What are the treatment options for dysuria (painful urination)?

Treatment of Dysuria (Painful Urination)

For dysuria, obtain a urine culture and immediately start empiric antibiotic therapy with nitrofurantoin or trimethoprim-sulfamethoxazole for 3-5 days in women with uncomplicated UTI, adjusting based on local resistance patterns and patient-specific factors. 1

Initial Diagnostic Approach

Obtain urine culture before starting antibiotics to guide therapy, especially for recurrent or complicated infections. 1 Dysuria has over 90% accuracy for UTI diagnosis in young women when vaginal symptoms are absent. 1

Key diagnostic steps include:

• Urinalysis (dipstick and microscopic examination) to confirm infection 2, 3
• Urine culture and susceptibility testing before initiating treatment 1, 4
• Assess for vaginal discharge, which decreases UTI likelihood and suggests cervicitis or other causes 2

Empiric Antibiotic Treatment

For Uncomplicated UTI in Women:

First-line options (choose based on local resistance patterns): 1

• Nitrofurantoin for 3-5 days 1
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 3-5 days 1, 5

Avoid fluoroquinolones if used in the last 6 months due to resistance risk. 1, 6

For Complicated UTI (Diabetes, Structural Abnormalities, Immunosuppression):

Treatment duration: 7-14 days 6, 4

Antibiotic options: 6

• Ciprofloxacin 500-750 mg twice daily (only if local resistance <10%) 6, 4
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days 6
• Cefpodoxime 200 mg twice daily for 10-14 days 6

For Male UTI:

All male UTIs are considered complicated and require 14-day treatment when prostatitis cannot be excluded. 4

Empiric options: 4

• Amoxicillin plus aminoglycoside
• Second-generation cephalosporin plus aminoglycoside
• Intravenous third-generation cephalosporin

Ciprofloxacin may be used orally only when local resistance is <10%, patient doesn't require hospitalization, and has β-lactam anaphylaxis. 4

Follow-Up and Adjustment

Reassess symptoms after 48-72 hours of antibiotic therapy. 1, 6 If symptoms persist:

• Repeat urine culture before prescribing additional antibiotics 1
• Adjust therapy based on culture results when available 1, 6
• Consider non-infectious causes including sexually transmitted infections, bladder irritants, or chronic pain conditions 2, 7

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria in general population, diabetic patients, or catheterized patients 1, 6
• Do NOT use fluoroquinolones if patient used them in last 6 months or is from urology department 6, 4
• Do NOT assume all dysuria is UTI - consider sexually transmitted organisms (especially Chlamydia trachomatis in younger patients), urethral pain syndrome, interstitial cystitis, or genitourinary malignancy 2, 3, 7
• Do NOT rely on virtual encounters without laboratory testing, as this increases recurrent symptoms and unnecessary antibiotic courses 2

Special Populations

Post-menopausal women with recurrent UTIs: Consider vaginal estrogen therapy to reduce future UTI risk if no contraindication exists. 8

Diabetic patients: Use 14-day treatment duration, especially with poor glycemic control. 6

Patients with Hunner lesions (interstitial cystitis): Perform cystoscopy with fulguration or triamcinolone injection rather than antibiotics. 8