What are the next steps for a patient with dysuria and a normal urinalysis?

Dysuria with Normal Urinalysis: Next Steps

In a patient with dysuria and normal urinalysis, consider sexually transmitted infections (particularly urethritis/cervicitis), bladder irritants, vaginal causes in women, and prostatitis in men—obtain appropriate cultures and consider empiric treatment based on risk factors while ruling out non-infectious causes. 1

Immediate Diagnostic Considerations

Sexually Transmitted Infections (Most Common in Younger Patients)

• Urethritis or cervicitis from STIs can present with dysuria despite normal urinalysis, as these organisms infect the urethra/cervix rather than the bladder. 1, 2
• In younger patients (especially <35 years), Chlamydia trachomatis is the most common cause of dysuria with normal urinalysis. 2
• If initial testing for gonorrhea and chlamydia is negative but symptoms persist, test specifically for Mycoplasma genitalium. 1
• Obtain urethral swabs in men or endocervical/vaginal swabs in women for nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia. 3

Age-Specific Approach

• In men >35 years: Consider prostatitis or bladder outlet obstruction from benign prostatic hyperplasia, even with normal urinalysis. 2
• In younger, sexually active patients: STI-related urethritis is the primary consideration. 2
• Perform digital rectal examination in older men to assess prostate size, consistency, and tenderness. 3

Critical History Elements to Elicit

Sexual and Discharge History

• Vaginal discharge significantly decreases the likelihood of UTI and should prompt evaluation for vaginitis or cervicitis instead. 1
• Document sexual activity, new partners, and condom use to assess STI risk. 3
• Ask about urethral discharge in men, which suggests urethritis. 3

Timing and Character of Dysuria

• Pain at the beginning of urination suggests urethral pathology. 4
• Pain during or throughout urination suggests bladder involvement. 4
• Pain after urination may indicate bladder or prostatic disease. 4

Other Lower Urinary Tract Symptoms

• Assess for frequency, urgency, nocturia, hesitancy, weak stream, and incomplete emptying using validated questionnaires like I-PSS. 3
• Document any hematuria (even if not visible), as this requires separate urologic evaluation. 5, 6

Non-Infectious Causes to Consider

Bladder Irritants and Medications

• Review exposure to soaps, bubble baths, spermicides, douches, and feminine hygiene products. 7
• Assess medication history, particularly recent chemotherapy agents or other bladder irritants. 2

Structural and Inflammatory Conditions

• Interstitial cystitis/bladder pain syndrome presents with chronic dysuria, frequency, and urgency despite negative cultures. 7
• Urolithiasis can cause dysuria if stones are in the bladder or distal ureter. 2
• In postmenopausal women, atrophic vaginitis from hypoestrogenism is common. 3

Dermatologic Causes

• Examine external genitalia for lesions, ulcers, or dermatitis that could cause pain referred to urination. 1

When to Obtain Urine Culture

Urine culture is indicated for:

• Recurrent dysuria or suspected complicated UTI, even if urinalysis appears normal. 1
• Men with dysuria (higher likelihood of complicated infection). 2
• Patients who fail initial empiric therapy. 1
• Pregnancy or immunocompromised states. 3

Treatment Approach

Empiric Treatment Considerations

• Do NOT empirically treat with antibiotics for presumed UTI when urinalysis is normal, as this leads to unnecessary antibiotic exposure and may delay correct diagnosis. 1
• If STI risk factors are present and testing is pending, consider empiric treatment for chlamydia and gonorrhea per local guidelines. 3
• Virtual encounters without laboratory testing increase recurrent symptoms and antibiotic courses—in-person evaluation with appropriate testing is preferred. 1

If Symptoms Persist After Initial Evaluation

• Repeat urinalysis and culture to confirm findings. 5
• Consider cystoscopy if symptoms are chronic and no cause identified, particularly in patients >60 years or with risk factors for bladder pathology. 3
• Refer to urology for persistent unexplained dysuria, especially with any degree of hematuria. 5, 6
• Consider nephrology referral if proteinuria, elevated creatinine, or dysmorphic RBCs develop. 5

Common Pitfalls to Avoid

• Do not assume anticoagulation or antiplatelet therapy explains dysuria or any associated hematuria—these medications unmask but do not cause urinary symptoms. 6
• Do not dismiss symptoms in women as "just a UTI" without proper evaluation, as women are significantly underreferred for urologic evaluation. 6
• Do not delay STI testing in younger patients based on normal urinalysis alone. 1, 2
• Do not overlook prostate examination in older men with dysuria, as prostatitis may not show pyuria on urinalysis. 3, 2