Management of Dysuria with Negative Urinalysis
For patients with dysuria and a negative urinalysis, the next step should be to evaluate for non-infectious causes of urethral irritation while considering empiric treatment for sexually transmitted infections in high-risk individuals.
Initial Assessment
When a patient presents with burning on urination but has a clear urinalysis, several important considerations must guide management:
- A negative urinalysis (negative nitrite AND negative leukocyte esterase) has a high negative predictive value (95-98%) for urinary tract infection 1
- Dysuria without laboratory evidence of infection requires investigation of alternative diagnoses
Diagnostic Algorithm
Step 1: Assess for Risk Factors and Associated Symptoms
- Sexual history (new partners, unprotected intercourse)
- Presence of vaginal/urethral discharge
- Genital skin conditions or lesions
- Irritative voiding symptoms (frequency, urgency, nocturia)
- Recent urethral instrumentation or catheterization
- Medication use (potential irritants)
Step 2: Focused Physical Examination
- External genitalia examination for lesions, discharge, or anatomic abnormalities
- Pelvic/prostate examination as indicated by gender and risk factors
- Assessment for costovertebral angle tenderness
Step 3: Laboratory Testing Based on Risk Stratification
For sexually active patients or those with discharge:
- Testing for sexually transmitted infections (STIs):
- Nucleic acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae
- Consider Mycoplasma genitalium testing if persistent urethritis with negative initial testing 2
For patients with recurrent symptoms:
- Urine culture (even with negative dipstick, as some pathogens may not produce nitrites)
- Consider specialized testing for:
- Urethral stricture (uroflowmetry if male) 3
- Interstitial cystitis/bladder pain syndrome
Management Recommendations
For patients with suspected non-infectious urethritis:
- Increase fluid intake
- Avoid potential bladder irritants (caffeine, alcohol, spicy foods)
- Consider short-term urinary analgesics (phenazopyridine)
For patients with high risk for STIs:
- Empiric treatment for chlamydia and gonorrhea per local guidelines
- Partner notification and treatment as appropriate
For patients with suspected anatomic abnormalities:
- Referral for urological evaluation if symptoms persist or recur
- Consider uroflowmetry and post-void residual assessment in men with obstructive symptoms 3
Follow-up Recommendations
- If symptoms resolve with initial management: no further testing needed
- If symptoms persist after 7-10 days: reassessment with consideration of:
- Urine culture
- STI testing if not previously performed
- Urological referral for cystoscopy if symptoms persist beyond 4 weeks
Important Caveats
- A negative urinalysis does not completely exclude infection, particularly in early infection or with certain pathogens
- Persistent dysuria despite negative testing warrants further investigation rather than repeated empiric antibiotic courses 2
- Virtual management of dysuria without laboratory testing may increase recurrent symptoms and unnecessary antibiotic use 2