What is the likely diagnosis and treatment for a 49-year-old male with dysuria (painful urination) that worsens at the end of urination, leukocyturia (moderate leukocytes in urine), and hematuria (small amount of blood in urine), with symptoms improving with increased fluid intake?

Differential Diagnosis and Management for 49-Year-Old Male with Terminal Dysuria

This clinical presentation is most consistent with bacterial cystitis (complicated UTI given male sex), and empiric antibiotic therapy for 7-14 days should be initiated immediately while awaiting urine culture results. 1

Primary Diagnosis: Complicated Urinary Tract Infection (Cystitis)

Why This is a Complicated UTI

• UTI in men is complicated by default due to anatomical factors and potential prostatic involvement, regardless of age 1
• The presence of moderate leukocytes and small blood on urinalysis with dysuria strongly supports bacterial cystitis 2
• Terminal dysuria (pain at end of urination) is characteristic of bladder inflammation from infection 2
• Symptom improvement with increased fluid intake suggests dilution of irritants and bacterial load, consistent with lower UTI 1

Critical Diagnostic Steps

Immediate workup required:

• Obtain urine culture before starting antibiotics to guide therapy if initial treatment fails 1
• Perform digital rectal exam (DRE) to assess for prostatic tenderness, as prostatitis must be considered in the differential 1
• Assess for systemic symptoms (fever, chills, flank pain) that would indicate pyelonephritis or urosepsis requiring more aggressive management 1

Key Differential Diagnoses to Consider

1. Acute Bacterial Prostatitis

• Must be evaluated via DRE for prostatic tenderness 1
• Would present with similar dysuria but typically includes perineal/suprapubic pain, fever, and obstructive voiding symptoms 3
• If prostatitis is present, treatment duration extends to 4-6 weeks

2. Benign Prostatic Hyperplasia (BPH) with Secondary UTI

• BPH predisposes to UTI in men of this age by creating urinary stasis 1
• Chronic urinary retention creates environment for bacterial growth 1
• Would present with additional obstructive symptoms (weak stream, hesitancy, incomplete emptying) 3

3. Urolithiasis (Less Likely)

• Hematuria could suggest stone disease, but terminal dysuria is not typical 3
• Absence of flank pain and colicky symptoms makes this less likely
• Symptom improvement with hydration could occur with small stones, but leukocyturia points more toward infection

4. Interstitial Cystitis/Bladder Pain Syndrome (Unlikely)

• Requires symptoms present for at least 6 weeks with documented negative cultures 3
• This is an acute presentation, making IC/BPS unlikely
• IC/BPS would not show moderate leukocytes on UA 3

Recommended Treatment Approach

First-Line Empiric Antibiotic Therapy

Option 1 (Preferred): Fosfomycin 3g single dose

• Recommended by the American College of Physicians for complicated UTI 1
• Low resistance rates and safe in renal impairment 1
• However, for male complicated UTI, extend treatment to 7-14 days 1

Option 2: Trimethoprim-sulfamethoxazole (TMP-SMX) for 7-14 days

• Appropriate if local resistance <20% and no contraindications 1
• Standard dosing: 160/800mg twice daily

Avoid: Fluoroquinolones (ciprofloxacin, levofloxacin)

• Higher risk of adverse effects including tendon rupture and CNS effects 1
• Reserve for culture-directed therapy if needed

Critical Management Points

Monitoring and Follow-up:

• Assess clinical response within 48-72 hours - if no improvement, consider prostatitis or resistant organism 1
• Obtain follow-up urine culture after treatment completion to ensure eradication 1
• If fever develops or symptoms worsen, consider imaging to rule out abscess or upper tract involvement 3

Prevention strategies:

• Encourage continued increased fluid intake to prevent recurrence 1
• If recurrent UTIs develop, consider methenamine hippurate as first-line suppressive therapy 1
• Evaluate for underlying urologic abnormalities (BPH, stones, retention) if infections recur 3

Red Flags Requiring Urgent Evaluation

• Development of fever, chills, or flank pain (suggests pyelonephritis) 1
• Inability to void or palpable bladder distention (acute retention) 3
• Gross hematuria (requires full hematuria workup including cystoscopy if risk factors present) 3
• Lack of clinical improvement within 48-72 hours of appropriate antibiotics 1

Common Pitfall: Do not assume this is simple cystitis requiring only 3-5 days of antibiotics - all UTIs in men are complicated and require 7-14 days of treatment 1, 2