What is the treatment for a patient with dysuria (burning with urination) and trace leukocytes in their urine, but negative nitrites and otherwise normal lab results?

Treatment Approach for Dysuria with Trace Leukocytes and Negative Nitrites

Do NOT prescribe antibiotics for this patient—isolated dysuria with only trace leukocytes and negative nitrites does not meet criteria for urinary tract infection and requires evaluation for alternative causes. 1, 2

Diagnostic Criteria for UTI Treatment

The European Association of Urology establishes that antibiotics should ONLY be prescribed when the patient has recent-onset dysuria PLUS one or more of the following: 1

• Urinary frequency
• Urgency
• New incontinence
• Systemic signs (fever >100°F/37.8°C, chills, hypotension)
• Costovertebral angle pain or tenderness of recent onset

Your patient has isolated dysuria without these accompanying features—this does not warrant antibiotic therapy. 1, 2

Why This Patient Should Not Receive Antibiotics

• Trace leukocytes alone are insufficient: Pyuria is the best determinant of bacteriuria requiring therapy, with significant values being ≥8-10 WBC/high-power field on manual microscopy or ≥10 WBC/mm³ on hemocytometer—"trace" does not meet this threshold. 3

• Negative nitrites are meaningful: When both nitrite and leukocyte esterase are negative on dipstick, this often suggests absence of UTI (specificity 20-70% in elderly patients). 2, 4

• Risk of treating asymptomatic bacteriuria: Approximately 40% of institutionalized elderly patients have asymptomatic bacteriuria, which causes neither morbidity nor increased mortality and should never be treated. 1

Alternative Causes to Evaluate

Since this presentation does not represent UTI, systematically evaluate for: 5

• Sexually transmitted infections: Urethritis from Chlamydia trachomatis or Neisseria gonorrhoeae (15-55% of nongonococcal urethritis cases), especially if the patient has risk factors or new sexual partners 6

• Vaginitis: If the patient is female with vulvovaginal symptoms, perform vaginal examination and testing 5

• Dermatologic conditions: Local irritation, contact dermatitis, or lichen sclerosus 5

• Medication-related causes: Recent changes in medications that may cause urethral irritation 5

• Interstitial cystitis/bladder pain syndrome: Consider if symptoms are chronic or recurrent without evidence of infection 5

• Local trauma: Recent sexual activity, catheterization, or instrumentation 5

Recommended Management Strategy

Obtain specific testing based on risk factors: 6, 5

• If sexually active or at risk for STIs: Test for Chlamydia trachomatis and Neisseria gonorrhoeae using nucleic acid amplification tests (more sensitive than culture) 6

• If vaginal symptoms present: Perform pelvic examination with vaginal pH, wet mount, and whiff test 5

• If male patient: Examine for urethral discharge; if present, obtain Gram stain showing >5 WBCs per oil immersion field to confirm urethritis 6

Active monitoring approach: 1

• Advise the patient to return if symptoms worsen or new symptoms develop (fever, flank pain, frequency, urgency) 1, 2

• Reassess in 48-72 hours if symptoms persist 2, 4

• Only initiate antibiotics if true UTI criteria develop or alternative infectious cause is confirmed 1

Critical Pitfall to Avoid

Do not provide empiric antibiotic treatment without documentation of infection. The only exception is for patients at high risk who are unlikely to return for follow-up—even then, treatment should target both gonorrhea and chlamydia if urethritis is suspected, NOT presumed UTI. 6