What is the ER workup and treatment plan for a 56-year-old male with dysuria?

ER Workup and Treatment for 56-Year-Old Male with Dysuria

In a 56-year-old male presenting with dysuria, obtain urinalysis and urine culture immediately, then initiate empiric antibiotics only if he has dysuria PLUS additional symptoms (frequency, urgency, fever, or costovertebral angle tenderness)—isolated dysuria alone does not warrant antibiotics and requires evaluation for alternative causes. 1, 2

Initial Diagnostic Workup

History - Key Elements to Elicit

• Recent-onset dysuria with accompanying symptoms: Specifically ask about urinary frequency, urgency, new incontinence, fever, chills, or flank pain 1, 2
• Sexual history: In men under 35, sexually transmitted organisms like Chlamydia trachomatis predominate; in men over 35, coliform bacteria are more common 3
• Prostate symptoms: Lower urinary tract symptoms suggesting benign prostatic hyperplasia or prostatitis 4, 2
• Red flags requiring specialist referral: Hematuria, abnormal PSA, pain suggesting prostatitis, recurrent infections, palpable bladder, or neurological disease 4

Physical Examination - Critical Components

• Vital signs: Fever >100°F (37.8°C), hypotension, or tachycardia suggest systemic infection requiring aggressive treatment 1
• Abdominal examination: Palpable bladder suggests urinary retention 4
• Digital rectal examination (DRE): Assess for prostate tenderness (prostatitis), enlargement (BPH), or suspicious nodules (cancer) 4
• Costovertebral angle tenderness: Indicates possible pyelonephritis 1

Laboratory Testing

• Urinalysis (dipstick and microscopic): Mandatory in all patients with dysuria 2, 5, 3
  • Negative nitrite AND leukocyte esterase makes UTI unlikely 2
  • Note that dipstick specificity is only 20-70% in elderly patients 2, 6
• Urine culture with susceptibilities: Always obtain before starting antibiotics to guide targeted therapy, especially critical in men where UTI is considered complicated 2, 7
• Consider urethral/STI testing: If patient is sexually active or under 35 years old, test for Chlamydia, Gonorrhea, and Mycoplasma genitalium if initial testing negative 5, 3

Treatment Algorithm

When to Treat with Antibiotics

Only prescribe antibiotics if the patient has dysuria PLUS one or more of the following: 1

• Urinary frequency or urgency
• New incontinence
• Systemic signs (fever, chills, hypotension)
• Costovertebral angle pain/tenderness

If dysuria is isolated without these features, do NOT prescribe antibiotics for UTI—actively monitor and evaluate for non-infectious causes (urethritis, prostatitis, calculi, trauma) 1, 5

Empiric Antibiotic Selection (While Awaiting Culture)

UTI in males is considered complicated and requires 7-14 days of treatment (14 days if prostatitis cannot be excluded) 2, 7

First-line options based on local resistance patterns: 1, 2, 6

• Trimethoprim-sulfamethoxazole (if local resistance <20%)
• Nitrofurantoin 100mg twice daily for 7 days (avoid if CrCl <30 mL/min)
• Fosfomycin 3g single dose (excellent for renal impairment)
• Pivmecillinam (where available)

Avoid fluoroquinolones if: 1, 2, 6

• Local resistance >10%
• Patient used them in last 6 months
• Elderly patient (increased risk of tendon rupture, CNS effects, QT prolongation)

Special Considerations for This Age Group

At 56 years old, consider: 3

• Coliform bacteria (E. coli) are the most likely pathogens
• Urinary stasis from benign prostatic hyperplasia increases infection risk
• Prostatitis must be excluded—if suspected, treat for 14 days minimum 2

Imaging Indications (Not Routine)

Upper urinary tract imaging (renal ultrasound) indicated if: 4

• History of upper urinary tract infection
• Hematuria (microscopic or macroscopic)
• History of urolithiasis
• Renal insufficiency
• Recent onset nocturnal enuresis

Critical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria: Common in elderly but causes no morbidity or mortality 1, 6
• Do not use fluoroquinolones empirically when resistance rates are high or in elderly patients with recent exposure 1, 2, 6
• Do not assume all dysuria is UTI: Consider urethritis, prostatitis, STIs, calculi, and non-infectious causes 5, 3
• Do not skip urine culture in males: UTI in men is complicated and requires culture-guided therapy 2, 7

Follow-Up and Monitoring

• Evaluate clinical response within 48-72 hours of initiating therapy 2, 6
• Adjust antibiotics based on culture results and susceptibility patterns 2, 6
• Refer to urology if: Red flag symptoms present, treatment failure, recurrent infections, or anatomical abnormalities suspected 4