What is the treatment approach for a male patient presenting with dysuria and frequency?

Treatment Approach for Male Dysuria and Frequency

The initial evaluation must include a complete history, physical examination with digital rectal exam, urinalysis, and urine culture to differentiate between infectious causes (UTI/STI), benign prostatic hyperplasia, and other etiologies—with treatment directed by the underlying cause identified. 1, 2

Initial Diagnostic Workup

History and Physical Examination

• Obtain detailed symptom history focusing on duration, severity, associated symptoms (hematuria, fever, discharge), sexual activity history, and previous episodes to distinguish infectious from non-infectious causes 1, 3
• Assess age-related risk factors: younger men (<35 years) are more likely to have urethritis from sexually transmitted infections, while older men typically have UTI related to prostatic hyperplasia or BPH-related lower urinary tract symptoms 1, 4
• Perform digital rectal examination to evaluate prostate size, consistency, tenderness, and rule out prostatitis or malignancy 1, 2
• Examine external genitalia and suprapubic area for bladder distention, urethral discharge, or skin lesions 5, 1

Laboratory Testing

• Urinalysis is mandatory for all men with dysuria to detect infection, hematuria, proteinuria, or pyuria 1, 2
• Urine culture should always be performed in men, as all male UTIs are considered complicated infections requiring culture-guided antibiotic therapy 1, 4
• Complete the International Prostate Symptom Score (IPSS) questionnaire to objectively quantify symptom severity and bother 1, 6
• Obtain a 3-day frequency-volume chart when nocturia or frequency is prominent to identify nocturnal polyuria or excessive fluid intake 5, 1, 6
• Measure post-void residual volume to evaluate for urinary retention 2, 6

Treatment Algorithm Based on Etiology

For Infectious Causes (UTI)

• Initiate empiric antibiotic therapy based on local resistance patterns while awaiting culture results 1
• First-line antibiotics for uncomplicated male UTI include trimethoprim, trimethoprim/sulfamethoxazole, or nitrofurantoin for 7 days 4
• Adjust antibiotics based on culture and susceptibility results, as men require longer treatment courses than women 4
• Consider urethritis or prostatitis in the differential, particularly in younger sexually active men 4

For Non-Infectious Causes (BPH/LUTS)

• Alpha-1 adrenoceptor antagonists (tamsulosin or alfuzosin) are first-line therapy for BPH-related dysuria and frequency due to rapid onset, good efficacy, and favorable side effect profile 1, 2, 6
• Assess treatment response after 2-4 weeks of alpha-blocker therapy 1, 2
• Add 5α-reductase inhibitors (finasteride or dutasteride) for men with prostate enlargement >30-40cc, as combination therapy is more effective for long-term symptom management and reducing disease progression 2, 6
• Consider phosphodiesterase-5 inhibitors (tadalafil) for men with concurrent erectile dysfunction, as this addresses both LUTS and sexual dysfunction 2, 6

For Overactive Bladder Symptoms

• Anticholinergics (trospium, oxybutynin) or beta-3 agonists can be used for predominant storage symptoms, but exercise caution in men with elevated post-void residual volumes due to risk of urinary retention 2, 6

Non-Pharmacological Management

• Regulate fluid intake, especially in the evening, to reduce nocturia 1
• Avoid dietary irritants including excessive alcohol and highly seasoned foods 1
• Encourage physical activity to avoid sedentary lifestyle 1

Follow-Up Strategy

• Evaluate patients 4-12 weeks after initiating treatment using IPSS questionnaire and post-void residual measurement to assess response 1, 2, 6
• Annual follow-up for stable patients to monitor for symptom progression or complications 1, 6

Mandatory Immediate Urology Referral

• Refer before initiating treatment if any of the following are present: 1, 2
  • Neurological disease
  • Findings suspicious for prostate cancer
  • Hematuria
  • Abnormal PSA
  • Recurrent infections
  • Severe obstruction (Qmax <10 mL/second)

Common Pitfalls to Avoid

• Never treat empirically without urinalysis and culture in men, as all male UTIs are complicated 1, 2
• Do not overlook prostate size when selecting treatment—alpha-blockers alone are more effective for prostates <40cc, while larger prostates benefit from combination therapy with 5α-reductase inhibitors 2
• Avoid initiating anticholinergics in men with significant post-void residual volumes without first addressing obstruction 2
• Do not assume UTI in younger men without considering sexually transmitted infections, particularly urethritis 1, 4
• Warn patients on alpha-blockers about ejaculatory dysfunction and increased risk of intraoperative floppy iris syndrome if cataract surgery is planned 2