What is the treatment for burning micturition (dysuria)?

Treatment of Burning Micturition (Dysuria)

The first-line treatment for burning micturition (dysuria) is to identify and treat the underlying cause, typically with antibiotics for urinary tract infections, while phenazopyridine can be used for symptomatic relief for up to 2 days. 1

Diagnostic Approach

Burning micturition (dysuria) is most commonly caused by:

1. Urinary tract infection (UTI) - Most common cause
2. Sexually transmitted infections - Particularly in younger patients
3. Urethritis - Both infectious and non-infectious causes
4. Interstitial cystitis
5. Prostatitis (in men)
6. Medication side effects
7. Urinary tract trauma or instrumentation

Key Diagnostic Steps:

• Urinalysis - Check for leukocytes, nitrites, and bacteria
• Urine culture - To identify specific pathogens and antibiotic sensitivities
• STI testing - Particularly in sexually active patients with dysuria

Treatment Algorithm

1. For Uncomplicated UTI (most common cause):

• First-line antibiotics 2:
  • Nitrofurantoin 100mg twice daily for 5 days
  • Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (if local resistance <20%)
  • Fosfomycin 3g single dose

2. For Symptomatic Relief:

• Phenazopyridine (FDA-approved for urinary pain relief) 1:
  • Dosage: 100-200mg three times daily
  • Maximum duration: 2 days
  • Important: This medication only treats symptoms, not the underlying cause
  • Note: Will turn urine orange/red (patients should be warned)

3. For Urethritis:

• If gonococcal infection 3:

  • Ceftriaxone 1g IM or IV single dose plus
  • Azithromycin 1g PO single dose

• If non-gonococcal urethritis 3:

  • Doxycycline 100mg orally twice daily for 7 days

4. For Recurrent UTIs:

• Prophylactic options 2:
  • Trimethoprim-sulfamethoxazole 40mg/200mg once daily or three times weekly
  • Nitrofurantoin 50-100mg daily
  • Cephalexin 125-250mg daily
  • Fosfomycin 3g every 10 days

Special Considerations

Pregnant Women:

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

Elderly Patients:

• Adjust antibiotic choice based on renal function
• Avoid nitrofurantoin if creatinine clearance <30 mL/min 2

Renal Impairment:

• Fosfomycin 3g single dose is preferred for CrCl <30 mL/min 2

Non-Pharmacological Measures

• Increase fluid intake to help flush bacteria from the urinary tract
• Urinate frequently and completely
• For postmenopausal women with recurrent UTIs, vaginal estrogen replacement is strongly recommended 2

Important Caveats

• Do not treat asymptomatic bacteriuria except in pregnancy or before urologic procedures 3
• Reassess if symptoms persist beyond 72 hours of appropriate treatment 2
• Avoid fluoroquinolones as first-line therapy due to increasing resistance and potential adverse effects 2, 4
• Consider anatomical abnormalities if infections are recurrent or treatment fails 3

When to Refer to Specialist

• Recurrent infections (≥3 episodes in 12 months)
• Persistent symptoms despite appropriate treatment
• Complicated infections (pyelonephritis, anatomical abnormalities)
• Hematuria after treatment
• Male patients with recurrent UTIs

Remember that while phenazopyridine provides rapid symptomatic relief, it should not delay appropriate antibiotic treatment of the underlying cause of dysuria 1.