What is the treatment for dysuria (painful urination)?

Treatment of Dysuria

The treatment of dysuria depends critically on identifying the underlying cause through targeted history and urinalysis, with infectious causes requiring pathogen-specific antibiotics and non-infectious causes requiring condition-specific interventions. 1

Diagnostic Approach Before Treatment

Obtain urinalysis on all patients presenting with dysuria to differentiate infectious from non-infectious causes, as empiric treatment without proper diagnosis leads to inappropriate antibiotic use. 2, 3

Key Historical Elements to Elicit:

• Sexual activity and new partners (suggests sexually transmitted infection rather than simple UTI) 2, 4
• Vaginal discharge presence (decreases likelihood of UTI; investigate cervicitis instead) 2
• Duration of symptoms (must be present ≥6 weeks for chronic conditions like interstitial cystitis) 1
• In men >35 years: obstructive symptoms suggesting prostatic hyperplasia 4
• In elderly: recent-onset dysuria PLUS frequency, urgency, new incontinence, systemic signs, or costovertebral tenderness (only then prescribe antibiotics) 5

Laboratory Testing:

• Pyuria (≥8-10 WBC/hpf) is the best predictor of bacteriuria requiring treatment 6
• Nitrites on dipstick are highly specific for UTI, particularly in elderly patients 7
• Urine culture is mandatory for recurrent infections, complicated UTI, pregnancy, or when resistance patterns need clarification 1

Treatment Based on Etiology

For Uncomplicated UTI (Infectious Dysuria)

First-line antibiotic options (choose based on local resistance patterns): 8

• Nitrofurantoin for 3-5 days 8
• Trimethoprim-sulfamethoxazole for 3-5 days (only if local resistance <20%) 8, 9
• Fosfomycin trometamol 3g single dose 8

Avoid fluoroquinolones for empirical treatment if local resistance >10% or if patient used them in the last 6 months. 1

For Complicated UTI with Systemic Symptoms

Use combination IV therapy initially: 1

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Third-generation cephalosporin IV

Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded), though 7 days may suffice if patient is hemodynamically stable and afebrile ≥48 hours. 1

Critical: Address underlying urological abnormalities (obstruction, stones, anatomic defects) as antimicrobials alone will fail without correcting the complicating factor. 1

For Sexually Transmitted Urethritis

Differentiate gonococcal from non-gonococcal urethritis through appropriate testing. 1

If persistent urethritis with negative initial testing, obtain Mycoplasma genitalium testing. 2

For Mild-Moderate Uncomplicated Cystitis (Symptomatic Treatment)

Ibuprofen may be considered as an alternative to antimicrobials for symptom management in females with mild-moderate dysuria, though this approach risks delayed bacterial clearance and must be discussed with individual patients. 8

For Non-Infectious Dysuria

Postmenopausal Women with Hypoestrogenism:

Vaginal estrogen replacement (creams, rings, or tablets) is strongly recommended to prevent recurrent symptoms. 10

Dysfunctional Voiding:

Urotherapy is highly effective and includes: 10

• Education about bladder/bowel function
• Timed voiding schedules
• Adequate fluid intake
• Correct toilet posture with buttock and foot support
• Management of constipation (particularly important in children)

Interstitial Cystitis/Bladder Pain Syndrome:

Cystoscopy should be performed if Hunner lesions are suspected, as this is the only reliable diagnostic method and these patients respond well to specific treatment. 1

Treatment is individualized based on phenotype, with options including behavioral/non-pharmacologic approaches, oral medicines, bladder instillations, procedures, or major surgery for refractory cases. 1

Special Population Considerations

Elderly Patients:

Do NOT treat asymptomatic bacteriuria (present in ~40% of institutionalized elderly), as it causes neither morbidity nor increased mortality. 5

Only prescribe antibiotics if recent-onset dysuria PLUS accompanying symptoms (frequency, urgency, new incontinence, systemic signs, or costovertebral tenderness). 5

Avoid nitrofurantoin if creatinine clearance <30 mL/min. 10

Catheter-Associated UTI:

Remove or change catheter before specimen collection, as chronic indwelling catheters have universal bacteriuria; only treat if systemic signs present. 1, 5

Common Pitfalls to Avoid

• Never treat based on pyuria alone without symptoms, especially in elderly patients with incontinence where pyuria is common without infection. 7
• Never use fluoroquinolones empirically in urology department patients or those with recent fluoroquinolone exposure (last 6 months). 1
• Never ignore vaginal discharge as this decreases UTI likelihood and requires investigation for cervicitis. 2
• Never assume all dysuria is infectious—consider bladder irritants, skin lesions, chronic pain conditions, and medication effects. 2, 3