What are the treatment options for hematuria, suprapubic pain, and dysuria that occur after using a sexual enhancement spray?

Acute Chemical or Irritant Cystitis Following Sexual Enhancement Spray Use

Immediate Management

This presentation of hematuria, suprapubic pain, and dysuria occurring 4 days after using a sexual enhancement spray is most consistent with chemical or irritant cystitis, and you should immediately discontinue the spray, obtain urinalysis with culture to exclude infection, and initiate symptomatic treatment with phenazopyridine and NSAIDs while avoiding bladder irritants. 1, 2

Diagnostic Approach

Essential Initial Testing

• Obtain urinalysis on all patients with dysuria to differentiate infectious from non-infectious causes, as empiric treatment without proper diagnosis leads to inappropriate antibiotic use 2
• Urine culture is mandatory to document negative results and exclude bacterial infection, which is essential for distinguishing chemical cystitis from infectious causes 1, 2
• The temporal relationship (4 days post-exposure to spray) strongly suggests chemical irritation rather than infection 3, 1

Key Diagnostic Features

• Pain, pressure, or discomfort related to the urinary bladder distinguishes bladder pathology from urethritis, which typically presents with urethral discharge 1
• Symptoms include dysuria, frequency, urgency, hematuria, and suprapubic pain—all consistent with bladder irritation 4
• Negative urine culture despite dysuria is the hallmark that distinguishes chemical/irritant cystitis from infectious cystitis 1

Treatment Algorithm

First-Line Symptomatic Management

• Immediately discontinue the sexual enhancement spray and avoid all potential bladder irritants including caffeine, citrus, tomatoes, and spicy foods 3, 2
• Phenazopyridine (urinary analgesic) for symptomatic relief of dysuria and suprapubic pain 2
• NSAIDs for pain control as needed 3
• Increase fluid intake to dilute urine and flush irritants, but avoid excessive amounts that may worsen frequency 2

Behavioral Modifications

• Avoid bladder irritants as a first-line intervention—this includes the offending spray, caffeine, alcohol, artificial sweeteners, and acidic foods 1, 2
• Stress management and relaxation techniques may help reduce bladder sensitivity 1
• Timed voiding schedules with adequate fluid intake can prevent symptom exacerbation 2

If Symptoms Persist Beyond 2 Weeks

• Consider interstitial cystitis/bladder pain syndrome (IC/BPS) if symptoms persist for ≥6 weeks despite negative cultures 1, 2
• Manual physical therapy is indicated for patients with pelvic floor tenderness 1
• Oral medications such as amitriptyline, cimetidine, or hydroxyzine may provide relief for persistent symptoms 1

Critical Pitfalls to Avoid

Do Not Prescribe Antibiotics Without Documented Infection

• Empiric antibiotic treatment without proper diagnosis leads to inappropriate antibiotic use and does not address the underlying chemical irritation 2
• Antibiotics are only indicated if urine culture is positive or if systemic signs of infection develop 2

Do Not Ignore Persistent or Worsening Symptoms

• If hematuria persists beyond 2-3 weeks, refer to urology for cystoscopy to investigate secondary causes and exclude bladder lesions 3, 5
• Persistent symptoms after initial evaluation and treatment require further workup for both infectious and non-infectious causes 6
• Rare conditions like eosinophilic cystitis can present with identical symptoms (hematuria, dysuria, suprapubic pain) and require cystoscopy with biopsy for diagnosis 7, 5

Monitor for Complications

• Assess for upper urinary tract involvement if fever, flank pain, or systemic symptoms develop, which would indicate complicated infection requiring different management 2, 4
• Dilation of the upper urinary tract can occur with severe bladder inflammation 5

Expected Clinical Course

• Most cases of chemical cystitis resolve within 1-2 weeks after discontinuing the offending agent and implementing symptomatic treatment 1, 2
• Hematuria typically resolves first, followed by dysuria and frequency 5
• If symptoms persist ≥6 weeks, the diagnosis shifts to chronic bladder pain syndrome requiring different management strategies 1, 2