What is the treatment for dysuria (burning on urination)?

Treatment of Dysuria (Burning on Urination)

For otherwise healthy women with acute dysuria and no complicating features, treat empirically for uncomplicated cystitis with first-line antibiotics (nitrofurantoin 100mg twice daily for 5 days, fosfomycin 3g single dose, or trimethoprim-sulfamethoxazole if local resistance <20%), combined with phenazopyridine 200mg three times daily for symptomatic relief for up to 2 days. 1, 2, 3

Initial Assessment and Diagnosis

The approach to dysuria depends critically on identifying whether this represents uncomplicated cystitis versus other causes:

• Dysuria with frequency and urgency in women without vaginal symptoms has >90% accuracy for UTI and can be treated empirically without urinalysis. 1, 4
• Presence of vaginal discharge, irritation, or abnormal vaginal symptoms decreases likelihood of UTI and requires evaluation for vaginitis or sexually transmitted infections. 1, 5
• Men, pregnant women, patients with fever/flank pain, immunocompromised patients, or those with anatomic urinary tract abnormalities require urinalysis, urine culture, and consideration of complicated UTI treatment. 1

Antibiotic Treatment for Uncomplicated Cystitis

First-line options (choose one):

• Nitrofurantoin 100mg twice daily for 5 days 2
• Fosfomycin trometamol 3g single dose 2
• Trimethoprim-sulfamethoxazole for 3-5 days (only if local resistance <20%) 2, 4

Avoid fluoroquinolones unless local resistance to other agents is >10%, patient has anaphylaxis to beta-lactams, or no other options exist, as they contribute to antimicrobial resistance. 1, 4

Symptomatic Pain Management

Phenazopyridine (urinary analgesic) is the primary symptomatic treatment:

• Dose: 200mg orally three times daily 3
• Duration: Maximum 2 days, as there is no evidence of benefit beyond this timeframe 3
• Critical caveat: Phenazopyridine provides only symptomatic relief and does not treat the underlying infection—it must be combined with appropriate antibiotics 3
• Warn patients their urine will turn orange/red 3

Alternative analgesic approaches:

• Ibuprofen may be considered for mild-moderate symptoms as symptomatic therapy, though this approach risks delayed bacterial clearance and should be discussed with patients 2
• Avoid NSAIDs in patients with renal impairment as they may worsen kidney function 6
• For severe pain uncontrolled by phenazopyridine, short-term low-dose opiates may be considered with monitoring for constipation 6

Red Flags Requiring Escalation

Immediately escalate care if any of the following are present:

• Fever, rigors, flank pain, or costovertebral angle tenderness (suggests pyelonephritis requiring IV antibiotics and possible hospitalization) 1, 4
• Male sex (higher risk of complicated infection including prostatitis, requiring 14 days of treatment) 1
• Pregnancy (requires specific antibiotic selection and monitoring for adverse pregnancy outcomes) 1
• Catheter use within past 48 hours (catheter-associated UTI with 10% mortality risk from secondary bacteremia) 1
• Systemic symptoms including altered mental status, malaise, or hemodynamic instability (suggests urosepsis) 1

Sexually Transmitted Infections as Cause

If urethritis or cervicitis is suspected:

• Urethritis presents with dysuria and urethral discharge; differentiate between gonococcal and non-gonococcal causes 1
• Non-gonococcal urethritis is caused by Chlamydia trachomatis (23-55% of cases), Ureaplasma urealyticum (20-40%), Trichomonas vaginalis (2-5%), or Mycoplasma genitalium 1, 5
• Obtain urethral/vaginal cultures and treat for both gonorrhea and chlamydia if diagnostic tools unavailable 1
• Test for Mycoplasma genitalium if persistent urethritis/cervicitis with negative initial testing 5

Special Populations

Older/frail patients:

• Require recent-onset dysuria plus systemic signs (fever >37.8°C, rigors, or clear delirium) to diagnose UTI and prescribe antibiotics 1
• Do not treat based solely on cloudy urine, odor, or chronic baseline symptoms without acute changes 1
• Antibiotic selection and duration same as other adults unless complicating factors present 1

Catheter-associated UTI:

• Remove or replace catheter if feasible before initiating treatment 1
• Treat for 7-14 days depending on clinical response and whether prostatitis can be excluded in men 1

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria—positive urine culture without dysuria or systemic symptoms does not require antibiotics in non-pregnant patients 1
• Do not use phenazopyridine beyond 2 days or as monotherapy without antibiotics 3
• Do not perform cystoscopy or imaging routinely for uncomplicated recurrent UTI in otherwise healthy women 1
• Do not assume all dysuria is UTI—vaginal symptoms, trauma, interstitial cystitis, and dermatologic conditions can cause similar symptoms 7, 8