What causes a burning sensation when urinating and how is it treated?

Burning Sensation When Urinating: Causes and Treatment

A burning sensation during urination (dysuria) is most commonly caused by urinary tract infection, and in women with typical symptoms (frequency, urgency, suprapubic pain) without vaginal discharge, empiric antibiotic treatment can be initiated without further testing. 1, 2

Primary Causes by Patient Population

In Women

• Lower urinary tract infection (cystitis) is the predominant cause, typically from Escherichia coli and other coliform bacteria 1, 3
• Vaginitis should be suspected when dysuria accompanies vaginal discharge 1, 4
• Urethritis from sexually transmitted organisms (Chlamydia trachomatis, Mycoplasma genitalium) in sexually active women 1, 4
• Interstitial cystitis/bladder pain syndrome when symptoms persist without infection 1, 4

In Men

• Urinary tract infection is less common but more likely related to prostatic issues in men over 35 years 5
• Urethritis from sexually transmitted infections in younger men (under 35 years) 1, 5
• Prostatitis must be considered as a cause of dysuria in men 2, 5
• Benign prostatic hyperplasia causing urinary stasis and secondary infection in older men 5

Other Important Causes

• Urinary stones causing irritation and inflammation 1, 3
• Trauma or foreign body in the urinary tract 4
• Medication effects and dermatologic conditions 4

Diagnostic Approach

For Women with Uncomplicated Symptoms

• Self-diagnosis with typical symptoms (frequency, urgency, dysuria, suprapubic pain) without vaginal discharge is sufficiently accurate to diagnose UTI and initiate treatment without testing 1, 2
• Urine culture is NOT needed for initial uncomplicated presentation 1, 2

When Testing IS Required

Obtain urine culture and susceptibility testing in these situations: 1, 6

• Suspected pyelonephritis (fever, flank pain, costovertebral angle tenderness)
• Symptoms not resolving or recurring within 4 weeks after treatment
• Atypical presentation
• Pregnancy
• Men with any UTI symptoms
• History of resistant organisms
• Recurrent infections

For Men

• Always obtain urine culture before treatment to guide antibiotic selection 2
• Consider urethral and prostatic causes in addition to cystitis 2, 5

Treatment Recommendations

First-Line Antibiotics for Uncomplicated Lower UTI in Women

Choose one of the following: 1, 6, 2

• Fosfomycin trometamol 3g single dose
• Nitrofurantoin 100mg twice daily for 5 days
• Pivmecillinam 400mg three times daily for 3-5 days
• Trimethoprim 200mg twice daily for 5 days (if local resistance <20%) 1
• Trimethoprim/sulfamethoxazole 160/800mg twice daily for 3 days (if local resistance <20%) 1, 7

For Men with Uncomplicated UTI

Treat for 7 days with: 2

• Trimethoprim
• Trimethoprim/sulfamethoxazole
• Nitrofurantoin

For Upper UTI (Pyelonephritis)

Use more aggressive therapy: 1, 6

• Amoxicillin plus an aminoglycoside, OR
• Second-generation cephalosporin plus an aminoglycoside, OR
• Intravenous third-generation cephalosporin

Critical Prescribing Caveat

Avoid fluoroquinolones for empirical treatment if: 1, 6

• Patient has used fluoroquinolones in the last 6 months
• Local resistance rate exceeds 10%
• Patient is from a urology department

Alternative and Adjunctive Approaches

Symptomatic Treatment

• Nonsteroidal anti-inflammatory drugs can be used for symptom relief, and delayed antibiotics may be considered in women with mild-to-moderate symptoms given the low risk of complications 1, 2

Prevention of Recurrent UTIs

Non-antimicrobial measures should be tried first: 1, 2

• Increased fluid intake
• Cranberry products (though evidence quality is low)
• Methenamine hippurate
• Vaginal estrogen in postmenopausal women
• Probiotics for vaginal flora regeneration

Antimicrobial prophylaxis should only be used when non-antimicrobial interventions fail 1, 6

Red Flags Requiring Urgent Evaluation

Refer or escalate care immediately if: 1, 6

• Fever >38°C with flank pain (suggests pyelonephritis)
• Signs of sepsis (altered mental status, hypotension, tachypnea)
• Inability to void or urinary retention
• Gross hematuria
• Symptoms in pregnancy
• Failure to respond to appropriate antibiotics within 72 hours

Common Pitfalls to Avoid

• Do not routinely order urine cultures for uncomplicated cystitis in women with typical symptoms, as this increases costs without improving outcomes 1, 2
• Do not use nitrofurantoin, fosfomycin, or pivmecillinam for pyelonephritis, as insufficient data support their efficacy for upper tract infections 1
• Do not assume all dysuria is infection—consider vaginitis in women with discharge, urethritis in sexually active patients, and interstitial cystitis when cultures are repeatedly negative 1, 4
• Do not overlook sexually transmitted infections as a cause of urethritis, particularly in younger patients 1, 5