What is the best course of action for a patient with dysuria, frequent urination, and itching for a week, despite having normal urine?

Evaluation and Management of Dysuria with Normal Urinalysis

This patient likely has either a sexually transmitted infection (STI), urethral syndrome, or early/low-burden urinary tract infection (UTI) that was not detected on urinalysis—you should obtain a urine culture, perform STI testing including gonorrhea, chlamydia, and consider Mycoplasma genitalium, and examine for vaginal discharge or cervicitis. 1, 2

Immediate Diagnostic Approach

The presence of dysuria, frequency, and itching for a week with normal urinalysis requires a more comprehensive evaluation than typical uncomplicated cystitis 1, 2:

Key Clinical Distinctions

• Vaginal discharge assessment is critical: The presence of vaginal discharge significantly decreases the likelihood of UTI and should prompt investigation for cervicitis or vaginitis 1, 2
• Itching is not a typical UTI symptom: This suggests either vulvovaginal involvement (candidiasis, bacterial vaginosis, STI) or urethral syndrome rather than simple cystitis 2, 3
• Normal urinalysis does not rule out infection: Even with negative dipstick testing in symptomatic patients with high pretest probability, infection may still be present 4

Recommended Testing Strategy

Essential Tests

• Urine culture: This is the gold standard and should be obtained, as symptomatic women can have UTI with bacterial counts as low as 10² CFU/mL, which may not show positive on dipstick 1, 4
• STI testing: Test for gonorrhea and chlamydia via nucleic acid amplification testing (NAAT), particularly if the patient is sexually active 1, 2
• Pelvic examination: Look specifically for vaginal discharge, cervical motion tenderness, or vulvar lesions 2, 3

Additional Testing if Initial Workup Negative

• Mycoplasma genitalium testing: If persistent urethritis or cervicitis with negative initial STI testing 2
• Vaginal wet mount and pH: To evaluate for bacterial vaginosis or trichomoniasis if discharge is present 3

Differential Diagnosis Priority

Based on the symptom constellation (dysuria + frequency + itching), consider in order 2, 3:

1. Vulvovaginal candidiasis: Itching is the hallmark symptom
2. STI (chlamydia, gonorrhea, M. genitalium): Particularly if sexually active
3. Low-burden UTI: May not show positive on dipstick but culture-positive
4. Urethral syndrome: Dysuria and frequency without bacteriuria
5. Chemical irritation: From soaps, douches, or spermicides

Management Pending Results

Do NOT Treat Empirically

• Avoid empiric antibiotics for presumed UTI: With normal urinalysis and atypical symptoms (itching), empiric treatment increases risk of misdiagnosis, antibiotic resistance, and treatment failure 1, 5
• Do not treat asymptomatic bacteriuria: If culture grows bacteria but symptoms resolve, treatment is not indicated in non-pregnant women 1

Symptomatic Management

• Consider symptomatic therapy: Ibuprofen or phenazopyridine for dysuria while awaiting culture results 1
• Avoid bladder irritants: Advise avoiding caffeine, alcohol, spicy foods, and acidic beverages 3

Treatment Based on Results

If Urine Culture Positive (≥10² CFU/mL with symptoms)

First-line antibiotics for uncomplicated cystitis 1:

• Fosfomycin trometamol 3g single dose (preferred for women)
• Nitrofurantoin 50-100mg four times daily for 5 days
• Trimethoprim-sulfamethoxazole only if local resistance <20% 6, 4

If STI Testing Positive

• Treat according to CDC guidelines for specific organism identified 2
• Partner notification and treatment is essential 2

If All Testing Negative

Consider 2, 3:

• Urethral syndrome: May respond to short course of doxycycline
• Interstitial cystitis/bladder pain syndrome: If symptoms are chronic
• Pelvic floor dysfunction: Refer to pelvic floor physical therapy
• Vulvodynia or dermatologic conditions: Dermatology referral if vulvar lesions present

Critical Pitfalls to Avoid

• Do not diagnose UTI based on symptoms alone when urinalysis is negative—obtain culture 1, 4, 5
• Do not miss STI: Sexual history and appropriate testing are essential in reproductive-age women 2
• Do not ignore the "itching": This symptom points away from simple UTI toward vulvovaginal or dermatologic causes 2, 3
• Do not repeat urinalysis if culture is negative: Focus on alternative diagnoses rather than repeated urine testing 1