (DRE) may be performed as part of the assessment 4.
• However, the sensitivity of DRE for detecting urethral injuries is low, and other clinical indices such as meatal blood and hematuria may be more useful in diagnosing urethral trauma 5.
• For men with lower UTI symptoms, antibiotics should always be considered, and urine culture and susceptibility results can guide the antibiotic choice 6.
• First-line antibiotics for men with uncomplicated UTI include trimethoprim, trimethoprim/sulfamethoxazole, and nitrofurantoin for seven days 6.
• Symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics may be considered, as the risk of complications is low 6.

Additional Considerations

• The patient's age and potential comorbidities should be taken into account when selecting a treatment option.
• A urine culture with susceptibility testing may be necessary to adjust the antibiotic choice after initial empiric treatment, especially in nonfrail men 65 years and older with no relevant comorbidities 6.
• Other potential causes of urethral burning, such as urethritis or prostatitis, should be considered and evaluated accordingly 6.