Initial Management of Dysuria and Hematuria in Females
For a female presenting with dysuria and hematuria suggestive of uncomplicated UTI, initiate empiric antibiotic therapy with nitrofurantoin 100 mg twice daily for 5 days as first-line treatment without requiring urine culture if she has no complicating factors. 1
Immediate Clinical Assessment
Determine if Uncomplicated vs Complicated UTI
Uncomplicated UTI criteria (all must be present): 2
- Non-pregnant female
- No structural urinary tract abnormalities
- No diabetes or immunosuppression
- No indwelling catheter
- No recent urologic procedures
- Symptoms resolve promptly with appropriate therapy
Complicating factors requiring further workup: 2, 3
- Male sex
- Pregnancy
- Diabetes or immunosuppression
- Urologic obstruction or structural abnormalities
- Recent urologic procedure
- Gross hematuria persisting after infection resolution
- Symptoms of pyelonephritis (fever, flank pain, systemic symptoms)
- Recurrent infections (≥3 episodes in 12 months)
Key Historical Features to Elicit
Symptoms favoring cystitis: 4, 5
- Dysuria with increased urinary frequency and urgency
- Absence of vaginal discharge or irritation
- Suprapubic discomfort
Red flags requiring urine culture: 1, 3
- Symptoms persisting despite prior treatment
- Recurrent infections
- Pregnancy
- Presence of complicating factors listed above
Diagnostic Testing Strategy
When Culture is NOT Required
For uncomplicated presentations in non-pregnant women: 1
- Dysuria with frequency/urgency
- No vaginal symptoms
- No complicating factors
- First episode or infrequent recurrences
Empiric treatment can proceed based on clinical diagnosis alone. 1
When Culture IS Required
Obtain urine culture before starting antibiotics in: 1, 3
- Recurrent UTIs
- Treatment failures
- Pregnant women
- Presence of any complicating factors
- Symptoms persisting despite appropriate therapy
Urinalysis Interpretation
Pyuria is the best predictor of bacteriuria requiring treatment: 6
- Manual microscopy: ≥8 WBC/high-power field indicates infection
- Automated microscopy: >2 WBC/hpf is significant
Nitrites on dipstick are highly specific for UTI, particularly in elderly patients. 5 However, negative dipstick does not rule out UTI in symptomatic patients with high pretest probability. 5
First-Line Antibiotic Treatment
Preferred Regimens (choose one):
Nitrofurantoin 100 mg twice daily for 5 days - preferred first-line agent due to low resistance rates 1, 3
Fosfomycin trometamol 3 g single dose - convenient single-dose option 1, 3
Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days - only if local resistance <20% 1, 7
Antibiotics to AVOID as First-Line
Do not use fluoroquinolones (ciprofloxacin, levofloxacin) empirically due to: 1, 3
- Increasing resistance rates
- Serious adverse effects including tendinopathies and aortic aneurysms
- Reserve for complicated infections only
Management of Hematuria Component
Acute Phase
Hematuria accompanying acute cystitis typically resolves with appropriate antibiotic therapy. 2 No additional workup is needed if hematuria resolves completely after infection treatment. 2
When to Investigate Further
Obtain imaging or specialist referral if: 2
- Gross hematuria persists after infection resolution
- Recurrent hematuria with negative cultures
- Associated with urea-splitting bacteria (suggests stones)
- Patient has risk factors for malignancy or stones
Follow-Up and Recurrence Prevention
Post-Treatment Monitoring
Urine culture is NOT needed after successful treatment (symptom resolution). 3
Repeat culture before additional antibiotics if: 8, 1
- Symptoms persist despite treatment
- Symptoms recur rapidly (within 2 weeks)
- Multiple treatment failures
For Recurrent UTIs (≥3 episodes in 12 months)
Non-antibiotic prevention strategies (try first): 1, 3
- Increase fluid intake throughout the day
- Post-coital voiding
- Avoid spermicide-containing contraceptives
- Vaginal estrogen therapy for postmenopausal women (strongly recommended)
- Methenamine hippurate as non-antibiotic prophylaxis
- Lactobacillus-containing probiotics
Antibiotic prophylaxis (if non-antibiotic measures fail): 1, 3
- Nitrofurantoin 50-100 mg daily for 6-12 months
- Consider self-start therapy in reliable patients who obtain urine specimens before starting
Critical Pitfalls to Avoid
Do NOT treat asymptomatic bacteriuria (except in pregnancy or before urologic procedures) - this increases antimicrobial resistance and recurrent UTI episodes. 1, 3
Do NOT classify recurrent UTIs as "complicated" based solely on recurrence - this drives inappropriate broad-spectrum antibiotic use with prolonged durations. 8, 1, 3
Do NOT prescribe additional antibiotics for persistent symptoms without repeat urine culture - symptoms may not represent bacterial infection. 8, 1
Do NOT routinely obtain imaging for recurrent UTIs without risk factors - imaging has low yield in patients responding promptly to therapy with <2 episodes per year. 2