Treatment for Dysuria and Hematuria in a Young Male
This 31-year-old male with dysuria and hematuria requires empiric antibiotic treatment for presumed urinary tract infection (UTI) or urethritis, with first-line therapy being trimethoprim-sulfamethoxazole for 7 days or nitrofurantoin for 7 days, while awaiting urine culture results to guide definitive therapy. 1, 2
Diagnostic Considerations
The clinical presentation requires differentiation between several conditions:
- Lower UTI (cystitis) is likely given dysuria and hematuria without fever or systemic symptoms 3, 2
- Urethritis must be strongly considered in a sexually active male with one partner, especially since he denies penile discharge (though absence of discharge does not exclude urethritis) 1
- The absence of fever, flank pain, nausea, and vomiting makes pyelonephritis unlikely 1
Men with lower UTI symptoms should always receive antibiotics and require urine culture with susceptibility testing to guide antibiotic choice. 2 This differs from women, where empiric treatment without culture is often acceptable for uncomplicated cases.
Immediate Management
Empiric Antibiotic Therapy
Start treatment immediately while awaiting culture results:
First-line options for 7 days: 2
Treatment duration: Men require 7 days of therapy (not the 3-5 days used in women) to account for possible subclinical prostatitis 1, 2
Critical Pitfall to Avoid
Do not treat this as simple cystitis with short-course therapy. 1 The 2024 EAU guidelines specifically state that complicated UTIs in men should be treated for 7-14 days, with 14 days recommended when prostatitis cannot be excluded. 1
Urethritis Evaluation
Given the sexual history, urethritis workup is essential:
- If urethritis is suspected clinically, empiric treatment should cover both gonococcal and non-gonococcal causes 1
- Nucleic acid amplification testing should be performed for Chlamydia trachomatis, Neisseria gonorrhoeae, and if initial testing is negative with persistent symptoms, Mycoplasma genitalium 1, 3
- The absence of visible discharge does not exclude urethritis, as many urethral infections are asymptomatic or have minimal symptoms 1
Culture-Guided Adjustment
Once urine culture results return:
- Tailor antibiotics based on susceptibility patterns 1, 2
- If culture shows typical uropathogens (E. coli, Klebsiella, Proteus, Enterobacter), continue appropriate antibiotic for full 7-day course 4, 2
- If symptoms persist after 48-72 hours or worsen, consider imaging to exclude complications such as obstruction or abscess 1
When to Escalate Care
Immediate re-evaluation is needed if:
- Fever develops (suggests progression to pyelonephritis or prostatitis) 1
- Urinary retention occurs 5
- Flank pain or systemic symptoms emerge 1
- No improvement after 48-72 hours of appropriate antibiotics 1
Partner Management
Evaluate and treat sexual partner(s) if urethritis is confirmed, while maintaining patient confidentiality. 1