What is the recommended treatment for a patient with dysuria and urinary frequency without evidence of bacterial infection?

Treatment of Dysuria Without Bacterial Infection

For patients with dysuria and urinary frequency but no evidence of bacterial infection, symptomatic treatment with phenazopyridine for up to 2 days is appropriate while investigating non-infectious causes, and antibiotics should be withheld. 1

Immediate Management

Symptomatic Relief

• Phenazopyridine (100-200 mg three times daily) provides symptomatic relief of pain, burning, urgency, and frequency arising from lower urinary tract irritation. 1
• Treatment should not exceed 2 days, as there is no evidence of benefit beyond this timeframe. 1
• This approach is safe and appropriate when bacterial infection has been ruled out. 1

Antibiotic Stewardship

• Do not initiate or continue antibiotics when there is no clinical evidence of bacterial infection. 2
• Discontinuing antibiotics within 24 hours for patients without bacterial infection is safe and reduces duration of therapy by approximately 2.6 days without increasing mortality or readmission rates. 2
• Treating asymptomatic bacteriuria or prescribing antibiotics without confirmed infection leads to antimicrobial resistance without symptom improvement. 3

Evaluation for Non-Infectious Causes

Key Differential Diagnoses to Consider

• Bladder irritants (caffeine, alcohol, spicy foods, artificial sweeteners) 4, 5
• Interstitial cystitis/painful bladder syndrome - chronic pain condition presenting with frequency and dysuria 6
• Urethral or bladder trauma from catheterization, instrumentation, or sexual activity 1, 5
• Urethral stricture or diverticulum - particularly in patients with history of trauma or instrumentation 7
• Calculi in the lower urinary tract 5
• Hypoestrogenism in postmenopausal women causing atrophic changes 5
• Sexually transmitted infections (even with negative initial testing, consider Mycoplasma genitalium) 4

Specific History Elements to Elicit

• Recent instrumentation, catheterization, or endoscopic procedures 1
• Temporal relationship to sexual activity 5
• Presence of vaginal discharge (decreases likelihood of UTI, suggests cervicitis) 4
• Dietary triggers and fluid intake patterns 6
• Medication history, particularly recent fluoroquinolone use 8
• In men: obstructive symptoms suggesting benign prostatic hyperplasia 8

When to Refer or Pursue Advanced Evaluation

Indications for Cystoscopy

• Concomitant hematuria 8
• Recurrent symptoms despite appropriate initial management 8
• Suspected anatomical abnormalities including strictures or diverticula 8, 7

Indications for Urology Referral

• Persistent symptoms after initial treatment and symptom management 8, 4
• Findings suspicious for malignancy 8
• Recurrent urinary retention 8
• Severe obstruction requiring interventional therapy 8

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria - this applies to most populations including older adults, diabetics, patients with spinal cord injury, and those with indwelling catheters. 3
• Do not perform surveillance urine cultures in asymptomatic patients, as this leads to unnecessary antibiotic use and resistance. 3
• Avoid empiric antibiotics based solely on urinary symptoms without confirmed infection, as this increases antibiotic resistance and Clostridioides difficile infection risk. 3
• Do not delay definitive diagnosis - phenazopyridine provides only symptomatic relief and should not substitute for identifying the underlying cause. 1

Follow-Up Strategy

• Reassess at 2-4 weeks if symptoms persist despite symptomatic management. 8
• If symptoms resolve with phenazopyridine alone, consider non-infectious causes and counsel on bladder irritant avoidance. 1, 6
• For persistent or recurrent symptoms, proceed with further evaluation including consideration of cystoscopy and specialist referral. 8, 4