What is the treatment for dysuria in males?

Treatment of Dysuria in Males

For male dysuria, initiate treatment based on age and infection status: younger men (<35 years) require empiric therapy for sexually transmitted infections, older men need evaluation and treatment for urinary tract infection often complicated by benign prostatic hyperplasia, and non-infectious cases should be managed with alpha-blockers as first-line therapy. 1, 2

Initial Diagnostic Workup

Before initiating treatment, obtain the following mandatory assessments:

• Complete medical history focusing on symptom duration, severity, sexual activity history, and previous episodes to differentiate infectious from non-infectious causes 1
• Physical examination including suprapubic area evaluation, external genitalia inspection, and digital rectal examination to assess prostate size and tenderness 1, 2
• Urinalysis (both dipstick and microscopic examination) to detect infection, hematuria, proteinuria, or glycosuria—this is essential for all men with dysuria 1, 3
• Urine culture to guide appropriate antibiotic therapy, particularly since all UTIs in men are considered complicated 1
• International Prostate Symptom Score (IPSS) questionnaire to quantify symptom severity and quality of life impact 1, 2
• Post-void residual volume measurement to evaluate for urinary retention 2, 4
• Frequency-volume chart for at least 3 days, especially when nocturia is prominent 5, 2

Age-Based Treatment Algorithm

Younger Men (<35 years)

• Empiric antibiotic therapy for sexually transmitted infections is the primary approach, as urethritis from organisms like Chlamydia trachomatis predominates in this age group 1, 3
• If persistent urethritis occurs with negative initial testing, obtain Mycoplasma genitalium testing 6

Older Men (≥35 years)

• Empiric antibiotic therapy based on local resistance patterns for suspected UTI, as coliform bacteria (especially E. coli) are the predominant pathogens 1, 7, 3
• UTI in older men typically results from urinary stasis secondary to benign prostatic hyperplasia 1, 3

Treatment for Non-Infectious Dysuria (BPH-Related)

First-Line Pharmacological Therapy

• Alpha-1 adrenoceptor antagonists (tamsulosin or alfuzosin) are the first-line treatment due to rapid onset of action, good efficacy, and low adverse event rates 1, 2
• These medications relax smooth muscle in the prostate and bladder neck, improving urinary flow 2
• Assess treatment effectiveness after 2-4 weeks of alpha-blocker therapy 1, 2
• Common side effects include asthenia, dizziness, and orthostatic hypotension 2

Combination Therapy for Prostate Enlargement

• For men with prostate enlargement, add 5α-reductase inhibitors (finasteride or dutasteride) to the alpha-blocker, as this combination is more effective for long-term symptom management and reducing disease progression in men with larger prostates 2
• Assess 5α-reductase inhibitor effectiveness after 3 months of therapy 1

Alternative Pharmacological Options

• For predominant storage symptoms, consider anticholinergics or beta-3 agonists, but exercise caution with anticholinergics in men with elevated post-void residual volumes 2
• For concurrent erectile dysfunction, consider phosphodiesterase-5 inhibitors (tadalafil), which address both LUTS and erectile dysfunction 2

Non-Pharmacological Management

• Regulate fluid intake, especially in the evening, to manage symptoms 1
• Avoid dietary indiscretions including excessive alcohol and highly seasoned or irritative foods 1
• Encourage physical activity to avoid sedentary lifestyle 1

Follow-Up Strategy

• Evaluate patients 4-12 weeks after initiating treatment to assess response using standardized questionnaires like IPSS 1, 2
• Measure post-void residual volume at follow-up to monitor for urinary retention 2
• Annual follow-up for stable patients to detect symptom progression or complications 1, 2

Mandatory Immediate Urology Referral Criteria

Refer to urology before initiating treatment if any of the following are present:

• Neurological disease 1, 4
• Severe obstruction (Qmax <10 mL/second) 1, 4
• Findings suspicious for prostate cancer 1, 2
• Hematuria 1, 2
• Abnormal PSA 1, 2
• Recurrent infections 1, 4
• Palpable bladder or significantly elevated post-void residual 4

Critical Pitfalls to Avoid

• Never initiate treatment for non-infectious dysuria without ruling out infectious causes through urinalysis and urine culture 2
• Do not ignore prostate size when selecting treatment—alpha-blockers alone are more effective for smaller prostates (<40 mL), while combination therapy is needed for larger glands 2
• Avoid initiating anticholinergics in men with significant post-void residual volumes due to risk of acute urinary retention 2
• Be aware that alpha-blockers may cause ejaculatory dysfunction, particularly selective agents like tamsulosin and silodosin 2
• Warn patients on alpha-blockers scheduled for cataract surgery about increased risk of intraoperative floppy iris syndrome 2