What is the initial workup and treatment for a male patient presenting with dysuria (painful urination)?

Initial Workup and Treatment for Male Dysuria

The initial workup for male dysuria should include a complete medical history, physical examination, urinalysis, and urine culture to determine if the cause is infectious (urinary tract infection or sexually transmitted infection) or non-infectious in nature. 1

Diagnostic Evaluation

History and Physical Examination

• Obtain a complete medical history focusing on symptom duration, severity, associated symptoms (discharge, hematuria, fever), sexual activity, and previous episodes 1
• Physical examination should include evaluation of the suprapubic area, external genitalia, and digital rectal examination to assess prostate size and tenderness 1
• Digital rectal examination can help estimate prostate volume, though it is less accurate than ultrasonography 1

Laboratory Testing

• Urinalysis is essential for all men with dysuria to detect infection, proteinuria, hematuria, or glycosuria 1
• Urine culture should be performed to guide appropriate antibiotic therapy, especially for recurrent or suspected complicated infections 1
• In sexually active men under 35 years, testing for sexually transmitted infections (particularly Neisseria gonorrhoeae and Chlamydia trachomatis) is recommended as these are common causes of urethritis in this age group 1, 2

Additional Testing (Based on Initial Findings)

• Uroflowmetry may be useful to correlate symptoms with objective findings and monitor treatment outcomes 1
• Post-void residual urine measurement helps identify patients at increased risk of acute urinary retention 1
• Prostate-specific antigen (PSA) testing should be considered if prostate cancer is suspected based on digital rectal examination findings 1
• Upper urinary tract imaging (ultrasonography) is indicated in patients with hematuria, history of urolithiasis, renal insufficiency, or recurrent urinary tract infections 1

Differential Diagnosis

Infectious Causes

• Urinary tract infection (UTI) - more common in older men, often associated with urinary stasis due to prostatic hyperplasia 1, 2
• Urethritis due to sexually transmitted infections - more common in younger men, particularly those under 35 years 1, 2
• Prostatitis - can present with dysuria, perineal pain, and obstructive voiding symptoms 1

Non-Infectious Causes

• Benign prostatic hyperplasia (BPH) - common in older men, causing lower urinary tract symptoms including dysuria 1
• Urolithiasis - may present with intermittent dysuria and flank pain 1
• Bladder or prostate malignancy - should be suspected in men with hematuria and risk factors 1
• Medication-induced dysuria - certain medications can irritate the urethral mucosa 2

Treatment Approach

For Suspected UTI

• Empiric antibiotic therapy should be initiated based on local resistance patterns 1
• Trimethoprim-sulfamethoxazole is indicated for urinary tract infections due to susceptible strains of E. coli, Klebsiella, Enterobacter, Morganella morganii, and Proteus species 3
• Treatment duration should be 7-14 days (14 days for men when prostatitis cannot be excluded) 1
• In men, all UTIs are considered complicated and require longer treatment courses compared to women 1

For Suspected STI-Related Urethritis

• Testing to determine the specific etiology is recommended as both chlamydia and gonorrhea are reportable conditions 1
• If diagnostic tools are unavailable, patients should be treated for both gonococcal and non-gonococcal urethritis 1
• Partner notification and treatment are essential components of management 1

For BPH-Related Symptoms

• Initial management may include lifestyle modifications (fluid intake regulation, avoiding alcohol and caffeine) 1
• Alpha-blockers are typically first-line pharmacological therapy for BPH-related LUTS, with effectiveness usually assessed after 2-4 weeks 1
• 5-alpha reductase inhibitors may be added for men with prostate volumes >30cc, with effectiveness usually assessed after 3 months 1

Follow-Up

• Patients should be evaluated 4-12 weeks after initiating treatment to assess response to therapy 1
• Reassessment should include symptom evaluation using standardized questionnaires like the International Prostate Symptom Score (IPSS) 1
• If symptoms persist despite appropriate treatment, referral to a urologist is recommended for further evaluation and possible interventional treatment 1

Special Considerations

• All UTIs in men are considered complicated and require thorough evaluation 1
• Recurrent or persistent dysuria despite appropriate treatment warrants further investigation for anatomical abnormalities, calculi, or malignancy 1
• Men with findings suspicious for prostate cancer, hematuria, abnormal PSA, recurrent infection, or neurological disease should be referred to a urologist before initiating treatment 1