Management of Female Urethral Discomfort with Burning and Microhematuria
For female urethral discomfort and burning with negative urinalysis but small amount of blood, a comprehensive evaluation for interstitial cystitis/bladder pain syndrome (IC/BPS) should be performed, with phenazopyridine for symptomatic relief while pursuing diagnosis. 1
Initial Assessment and Diagnosis
- Obtain a detailed history documenting the number of voids per day, constant urge sensation, and the location, character, and severity of pain/discomfort 1
- Document any dyspareunia, dysuria, and relationship of pain to menstruation in women 1
- Perform a brief neurological examination to rule out occult neurologic problems 1
- Evaluate for incomplete bladder emptying to rule out occult retention 1
- Perform a urine culture even with negative urinalysis to detect lower levels of clinically significant bacteria not identifiable with dipstick or microscopic exam 1
- Establish baseline voiding symptoms and pain levels using validated tools like the genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), or visual analog scale (VAS) 1
Diagnostic Considerations
- Microhematuria with negative urinalysis may indicate several conditions including IC/BPS, urethral pathology, or early urinary tract infection 1
- Consider cystoscopy if Hunner lesions are suspected, as this is the only reliable way to diagnose their presence 1
- Cystoscopy should be performed without requiring patients to fail behavioral or medical treatments first if Hunner lesions are suspected 1
- For patients with microhematuria, consider risk stratification based on the 2025 AUA/SUFU guidelines to determine the need for further evaluation 1
Treatment Approach
Immediate Symptomatic Relief
- Phenazopyridine HCl is indicated for symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa 2
- Limit phenazopyridine treatment to 2 days if treating a suspected urinary tract infection concurrently with antibiotics 2
- The analgesic action may reduce or eliminate the need for systemic analgesics while pursuing definitive diagnosis 2
Evaluation of Microhematuria
- For patients with microhematuria and urethral symptoms, engage in shared decision-making regarding further evaluation 1
- Consider factors such as time since initial evaluation, presence of other risk factors, and overall risk stratification 1
- Changes in clinical status (gross hematuria, higher degrees of microhematuria, or new/worsening symptoms) merit further evaluation 1
Management of IC/BPS
- For suspected IC/BPS, begin with behavioral/non-pharmacologic approaches 1
- Consider oral medications and bladder instillations based on symptom severity 1
- For patients with Hunner lesions identified on cystoscopy, specific treatments directed at these lesions may be more effective 1
Follow-Up Recommendations
- In patients with a negative evaluation for microhematuria, engage in shared decision-making regarding whether to repeat urinalysis in the future 1
- Most patients with a negative risk-stratified evaluation do not require ongoing urologic monitoring 1
- For persistent symptoms despite negative evaluation, consider referral to urology or gynecology for further assessment 3
- Monitor for changes in symptoms, especially the development of gross hematuria, which would warrant immediate reevaluation 4
Important Considerations
- Do not attribute microhematuria solely to antiplatelet or anticoagulant medications without further investigation 4
- Recurrent urinary tract infections in women with dysuria or irritative voiding symptoms are most commonly caused by reinfection with the original bacterial isolate 3
- Female urethral pathology can include cystic lesions (urethral diverticulum being most common), benign and malignant solid urethral lesions, and iatrogenic lesions 5
- Frequency of sexual intercourse is the strongest predictor of recurrent urinary tract infections in patients with recurrent dysuria 3