Treatment of Dysuria Caused by Urinary Tract Infection
For uncomplicated UTI causing dysuria, first-line treatment includes nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with antibiotic selection guided by local resistance patterns. 1, 2
Diagnosis Confirmation
- Acute-onset dysuria is highly specific for UTI, with >90% accuracy in young women without vaginal symptoms 2
- Urine culture should be obtained in cases of:
- Suspected acute pyelonephritis
- Symptoms that don't resolve or recur within 4 weeks after treatment
- Women presenting with atypical symptoms
- Pregnant women
- Recurrent UTIs 2
First-Line Antibiotic Treatment Options
| Antibiotic | Dosage | Duration | Comments |
|---|---|---|---|
| Fosfomycin trometamol | 3g single dose | 1 day | Recommended only for uncomplicated cystitis [2] |
| Nitrofurantoin | 100mg twice daily | 5 days | Available in multiple formulations [2] |
| Pivmecillinam | 400mg three times daily | 3-5 days | Alternative first-line option [2] |
| TMP-SMX | 160/800mg twice daily | 3 days | Not in last trimester of pregnancy [2,3] |
Alternative Options
- Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) if local E. coli resistance is <20% 2
- Trimethoprim 200mg twice daily for 5 days (not in first trimester of pregnancy) 2
Symptomatic Relief
- Phenazopyridine can provide symptomatic relief of pain, burning, urgency, and frequency while waiting for antibiotics to take effect 4
- Should not be used for more than 2 days as there's no evidence that combined administration with antibiotics provides greater benefit than antibiotics alone after this period 4
- For mild to moderate symptoms, symptomatic therapy with NSAIDs may be considered as an alternative to antimicrobial treatment in consultation with individual patients 2, 1
Special Considerations
Male Patients
- Male UTIs are considered complicated and require longer treatment (14 days) 5
- Recommended empiric therapy includes TMP-SMX for 7 days 2
- Fluoroquinolones should be avoided as first-line treatment due to increasing resistance 2, 5
Recurrent UTIs
- Defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 2
- Diagnosis requires documentation of positive urine cultures associated with prior symptomatic episodes 2
- Preventive strategies include:
Antimicrobial Stewardship Considerations
- Avoid fluoroquinolones for uncomplicated UTIs due to unfavorable risk-benefit ratio 2
- Beta-lactam antibiotics are not considered first-line therapy due to collateral damage effects and tendency to promote more rapid recurrence of UTI 2
- Nitrofurantoin shows lower likelihood of persistent resistance (20.2% at 3 months, 5.7% at 9 months) compared to ampicillin (84.9%), amoxicillin-clavulanate (54.5%), ciprofloxacin (83.8%), and trimethoprim (78.3%) 2
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria (except in pregnancy or prior to urological procedures) 1, 2
- Using fluoroquinolones as first-line therapy for uncomplicated UTIs 2
- Prescribing unnecessarily long antibiotic courses 2
- Failing to consider local resistance patterns when selecting antibiotics 2, 1
- Overlooking non-infectious causes of dysuria such as vaginitis, vulvar lesions, physical or chemical irritants, and sexually transmitted diseases 6, 7