What is the treatment for a patient with symptoms of dysuria (painful urination) and urinary frequency?

Treatment for Dysuria and Urinary Frequency

For a patient presenting with dysuria and urinary frequency, initiate empiric antibiotic therapy immediately after obtaining a urine culture, using first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) for 3-5 days in women with uncomplicated cystitis, or 14 days in men when prostatitis cannot be excluded. 1, 2

Initial Diagnostic Approach

Obtain urine culture before starting antibiotics to guide therapy and identify resistant organisms, particularly important for recurrent or complicated UTIs 1, 3. The presence of dysuria has over 90% accuracy for UTI diagnosis in young women when vaginal symptoms are absent 3, 1.

Key Clinical Distinctions

• Assess for complicating factors including fever, flank pain, systemic symptoms, diabetes, immunosuppression, structural abnormalities, pregnancy, or male sex—these indicate complicated UTI requiring longer treatment 3, 1
• Evaluate for vaginal discharge or irritation, as these decrease the likelihood of UTI and suggest alternative diagnoses like cervicitis or vaginitis requiring different management 4, 5
• In men, assume possible prostatic involvement and plan for 14-day treatment duration when prostatitis cannot be excluded 2, 3

Empiric Antibiotic Selection

For Uncomplicated Cystitis in Women (3-5 days):

• Nitrofurantoin (first-line option) 1, 6
• Trimethoprim-sulfamethoxazole if local resistance <20% 1, 7
• Fosfomycin-trometamol (single-dose alternative) 1, 6

Avoid fluoroquinolones as first-line therapy due to resistance concerns and ecological damage; reserve for second-line use or when first-line agents are contraindicated 1, 6, 3

For Complicated UTI or Men (7-14 days):

• Trimethoprim-sulfamethoxazole for 14 days if local resistance <20% and no recent fluoroquinolone use 2, 3
• Ciprofloxacin for 14 days only if local resistance <10%, entire treatment can be oral, patient doesn't require hospitalization, and no fluoroquinolone use in past 6 months 2, 3
• For systemic symptoms: Use IV third-generation cephalosporin, amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside 3

Symptomatic Relief

Phenazopyridine may be offered for symptomatic relief of pain, burning, urgency, and frequency during the first 2 days while antibiotics take effect, but should not delay definitive treatment 8. Treatment with phenazopyridine should not exceed 2 days as there is no evidence of additional benefit beyond this period 8.

Follow-Up and Monitoring

• Reassess symptoms after 48-72 hours of antibiotic treatment to ensure clinical improvement 2, 1
• If symptoms persist or recur within 2 weeks, obtain repeat urine culture before prescribing additional antibiotics and consider resistant organisms or non-infectious causes 3, 2, 1
• Routine post-treatment cultures are not indicated in asymptomatic patients 3

Common Pitfalls to Avoid

• Do not use fluoroquinolones empirically if local resistance ≥10% or patient has recent fluoroquinolone exposure within 6 months, as this leads to treatment failure 3, 2
• Do not treat asymptomatic bacteriuria in non-pregnant patients without risk factors, as this promotes resistance without benefit 3, 1
• Do not prescribe antibiotics for >7 days in women with uncomplicated cystitis, as shorter courses (3-5 days) are equally effective and reduce resistance 3, 1
• Adjust antibiotic dosing based on renal function to prevent toxicity, particularly with trimethoprim-sulfamethoxazole 2
• Do not delay obtaining urine culture in patients with recurrent UTIs, as documentation of positive cultures is essential for diagnosis and guides appropriate therapy 3