Initial Management of Dysuria
For patients presenting with dysuria, perform urinalysis immediately to differentiate infectious from non-infectious causes, and initiate empiric antibiotic therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) for uncomplicated urinary tract infection while awaiting culture results. 1, 2
Immediate Diagnostic Steps
Essential Initial Testing
- Obtain urinalysis on all patients with dysuria to detect infection, hematuria, or glycosuria 1, 2
- Order urine culture to guide appropriate antibiotic therapy, especially for recurrent or suspected complicated UTIs 1
- Perform urinalysis even in patients with straightforward presentations, as it significantly improves diagnostic accuracy 2, 3
Critical History Elements
- Sexual activity and new partners (suggests sexually transmitted infection) 2, 3
- Vaginal discharge (decreases likelihood of UTI; investigate cervicitis instead) 2
- Recent antibiotic use (particularly fluoroquinolones in last 6 months) 1
- Lower urinary tract symptoms in males (consider benign prostatic hyperplasia) 4, 1
- Recurrent symptoms (requires culture-directed therapy) 1, 2
Empiric Treatment for Uncomplicated UTI
First-Line Antibiotic Therapy
For uncomplicated UTI with systemic symptoms, initiate TMP-SMZ as first-line therapy unless local resistance exceeds 10% 1, 5
Standard dosing options:
- Single-dose therapy: TMP 320 mg + SMZ 1600 mg (two double-strength tablets) 6, 7
- 10-day therapy: TMP 160 mg + SMZ 800 mg twice daily 6, 7
Treatment Duration Decision
- Single-dose therapy is appropriate for uncomplicated first episodes in young women without recent UTI history 6, 7
- 10-day therapy is superior at 2 weeks but outcomes equalize by 6 weeks 6
- Use 10-day therapy if: history of UTI within previous 6 weeks (3.8-fold higher failure risk) or bacterial count ≥10⁵/mL (2.9-fold higher failure risk) 6
- Adverse effects occur in 4% with single-dose vs. 24% with 10-day therapy 7
Alternative Antibiotics
Avoid fluoroquinolones if:
For complicated UTI: Use amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or IV third-generation cephalosporin 1
Management of Specific Presentations
Male Patients with Dysuria and LUTS
Initiate alpha-blocker therapy (e.g., tamsulosin) if BPH suspected 4, 1
- Assess response at 2-4 weeks 4, 1
- Consider combination with 5α-reductase inhibitor if prostate enlarged (PSA >1.5 ng/mL) 1
- Follow-up at 4-12 weeks after treatment initiation 4
Acute Urethral Syndrome (Dysuria with Pyuria but Negative Culture)
Treat with antimicrobials if pyuria present (14 of 14 patients responded in studies) 7
- Do not treat if no pyuria (0 of 9 patients responded) 7
- Test for Mycoplasma genitalium if persistent urethritis/cervicitis with negative initial testing 2
Elderly Patients
Do not assume UTI based solely on nonspecific symptoms 8
- Require specific criteria: recent-onset dysuria, frequency/urgency, costovertebral angle tenderness, OR systemic signs 8
- Do not treat based on: cloudy urine, odor changes, nocturia alone, fatigue, or mental status changes without delirium 8
Follow-Up and Reassessment
Timing of Follow-Up
Indications for Further Workup
Refer to urology or perform additional testing if: 1, 2
- Persistent symptoms after initial treatment
- Hematuria accompanying dysuria
- Recurrent infections
- Suspected anatomical abnormalities
- Treatment failure
- Abnormal PSA in males
Consider cystoscopy for: 1
- Concomitant hematuria
- Recurrent symptoms
- Suspected anatomical anomalies
Common Pitfalls to Avoid
- Do not treat asymptomatic bacteriuria in patients with dysuria but no other UTI symptoms (leads to resistance without benefit) 1
- Do not rely on virtual encounters without laboratory testing (increases recurrent symptoms and antibiotic courses) 2
- Do not use single-dose therapy for patients with recent UTI (within 6 weeks) due to 3.8-fold higher failure rate 6
- Do not prescribe antibiotics to elderly based on nonspecific symptoms alone without meeting specific UTI criteria 8