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 urinalysis, urine culture, and assessment of lower urinary tract symptoms (LUTS) using the International Prostate Symptom Score (IPSS), followed by appropriate targeted treatment based on the identified cause. 1, 2

Diagnostic Approach

Initial Evaluation

• Obtain a detailed medical history focusing on symptom duration, severity, associated symptoms, sexual history, and medication use 3
• Perform a focused physical examination including external genitalia examination and digital rectal examination to evaluate prostate size and tenderness 3
• Conduct urinalysis to detect infection, hematuria, or glycosuria in all men with dysuria 1, 3
• Utilize the International Prostate Symptom Score (IPSS) to quantify symptom frequency and severity 1
• Obtain urine culture to guide appropriate antibiotic therapy if infection is suspected 3, 2

Additional Testing Based on Initial Findings

• Consider PSA testing in men with at least a 10-year life expectancy or when it may change management of voiding symptoms 1
• Measure post-void residual (PVR) volume to rule out significant urinary retention 1
• Consider uroflowmetry for men with LUTS suggesting abnormality of voiding/emptying 1
• Urine cytology may be considered in men with predominantly irritative symptoms, especially with smoking history or other risk factors for bladder cancer 1

Common Causes of Male Dysuria

Infectious Causes

• In younger men (<35 years), dysuria is often caused by sexually transmitted infections such as Chlamydia trachomatis 2
• In older men (>35 years), coliform bacteria (particularly E. coli) are the predominant pathogens 2, 4
• Urinary tract infections in older men frequently occur due to urinary stasis secondary to benign prostatic hyperplasia (BPH) 2

Non-infectious Causes

• BPH with associated LUTS 1
• Prostatitis (acute or chronic) 1
• Interstitial cystitis/bladder pain syndrome 1
• Urethral stricture or other anatomical abnormalities 3
• Bladder or prostate malignancy 4
• Urinary calculi 2, 4

Treatment Approach

For Infectious Causes

• For uncomplicated UTI due to coliform bacteria, trimethoprim-sulfamethoxazole is appropriate when local resistance patterns support its use 5
• For suspected sexually transmitted infections, appropriate antibiotics based on likely pathogens should be prescribed 2
• Urine culture results should guide definitive antibiotic selection 5, 6

For BPH-Related Symptoms

• Alpha-blockers should be initiated as first-line therapy for men with LUTS/BPH 1, 3
• Consider adding 5-alpha reductase inhibitors for men with prostate volume >30cc 1
• Reassess patients 4-12 weeks after initiating treatment to evaluate response using IPSS 1
• If symptoms do not improve or side effects are intolerable, consider changing medical management 1

For Other Causes

• Interstitial cystitis/bladder pain syndrome treatment should focus on pain management and symptom relief 1
• For urethral stricture or anatomical abnormalities, referral to urology for potential procedural intervention 3
• For suspected malignancy, prompt urological referral 4

Follow-up and Monitoring

• Patients should be evaluated 4-12 weeks after initiating treatment to assess response 1
• Reevaluation should include the IPSS and may include PVR and uroflowmetry 1
• Patients with persistent symptoms despite appropriate treatment should undergo further evaluation and consideration of specialist referral 1, 3

Common Pitfalls to Avoid

• Empiric antibiotic treatment without urinalysis or culture may lead to inappropriate treatment and antibiotic resistance 5, 6
• Failure to consider non-infectious causes of dysuria may delay appropriate diagnosis and treatment 4, 7
• Not assessing post-void residual in older men with dysuria may miss significant urinary retention 1, 3
• Overlooking the possibility of prostate cancer in men with persistent dysuria and LUTS 1