From the Guidelines
For a female patient presenting with dysuria and painful urination for one month, with a urinalysis showing negative nitrites, I recommend an evaluation for non-infectious urethritis or interstitial cystitis, as the negative nitrites suggest this is not a typical urinary tract infection caused by gram-negative bacteria. The patient's symptoms, such as dysuria and painful urination, are consistent with a urinary tract issue, but the negative nitrites on urinalysis indicate that the cause may not be a typical bacterial infection 1.
First, a urine culture should be performed to rule out bacterial infection despite the negative nitrites, as recommended by the European Association of Urology guidelines on urological infections 1. If the culture is negative, consider phenazopyridine (Pyridium) 100-200mg three times daily for 2-3 days for symptom relief. It is also essential to advise the patient to drink plenty of water and avoid bladder irritants like caffeine, alcohol, spicy foods, and acidic beverages.
If symptoms persist, referral to a urologist or urogynecologist is warranted for further evaluation, which may include cystoscopy. The negative nitrites suggest that this could be due to a non-bacterial cause such as interstitial cystitis, urethral syndrome, or less commonly, infection with organisms that don't produce nitrites like Chlamydia, Mycoplasma, or Ureaplasma. Pelvic floor dysfunction or vulvodynia could also present with similar symptoms and should be considered if other evaluations are negative.
Key considerations in the evaluation and management of this patient include:
- Ruling out bacterial infection with a urine culture
- Providing symptom relief with medications like phenazopyridine
- Avoiding bladder irritants
- Referral to a specialist for further evaluation if symptoms persist
- Considering non-infectious causes of urethritis or interstitial cystitis.
From the Research
Possible Causes of Dysuria
- Dysuria, or difficult urination, can be caused by various factors, including urinary tract infections (UTIs) 2, 3, 4, 5.
- A negative nitrite result on a urinalysis does not necessarily rule out a UTI, as some bacteria may not produce nitrites 3, 5.
- Other possible causes of dysuria include sexually transmitted infections, bladder irritants, skin lesions, and chronic pain conditions 4.
Diagnostic Considerations
- A urinalysis is a useful diagnostic tool for evaluating dysuria, but a urine culture may be necessary to guide appropriate antibiotic use, especially in cases of recurrent or suspected complicated UTIs 3, 4, 5.
- Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis 4.
- A history of vaginal discharge may decrease the likelihood of a UTI, and other causes of dysuria, such as cervicitis, should be investigated 4.
Treatment Options
- Antibiotics targeted toward common uropathogens, such as Escherichia coli, Proteus, Klebsiella, and Staphylococcus saprophyticus, are the recommended treatment for UTIs 2, 3.
- The duration of treatment varies by specific drug and type of infection, ranging from 3 to 5 days for uncomplicated cystitis to 7 to 14 days for pyelonephritis 3.
- In some cases, treatment with doxycycline may be effective in reducing symptoms of dysuria, even in the absence of a positive urine culture 6.