What is the recommended treatment for an 18-year-old female patient complaining of dysuria?

Treatment of Dysuria in an 18-Year-Old Female

For an 18-year-old female with dysuria and typical symptoms of uncomplicated cystitis (frequency, urgency, absence of vaginal discharge), first-line treatment is fosfomycin 3g single dose or nitrofurantoin 100mg twice daily for 5 days. 1

Diagnostic Approach

• Diagnosis can be made clinically based on dysuria, frequency, and urgency without vaginal discharge, as these symptoms have high predictive value for uncomplicated cystitis in young women 1
• Urinalysis is not required if symptoms are typical and the patient has no complicating factors, though dipstick testing can increase diagnostic accuracy if the clinical picture is unclear 1
• Urine culture is NOT indicated for straightforward uncomplicated cystitis in this age group unless symptoms fail to resolve, recur within 4 weeks, or the patient presents with atypical symptoms 1

First-Line Treatment Options

Preferred Regimens (European Association of Urology 2024 Guidelines):

Fosfomycin trometamol:

• 3g single dose 1, 2
• Most convenient option with excellent compliance
• Nitrofurantoin demonstrated superior efficacy (70% vs 58% clinical resolution at 28 days, P=0.004) compared to fosfomycin in a 2018 randomized trial 3, though both remain guideline-recommended first-line options

Nitrofurantoin:

• 100mg twice daily for 5 days 1
• Multiple formulations acceptable (macrocrystals, monohydrate, or prolonged-release) 1
• Higher clinical cure rates than fosfomycin in head-to-head comparison (70% vs 58%) 3
• Equivalent to trimethoprim-sulfamethoxazole 3-day course with better resistance profile 4

Pivmecillinam:

• 400mg three times daily for 3-5 days 1
• Where available and based on local resistance patterns

Alternative Regimens

Only if local E. coli resistance is <20%:

• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) 1
• Trimethoprim 200mg twice daily for 5 days 1
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days 1

Non-Antimicrobial Option

• For mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antibiotics after shared decision-making with the patient 1
• This approach reduces antibiotic exposure but requires patient understanding that symptoms may persist longer

Follow-Up Considerations

• No routine post-treatment urinalysis or culture is needed if symptoms resolve 1
• If symptoms persist at end of treatment or recur within 2 weeks, obtain urine culture and treat with a different 7-day antibiotic regimen assuming resistance to the initial agent 1

Common Pitfalls to Avoid

• Do not prescribe fluoroquinolones as first-line therapy; reserve these for complicated infections or pyelonephritis due to resistance concerns and adverse effect profile 1
• Do not use trimethoprim-sulfamethoxazole empirically in areas with >20% E. coli resistance, as clinical cure rates drop significantly with resistant organisms (41% vs 84%, P<0.001) 4
• Do not obtain urine culture routinely in uncomplicated cystitis, as it increases costs without improving outcomes and is only indicated for treatment failures or atypical presentations 1
• Do not confuse with sexually transmitted infection: if vaginal discharge is present, this significantly decreases likelihood of UTI and cervicitis should be investigated instead 5, 6