Do you treat a patient with symptomatic dysuria if the urinalysis is negative?

Treatment of Symptomatic Dysuria with Negative Urinalysis

Yes, you should treat a patient with symptomatic dysuria even if the urinalysis is negative, particularly when there is recent onset of dysuria with frequency, urgency, or incontinence. 1

Diagnostic Considerations

Interpreting Negative Urinalysis Results

• Urinalysis has limitations in diagnosing UTIs:
  • Leukocyte esterase sensitivity: 72-97%, specificity: 41-86%
  • Nitrite sensitivity: 19-48%, specificity: 92-100% 2
  • Combined testing (either positive): sensitivity 46-100%, specificity 42-98% 2
• A negative urinalysis does not definitively rule out UTI in a symptomatic patient 3
• Negative results for both nitrite AND leukocyte esterase provide stronger evidence against UTI, but are not absolute 1

Clinical Decision Making Algorithm

1. Assess for classic UTI symptoms:

   • Recent onset dysuria
   • Frequency
   • Urgency
   • Incontinence
   • Costovertebral angle tenderness

2. If classic symptoms present, especially dysuria:

   • Treat empirically unless urinalysis shows negative nitrite AND negative leukocyte esterase 1
   • Consider obtaining urine culture before starting antibiotics to guide therapy if symptoms persist 2

3. If urinalysis is negative but symptoms persist:

   • Consider other causes of dysuria:
     • Sexually transmitted infections
     • Vaginitis/cervicitis (in women)
     • Urethritis
     • Interstitial cystitis
     • Bladder irritants
     • Skin conditions affecting urethral area 4

Treatment Approach

First-line Antibiotic Options

• Nitrofurantoin (preferred due to lower resistance rates)
• Trimethoprim-sulfamethoxazole (if local resistance <20%)
• Fosfomycin (convenient single-dose therapy) 2

Treatment Duration

• Uncomplicated UTI: 3-5 days
• Consider longer duration for complicated cases 2

Special Considerations

Risk of Undertreating

• Untreated UTIs can progress to pyelonephritis or sepsis, increasing morbidity and mortality 2
• The risk of progression is higher with symptomatic infections compared to asymptomatic bacteriuria

Risk of Overtreating

• Unnecessary antibiotics contribute to antimicrobial resistance
• Potential adverse effects from antibiotics
• Disruption of normal microbiota 2

Common Pitfalls to Avoid

1. Relying solely on urinalysis: Symptoms should guide treatment decisions, especially with classic dysuria presentation 3

2. Confusing asymptomatic bacteriuria with UTI: Asymptomatic bacteriuria should not be treated except in pregnancy or before urological procedures 2

3. Inadequate follow-up: Instruct patients to return if symptoms persist or worsen after treatment 2

4. Missing complicated UTI factors: Assess for signs of complicated infection requiring different management:

   • Male gender
   • Pregnancy
   • Immunosuppression
   • Urological abnormalities
   • Diabetes
   • Recent instrumentation 2

In summary, when a patient presents with classic dysuria symptoms, empiric treatment is appropriate even with negative urinalysis, unless both nitrite and leukocyte esterase are negative. Clinical judgment based on symptom presentation should guide treatment decisions.