What is the appropriate management for a patient presenting with dysuria?

Management of Dysuria

The appropriate management of dysuria begins with confirming true urinary tract infection (UTI) by documenting recent-onset dysuria PLUS at least one additional symptom (urgency, frequency, new incontinence, or systemic signs) before prescribing antibiotics, followed by first-line treatment with fosfomycin 3g single dose, nitrofurantoin, or trimethoprim-sulfamethoxazole based on local resistance patterns. 1, 2, 3

Initial Diagnostic Approach

Confirm UTI criteria before treating:

• Dysuria alone is insufficient for UTI diagnosis - you must document recent-onset dysuria PLUS one or more of: urinary frequency, urgency, new/worsening incontinence, systemic signs (fever >100°F, rigors), or costovertebral angle tenderness 2, 3
• Dysuria has >90% accuracy for UTI in young women when vaginal irritation and discharge are absent 1
• Critical pitfall: Isolated dysuria without accompanying symptoms warrants evaluation for alternative causes (sexually transmitted infections, vaginitis, urethritis, chemical irritants) rather than empiric antibiotics 3, 4

Obtain urinalysis and urine culture:

• Urinalysis should be performed in most patients presenting with dysuria 4
• Urine culture is mandatory before initiating antibiotics in patients with recurrent UTI to document microbial confirmation and guide targeted therapy 1
• Culture is especially critical in elderly patients (specificity of dipstick only 20-70%), those with complicated infections, or when diagnosis is uncertain 2, 3
• A positive culture with >10² colony-forming units/mL confirms UTI in symptomatic patients 5

First-Line Antibiotic Treatment

Recommended first-line agents (choose based on local antibiogram):

• Fosfomycin 3g single dose - optimal for elderly patients and those with renal impairment as it maintains therapeutic concentrations regardless of kidney function 2, 3
• Nitrofurantoin - avoid if creatinine clearance <30-60 mL/min due to inadequate urinary concentrations and toxicity risk 3
• Trimethoprim-sulfamethoxazole - use only if local resistance <20%; adjust dose for renal impairment 1, 3

Treatment duration:

• Treat acute cystitis episodes with the shortest reasonable duration, generally no longer than 7 days 1
• For complicated UTIs in elderly males, use 7-14 days, with 14 days when prostatitis cannot be excluded 2

Agents to avoid:

• Do NOT use amoxicillin-clavulanate for empiric UTI treatment - explicitly not recommended by guidelines 2, 3
• Avoid fluoroquinolones if local resistance >10% or if used in last 6 months, particularly in elderly due to increased adverse effects 3

Special Population Considerations

Elderly patients:

• Approximately 40% of institutionalized elderly have asymptomatic bacteriuria that should NOT be treated as it causes neither morbidity nor mortality 2, 3
• Elderly often present with atypical symptoms (altered mental status, functional decline) rather than classic dysuria 2
• Patient-initiated treatment (self-start) may be offered to select patients with recurrent UTI while awaiting cultures 1

Women with recurrent UTI:

• Frequency of sexual intercourse is the strongest predictor of recurrence 5
• Treatment options include continuous or postcoital prophylactic antibiotics, self-started antibiotics, cranberry products, and behavioral modification 5

When to Refer to Specialist

Immediate urology referral indicated for: 1

• Digital rectal exam suspicious for prostate cancer
• Hematuria (not explained by confirmed UTI)
• Abnormal PSA
• Pain suggesting complicated infection
• Recurrent infection despite appropriate treatment
• Palpable bladder or neurological disease
• Persistent bothersome lower urinary tract symptoms after basic management

Key Clinical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria - common in elderly but does not require antibiotics 2, 3
• Do not diagnose UTI based on pyuria or positive dipstick alone without corresponding acute symptoms 3, 6
• Do not assume all dysuria is UTI - vaginal discharge decreases likelihood of UTI and suggests cervicitis or vaginitis requiring different evaluation 4
• Overactive bladder (OAB) is commonly misdiagnosed as recurrent UTI - OAB has chronic (not acute) onset and lacks dysuria/hematuria 6
• Virtual encounters without laboratory testing increase recurrent symptoms and antibiotic courses - in-person evaluation with urinalysis is preferred 4