Management of Cystitis Symptoms in Men Without WBCs in Urine
When men present with cystitis symptoms but lack pyuria (no WBCs in urine), treatment should be deferred and testing for N. gonorrhoeae and C. trachomatis should be performed, as this presentation suggests urethritis rather than true cystitis, and empiric antibiotic treatment is only justified for high-risk patients unlikely to return for follow-up. 1
Diagnostic Framework: Distinguishing Urethritis from Cystitis
The absence of WBCs in urine is a critical finding that fundamentally changes the diagnostic approach:
Pyuria is expected with true UTI/cystitis: The absence of pyuria (negative leukocyte esterase test or <10 WBCs per high-power field on microscopy) effectively excludes a urinary source of infection with near 100% negative predictive value 1
Consider urethritis as the primary diagnosis: In men with dysuria and urinary frequency but no pyuria, urethritis (particularly nongonococcal urethritis) is far more likely than cystitis 1
Urethritis diagnostic criteria include: Mucopurulent/purulent discharge, >5 WBCs per oil immersion field on urethral Gram stain, or positive leukocyte esterase/≥10 WBCs per HPF in first-void urine 1
Recommended Management Algorithm
Step 1: Defer Empiric Treatment in Most Cases
Do not treat empirically if none of the urethritis criteria are met and the patient can return for follow-up 1
Obtain testing for sexually transmitted infections: Test specifically for N. gonorrhoeae and C. trachomatis using nucleic acid amplification tests, which are more sensitive than traditional culture techniques 1
Follow closely: Monitor the patient while awaiting test results 1
Step 2: Treat Based on Test Results
If testing confirms gonorrhea or chlamydia:
Provide appropriate antimicrobial therapy based on the specific pathogen identified 1
Refer sexual partners for evaluation and treatment 1
For confirmed nongonococcal urethritis (NGU):
Azithromycin 1 g orally as a single dose OR Doxycycline 100 mg orally twice daily for 7 days 1
Alternative regimens include erythromycin base 500 mg four times daily for 7 days, ofloxacin 300 mg twice daily for 7 days, or levofloxacin 500 mg once daily for 7 days 1
Step 3: Empiric Treatment Exception
Only treat empirically without documentation of urethritis in these specific circumstances 1:
- High-risk patients (e.g., adolescents with multiple partners) who are unlikely to return for follow-up evaluation
- Treat for both gonorrhea and chlamydia in these cases
- Partners must still be evaluated and treated
Important Clinical Pitfalls
Common Misdiagnosis: Interstitial Cystitis/Bladder Pain Syndrome
IC/PBS presents with cystitis-like symptoms but negative cultures: Patients have urinary frequency, urgency, and pelvic pain without identifiable pathology 2
Symptom overlap leads to inappropriate antibiotic use: Many IC/PBS patients are culture-negative but receive empiric antibiotics for presumed UTI 2
Consider IC/PBS if: Symptoms persist beyond 6 weeks, recurrent negative cultures, and no response to antibiotics 1, 2
Chemical/Drug-Induced Cystitis
Chemical cystitis mimics infectious cystitis: Can present with dysuria and frequency but may have minimal or absent pyuria 3
Consider medication history: Chemotherapeutic agents, ketamine abuse, or other chemical exposures can cause sterile cystitis 4, 3
Hemorrhagic cystitis may occur: Some cases progress to gross hematuria without infection 4, 3
When to Reconsider True UTI Despite Absent Pyuria
Rare exceptions where bacteriuria occurs without pyuria 1:
- Neutropenic patients (though uncommon in outpatient settings)
- Very early infection before inflammatory response develops
- In these cases, urine culture remains the definitive test
Key Differences: Male vs. Female UTI Management
All male UTIs are considered complicated and require different management than female cystitis 5, 6:
- Standard treatment duration is 14 days (not 3-5 days as in women) 5, 6
- Prostate involvement cannot be excluded at initial presentation 6
- Broader microbial spectrum with higher resistance rates 5, 7, 6
- Urine culture and susceptibility testing recommended before treatment 5, 7, 6
However, this 14-day recommendation applies only when pyuria IS present, confirming actual UTI rather than urethritis 5, 6.
Bottom Line Approach
The absence of WBCs in urine fundamentally changes the diagnosis from cystitis to probable urethritis. The CDC guidelines are explicit: without documentation of urethritis (including pyuria), defer treatment and test for STIs 1. Only high-risk patients who cannot follow up should receive empiric treatment for gonorrhea and chlamydia 1. This approach prevents unnecessary antibiotic exposure while ensuring appropriate pathogen-directed therapy when test results return positive.