How to treat dysuria?

Treatment of Dysuria

Obtain urinalysis and urine culture immediately in all patients with dysuria, and initiate empiric antibiotics only if dysuria is accompanied by additional symptoms such as frequency, urgency, fever, or costovertebral angle tenderness. 1

Initial Diagnostic Workup

The evaluation must differentiate infectious from non-infectious causes before treatment:

• Urinalysis (dipstick and microscopic) is mandatory in all patients presenting with dysuria—a negative nitrite and leukocyte esterase test makes UTI unlikely. 1, 2
• Urine culture with susceptibilities must be obtained before starting antibiotics to guide targeted therapy, especially since UTI in males is considered complicated. 1, 3
• History should specifically assess for recent-onset dysuria plus accompanying symptoms (frequency, urgency, new incontinence, fever, chills, flank pain), recent sexual activity, catheter use, and prior antibiotic exposure. 1, 2
• Physical examination must include vital signs, abdominal examination for bladder distention, digital rectal examination to assess prostate abnormalities, and perineal sensation assessment. 4, 1

Treatment Algorithm Based on Clinical Presentation

For Uncomplicated UTI (Dysuria + Positive Urinalysis, No Systemic Symptoms)

First-line antibiotic options for 3-5 days: 2

• Nitrofurantoin for 3-5 days
• Trimethoprim-sulfamethoxazole for 3-5 days
• Fosfomycin trometamol 3g single dose

Avoid fluoroquinolones if: 2, 3

• Local resistance >10%
• Patient used them in the last 6 months
• Elderly patient (increased risk of tendon rupture, CNS effects, QT prolongation) 1

For Complicated UTI (Males, Systemic Symptoms, Elderly >80 Years)

Treatment duration is 7-14 days, with 14 days recommended for men where prostatitis cannot be excluded. 1, 3

For patients with systemic symptoms requiring IV therapy initially: 2

• Amoxicillin plus aminoglycoside, OR
• Second-generation cephalosporin plus aminoglycoside, OR
• Third-generation cephalosporin IV

Transition to oral therapy once hemodynamically stable and afebrile ≥48 hours. 2

For Elderly Patients (Special Considerations)

• Do not treat asymptomatic bacteriuria—it causes neither morbidity nor increased mortality. 2
• Only prescribe antibiotics if recent-onset dysuria PLUS accompanying symptoms (frequency, urgency, new incontinence, systemic signs). 2, 3
• Avoid nitrofurantoin if creatinine clearance <30 mL/min. 2
• UTI in patients >80 years should be treated as complicated regardless of other factors. 3

Non-Infectious Causes Requiring Different Management

Postmenopausal Women with Hypoestrogenism

Vaginal estrogen replacement is strongly recommended to prevent recurrent symptoms. 2

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. 2

Interstitial Cystitis/Bladder Pain Syndrome

Cystoscopy should be performed if Hunner lesions are suspected (symptoms present ≥6 weeks), and treatment is individualized based on phenotype. 2

Catheter-Associated UTI

Remove or change catheter before specimen collection, and only treat if systemic signs present. 2

Follow-Up and Monitoring

• Evaluate clinical response within 48-72 hours of initiating therapy. 1, 3
• Adjust antibiotics based on culture results and susceptibility patterns. 1, 3
• Refer to urology if: red flag symptoms present, treatment fails, recurrent infections occur, or anatomical abnormalities suspected. 1
• Upper urinary tract imaging (renal ultrasound) is indicated if: history of upper UTI, hematuria, urolithiasis, renal insufficiency, or recent-onset nocturnal enuresis. 1

Critical Pitfalls to Avoid

• Do not empirically treat without urinalysis—this leads to inappropriate antibiotic use and missed non-infectious causes. 2
• Do not use fluoroquinolones empirically when local resistance rates are high (>10%) or in elderly patients with recent exposure. 1, 3
• Do not fail to address underlying urological abnormalities (obstruction, stones, anatomic defects)—antimicrobials alone will fail without correcting the complicating factor. 2
• Do not treat asymptomatic bacteriuria in elderly patients—this is a common error that increases antibiotic resistance without benefit. 2