Treatment of Dysuria
For patients presenting with dysuria, prescribe antibiotics ONLY if recent-onset dysuria is accompanied by urinary frequency, urgency, new incontinence, systemic signs, or costovertebral angle tenderness—isolated dysuria without these features should NOT be treated as UTI. 1
Initial Diagnostic Approach
Essential History Elements
- Confirm recent-onset dysuria with accompanying symptoms 1:
- Urinary frequency or urgency
- New incontinence
- Systemic signs (fever, chills)
- Costoverteboral angle pain/tenderness
- Assess for sexually transmitted infection risk factors: vaginal discharge, new sexual partner, urethral discharge 2, 3
- Identify complicated infection risk factors: male sex, pregnancy, urologic obstruction, recent procedures, age >80 years 4, 3
- Screen for non-infectious causes: new medications, chemical irritants, trauma, chronic pelvic pain 2, 3
Physical Examination Priorities
- In women: perform vaginal examination if discharge present—vaginal discharge decreases likelihood of UTI and suggests cervicitis or vaginitis 2, 3
- In men: assess for urethral discharge, prostatic tenderness 4, 5
- Check for costovertebral angle tenderness to identify upper tract involvement 3
Laboratory Testing Strategy
When to Order Urinalysis
- Perform urinalysis in most patients with dysuria except uncomplicated women with classic cystitis symptoms and no risk factors 2, 3
- Negative nitrite AND leukocyte esterase often suggests absence of UTI in elderly patients 4
When to Order Urine Culture
- Mandatory for: recurrent UTI, suspected complicated UTI, males, pregnancy, failed initial treatment 2, 3
- Elderly patients: obtain culture to guide targeted therapy given high rates of resistance 4
- Uncomplicated cystitis in young women: culture NOT necessary 6
Treatment Algorithm
For Uncomplicated Cystitis (Young Women)
First-line antibiotic options 1, 4:
- Fosfomycin 3g single dose
- Nitrofurantoin 100mg BID × 5 days
- Pivmecillinam (where available)
- Trimethoprim-sulfamethoxazole DS BID × 3 days (if local resistance <20%)
Duration: 3 days of therapy is superior to single-dose and adequate for uncomplicated cases 6
For Complicated UTI or Males
- Treat for 7-14 days 4
- Males: use 14-day course when prostatitis cannot be excluded 4
- Age >80 years: automatically consider complicated regardless of other factors 4
Fluoroquinolone Considerations
Avoid fluoroquinolones if 1, 4:
- Local resistance >10%
- Used in last 6 months
- Elderly patients (increased adverse effects)
Critical Pitfalls to Avoid
Do NOT Treat Asymptomatic Bacteriuria
- Approximately 40% of institutionalized elderly have asymptomatic bacteriuria but treatment causes neither reduced morbidity nor mortality 1
- Only treat if symptomatic with recent-onset dysuria plus accompanying features 1
Recognize Non-UTI Causes
If isolated dysuria without UTI features, evaluate for 2, 3:
- Sexually transmitted infections: test for gonorrhea, chlamydia, and Mycoplasma genitalium if persistent urethritis/cervicitis with negative initial testing 2
- Vaginitis: infectious, atrophic, or chemical 3, 7
- Interstitial cystitis/bladder pain syndrome: chronic symptoms with sterile urine without pyuria 8, 7
- Dermatologic conditions: vulvar lesions, contact dermatitis 3
Virtual Care Limitations
Evaluation and treatment through virtual encounters without laboratory testing increases recurrent symptoms and antibiotic courses 2—obtain urinalysis when feasible.
Symptomatic Relief
- Phenazopyridine 200mg TID may be considered for severe dysuria, but limit to 2 days maximum 1
- Reassess renal function before prescribing and adjust doses accordingly 1
Follow-up and Persistent Symptoms
- Evaluate clinical response within 48-72 hours 4
- Persistent symptoms after initial treatment require further workup for both infectious and non-infectious causes 2
- Consider cystoscopy if Hunner lesions suspected (interstitial cystitis) or to rule out bladder pathology 8
- Obtain urine culture if not done initially to guide antibiotic adjustment 4