Can sexually transmitted diseases (STDs) present with dysuria without discharge?

STDs Can Present with Dysuria Without Discharge

Yes, sexually transmitted diseases (STDs) can absolutely present with dysuria (painful urination) without any visible discharge. This is an important clinical consideration that should not be overlooked when evaluating patients with urinary symptoms.

Common STDs That Can Present with Isolated Dysuria

Chlamydia

• Chlamydia trachomatis infections are often asymptomatic (70-90% of cases) 1
• When symptomatic, dysuria may be the only presenting complaint, especially in men 1
• Despite the absence of discharge, chlamydia accounts for 30-40% of nongonococcal urethritis cases in men 1

Gonorrhea

• Can present with dysuria alone, particularly in early stages
• In men, urethral symptoms may precede visible discharge 2
• Women may experience dysuria without noticeable vaginal discharge

Herpes Simplex Virus (HSV)

• Genital herpes can cause significant dysuria due to urethral inflammation or when urine contacts genital lesions
• External dysuria may be the primary complaint, even when lesions are not immediately visible 2
• Patients may report pain with urination before vesicles or ulcers are clinically apparent

Trichomoniasis

• While often associated with discharge, some patients with trichomoniasis may present with isolated dysuria
• Men with trichomoniasis may have nongonococcal urethritis with dysuria but minimal or no discharge 2

Diagnostic Considerations

High Index of Suspicion

• An adolescent female with dysuria, abnormal urinalysis, and negative urine culture has a high probability of having an STI 3
• Studies show that among women presenting to emergency departments with dysuria diagnosed as UTI, 21% of those tested for chlamydia were positive 4

Testing Recommendations

• Nucleic acid amplification tests (NAATs) are the preferred diagnostic method for chlamydia and gonorrhea 1
• Can be performed on endocervical or urethral swab specimens, or urine specimens
• Patients with dysuria should be tested for STIs even when discharge is absent, especially if:
  • They are under 25 years of age
  • Have new or multiple sexual partners
  • Have risk factors for STIs

Diagnostic Pitfalls

• Only 17% of women with dysuria diagnosed with UTI in emergency departments were asked about sexual history 4
• Only 20% were tested for chlamydia, despite high prevalence 4
• Failure to consider STIs in patients with dysuria can lead to missed diagnoses and complications

Management Approach

1. Consider STI testing in all sexually active patients with dysuria, regardless of discharge
2. Test for chlamydia and gonorrhea using NAATs
3. If genital lesions are present, test for HSV and syphilis
4. Treat empirically while awaiting results if clinical suspicion is high

Treatment Options

• For suspected chlamydia: Doxycycline 100mg orally twice daily for 7 days (preferred) or azithromycin 1g orally in a single dose 1, 5
• For suspected gonorrhea: Ceftriaxone (dosage based on current guidelines due to increasing resistance) 5
• For suspected trichomoniasis: Metronidazole 2

Important Clinical Pearls

• Vaginal discharge decreases the likelihood of UTI and should prompt investigation for STIs 6
• Persistent dysuria after treatment for UTI should raise suspicion for an undiagnosed STI 6
• Sexual history is essential but often overlooked in patients presenting with dysuria 4
• Partner notification and treatment are crucial to prevent reinfection 1

Remember that the absence of discharge does not rule out an STI in patients with dysuria. Maintaining a high index of suspicion and appropriate testing can prevent missed diagnoses and reduce complications from untreated infections.