What are the causes and treatments of dysuria (painful urination)?

Dysuria: Causes and Treatment

For acute-onset dysuria in otherwise healthy women, obtain urinalysis to confirm urinary tract infection and treat with first-line antibiotics (nitrofurantoin 3-5 days, trimethoprim-sulfamethoxazole 3-5 days, or fosfomycin 3g single dose), but if urinalysis is negative or symptoms persist despite treatment, immediately stop antibiotics and evaluate for urethritis from sexually transmitted pathogens. 1, 2

Diagnostic Approach

Initial Assessment

• Dysuria is defined as pain, burning, or discomfort during urination and requires urinalysis on all patients to differentiate infectious from non-infectious causes. 1, 3
• Acute-onset dysuria has >90% accuracy for UTI in young women when vaginal irritation or discharge is absent. 4
• A normal urine dipstick (negative leukocyte esterase and nitrites) effectively rules out bacterial cystitis, making antibiotic therapy inappropriate. 2

Key Historical Features to Elicit

• Duration of symptoms: Must be present ≥6 weeks for chronic conditions like interstitial cystitis. 1
• Associated symptoms: Frequency, urgency, hematuria, new incontinence, or systemic signs (fever, flank pain). 4
• Vaginal symptoms: Discharge or irritation suggests vaginitis rather than UTI. 5
• Sexual history: Risk factors for sexually transmitted infections causing urethritis. 2, 5
• Recent antibiotic use: Particularly fluoroquinolones in the last 6 months affects treatment selection. 1

Laboratory Evaluation

• Urinalysis is mandatory except in uncomplicated young women with classic symptoms and no complicating features. 1, 5
• Urine culture should be obtained when initial specimen suggests contamination, for recurrent infections, or when diagnosis is uncertain. 4
• If dysuria persists with negative urinalysis and failed antibiotic treatment, test for urethritis pathogens (Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum). 2, 6

Treatment Based on Etiology

Uncomplicated UTI (Culture-Proven Bacterial Cystitis)

First-line antibiotic options 1:

• Nitrofurantoin for 3-5 days
• Trimethoprim-sulfamethoxazole for 3-5 days (if local resistance <20%) 7
• Fosfomycin trometamol 3g single dose

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

Complicated UTI with Systemic Symptoms

• Initial combination IV therapy with amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or third-generation cephalosporin. 1
• Treatment duration is 7-14 days, though 7 days may suffice if hemodynamically stable and afebrile ≥48 hours. 1
• Address underlying urological abnormalities (obstruction, stones, anatomic defects), as antimicrobials alone will fail without correcting the complicating factor. 1

Urethritis from Sexually Transmitted Pathogens

These pathogens cause urethral inflammation without pyuria or bacteriuria on standard urine testing. 2

Treatment regimens 2:

• Chlamydia: Doxycycline 100mg twice daily for 7 days OR azithromycin 1g single dose
• Gonorrhea: Ceftriaxone 500mg IM single dose
• Mycoplasma genitalium: Doxycycline 100mg twice daily for 7 days followed by moxifloxacin 400mg daily for 7 days if macrolide-resistant
• Partner notification and treatment is mandatory. 2

Non-Infectious Dysuria

Postmenopausal Hypoestrogenism

• Vaginal estrogen replacement is strongly recommended to prevent recurrent symptoms. 1

Dysfunctional Voiding

• Urotherapy is highly effective and includes education about bladder/bowel function, timed voiding schedules, adequate fluid intake, correct toilet posture, and management of constipation. 1

Interstitial Cystitis/Bladder Pain Syndrome

• Cystoscopy should be performed if Hunner lesions are suspected, with treatment individualized based on phenotype. 1

Special Population Considerations

Elderly Patients

• Only prescribe antibiotics if recent-onset dysuria PLUS frequency, urgency, new incontinence, systemic signs, or costovertebral tenderness. 1
• Do not treat asymptomatic bacteriuria, as it causes neither morbidity nor increased mortality. 1
• Avoid nitrofurantoin if creatinine clearance <30 mL/min. 1
• Elderly patients may present with atypical symptoms (fatigue, confusion, falls) rather than classic dysuria. 8

Catheter-Associated UTI

• Remove or change catheter before specimen collection, and only treat if systemic signs present. 1

Critical Red Flags Requiring Further Workup

• Fever, flank pain, or systemic symptoms suggest upper tract involvement requiring imaging and different management. 2
• Gross hematuria after infection resolution warrants urologic evaluation for stones, malignancy, or structural abnormalities. 2
• Recurrent symptoms within 2 weeks suggest bacterial persistence from anatomic abnormality requiring imaging. 2
• Post-void residual volume measurement should be considered if voiding dysfunction is suspected. 2

Common Pitfalls to Avoid

• Do not empirically treat suspected UTI without urinalysis, as this leads to inappropriate antibiotic use and antimicrobial resistance. 1
• Discontinue antibiotics immediately in patients with non-infectious dysuria, as they provide no benefit and may cause harm. 2
• Do not perform cystoscopy or upper tract imaging routinely in uncomplicated recurrent UTI. 4
• Expectant management with analgesics is likely underutilized; supportive care can be reasonably attempted while awaiting urine cultures. 4