What is the next course of action for a patient with dysuria, burning sensation, and foamy urine, and a previous Prostate-Specific Antigen (PSA) level of 1.5?

Acute Management of Dysuria with Foamy Urine

The immediate next step is to obtain a urinalysis with culture to diagnose and treat a likely urinary tract infection, as the burning dysuria and foamy urine are classic symptoms of acute cystitis or urethritis that require prompt antimicrobial therapy. 1, 2

Initial Diagnostic Workup

The presenting symptoms of burning dysuria and foamy urine strongly suggest an acute infectious or inflammatory process rather than a chronic prostatic condition:

• Urinalysis with microscopy and culture is essential to identify pyuria, bacteriuria, and the causative organism 3
• Post-void residual (PVR) measurement via ultrasound should be obtained to assess for urinary retention that may predispose to infection 1
• The PSA of 1.5 ng/mL is within normal range and does not require immediate action in the acute setting 4

Treatment Algorithm

If Urinalysis Confirms Infection:

• Start empiric antibiotic therapy with trimethoprim-sulfamethoxazole for uncomplicated urinary tract infection due to susceptible organisms including E. coli, Klebsiella, Enterobacter, Proteus mirabilis, and Proteus vulgaris 2
• Adjust antibiotics based on culture and sensitivity results when available 2

If Urinalysis is Negative for Infection:

• Consider non-infectious causes such as granulomatous prostatitis, which can present with dysuria, pyuria, and elevated PSA 3
• Perform digital rectal examination (DRE) to assess for prostate tenderness, nodularity, or asymmetry 1

PSA Interpretation in This Context

The PSA of 1.5 ng/mL does not warrant immediate concern for prostate cancer:

• PSA levels of 0-2 ng/mL carry only a 1% probability of prostate cancer 4
• PSA testing should be repeated only after resolution of any acute urinary tract infection, as infection and inflammation can artificially elevate PSA 5
• If PSA remains >1.5 ng/mL after infection treatment and the patient has bothersome lower urinary tract symptoms, consider combination therapy with alpha-blocker and 5α-reductase inhibitor for benign prostatic hyperplasia 4, 1

Red Flags Requiring Urologic Referral

Refer to urology if any of the following are present:

• Hematuria (microscopic or macroscopic) 4
• Abnormal DRE findings suspicious for prostate cancer (nodules, asymmetry, increased firmness) 4, 1
• Persistent symptoms after appropriate antibiotic therapy 1
• Palpable bladder suggesting significant urinary retention 4
• Recurrent urinary tract infections 4

Common Pitfalls to Avoid

• Do not attribute all urinary symptoms to benign prostatic disease in the presence of acute dysuria and foamy urine—infection must be ruled out first 1, 2
• Do not perform prostate biopsy during acute infection or inflammation, as this can worsen sepsis risk and PSA may be falsely elevated 5
• Do not delay antibiotic treatment while awaiting culture results if clinical suspicion for UTI is high 2

Follow-Up Plan

• Reassess symptoms in 2-4 weeks after completing antibiotic therapy 1
• Repeat urinalysis to confirm clearance of infection 1
• Repeat PSA only if clinically indicated after infection resolution and if results would change management 5
• If lower urinary tract symptoms persist after infection treatment, initiate evaluation for benign prostatic hyperplasia with symptom questionnaire and consideration of alpha-blocker therapy 1