What is the next step in managing dysuria in a 19-year-old female with negative Urine Tests (UTs)?

Management of Dysuria in a 19-Year-Old Female with Negative Urine Tests

In a 19-year-old female with dysuria and negative urine tests, obtain a detailed sexual history and test for atypical sexually transmitted infections, particularly Mycoplasma genitalium, before considering other diagnoses or empiric treatment. 1

Immediate Diagnostic Steps

Sexual History Assessment

• Document timing of dysuria relative to sexual activity, number of sexual partners, and specific sexual practices to stratify STI risk. 1 This is the critical first step that guides all subsequent management.
• Ask specifically about new partners, unprotected intercourse, and partner symptoms. 2

STI Testing Protocol

• If sexual history suggests any STI risk, test for Mycoplasma genitalium using nucleic acid amplification testing (NAAT) on first-catch urine. 1 This organism is frequently missed and causes persistent urethritis with negative standard cultures.
• Consider testing for Chlamydia trachomatis and Neisseria gonorrhoeae simultaneously, as these can present with dysuria and negative urine cultures. 2
• Evaluate for vaginal discharge on examination—its presence decreases likelihood of UTI and suggests cervicitis requiring different workup. 2, 3

Critical Pitfalls to Avoid

• DO NOT empirically prescribe fluoroquinolones or standard UTI antibiotics when cultures are negative. 1 This promotes antimicrobial resistance without addressing the underlying cause and violates antimicrobial stewardship principles. 4
• DO NOT treat asymptomatic bacteriuria if discovered incidentally during workup. 1 This fosters resistance and provides no clinical benefit.
• DO NOT perform routine cystoscopy in this young patient unless specific indications exist (hematuria, recurrent symptoms refractory to management, or suspicion of anatomic abnormalities). 1

If STI Testing is Negative

Consider Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

• IC/BPS should be considered when dysuria persists for at least 6 weeks with documented negative cultures. 1 Key features include bladder/pelvic pain or pressure, urinary frequency, strong urge to void, and dysuria without infection. 1
• Perform a brief neurological examination to rule out occult neurologic problems and evaluate for incomplete bladder emptying. 1
• Document baseline symptoms using validated tools such as the genitourinary pain index, interstitial cystitis symptom index, or visual analog scale. 1

First-Line IC/BPS Management

• Begin with behavioral and non-pharmacologic interventions: patient education, stress management techniques, dietary modifications (avoiding bladder irritants like caffeine, alcohol, acidic foods), and pelvic floor physical therapy. 1
• Oral medications can be offered concurrently: amitriptyline, pentosan polysulfate, or hydroxyzine. 1 These address the chronic pain and inflammatory components.

Alternative Non-Infectious Causes to Evaluate

• Chemical or mechanical irritation: Recent use of spermicides, douches, bubble baths, or new soaps can cause dysuria without infection. 5, 6
• Atrophic changes: Less likely in a 19-year-old but consider if patient has hypoestrogenic state (eating disorder, excessive exercise, hormonal contraception issues). 5
• Trauma: Recent vigorous sexual activity can cause urethral irritation presenting as dysuria. 5

Follow-Up Strategy

• If symptoms persist beyond 6 weeks despite addressing STI concerns, transition focus to IC/BPS management with multimodal therapy. 1
• Document response using the same validated symptom scales established at baseline. 1
• Consider urology referral if symptoms are refractory to initial behavioral and oral medication trials. 1
• Repeat urine culture if new symptoms develop or existing symptoms worsen to reassess for bacterial infection. 1

Key Clinical Pearls

• In young sexually active women, dysuria with negative standard urine tests most commonly represents either atypical STI (especially M. genitalium) or non-infectious urethritis. 1, 2
• Negative dipstick urinalysis does not rule out UTI in patients with high pretest probability based on symptoms, but in this case with negative cultures, infection is effectively excluded. 3
• Virtual encounters without laboratory testing for dysuria increase recurrent symptoms and unnecessary antibiotic courses—in-person evaluation with appropriate testing is preferred. 2