What is the treatment for non-urinary tract infection (UTI) and non-sexually transmitted disease (STD) related dysuria in men?

Treatment for Non-UTI and Non-STD Related Dysuria in Men

For men with non-infectious dysuria, alpha-blockers such as tamsulosin are the first-line pharmacological treatment due to their rapid onset of action, good efficacy, and low rate of adverse events. 1, 2, 3

Diagnostic Evaluation Before Treatment

• Complete a thorough medical history focusing on symptom duration, severity, associated symptoms, and previous episodes to rule out infectious causes 2
• Perform physical examination including evaluation of the suprapubic area, external genitalia, and digital rectal examination to assess prostate size and tenderness 2
• Obtain urinalysis and urine culture to definitively rule out infectious causes 2, 4
• Use a validated symptom score questionnaire such as the International Prostate Symptom Score (IPSS) to assess symptom severity and bother 1, 3
• Complete a frequency-volume chart for at least 3 days, especially when nocturia is a prominent symptom 1
• Measure post-void residual volume to evaluate for urinary retention 3
• Consider uroflowmetry before initiating treatment to establish baseline parameters 1

Treatment Algorithm

First-Line Treatment:

• Alpha-1 adrenoceptor antagonists (α1-blockers) such as tamsulosin or alfuzosin are the first-line treatment for non-infectious dysuria in men 1, 3, 5
• These medications work by relaxing smooth muscle in the prostate and bladder neck, improving urinary flow 1
• Efficacy should be assessed after 2-4 weeks of treatment 3
• Common side effects include asthenia, dizziness, and orthostatic hypotension 1

For Men with Prostate Enlargement:

• If prostate volume is >40 ml, consider adding 5α-reductase inhibitors (5-ARIs) such as finasteride or dutasteride to the α1-blocker 1, 3
• This combination is more effective for long-term symptom management and reducing disease progression in men with larger prostates 1

For Men with Predominant Storage Symptoms:

• If storage symptoms (frequency, urgency) predominate, consider anticholinergics or beta-3 agonists 1, 3
• Caution is needed when using anticholinergics in men with elevated post-void residual volumes 1

For Men with Concurrent Erectile Dysfunction:

• Consider phosphodiesterase-5 inhibitors (PDE5i) such as tadalafil, which can address both LUTS and erectile dysfunction 3

Follow-Up and Monitoring

• Evaluate patients 4-12 weeks after initiating treatment to assess response 1, 3
• Assessment should include symptom evaluation using standardized questionnaires like IPSS 3
• Measure post-void residual volume at follow-up to monitor for urinary retention 3
• Annual follow-up is recommended for stable patients to monitor for symptom progression 3

Special Considerations

• Men with findings suspicious for prostate cancer, hematuria, abnormal PSA, recurrent symptoms, or neurological disease should be referred to a urologist 2, 3
• Alpha-blockers may cause ejaculatory dysfunction, particularly selective α1-blockers like tamsulosin and silodosin 1
• Men on α1-blockers who are scheduled for cataract surgery are at increased risk of intraoperative floppy iris syndrome 1
• Self-management, including education, reassurance, periodic monitoring, and lifestyle advice, should be included in the management plan 1

Common Pitfalls to Avoid

• Failing to rule out infectious causes before initiating treatment for non-infectious dysuria 2, 4
• Not considering prostate size when selecting treatment (α1-blockers alone are more effective for smaller prostates <40 ml) 1
• Overlooking the possibility of bladder outlet obstruction due to benign prostatic hyperplasia in older men 6
• Treating symptoms without addressing the underlying condition 7
• Initiating anticholinergics in men with significant post-void residual volumes 1