What is the next step in managing a 13-year-old boy with penile pain during urination, previously treated with fosfomycin (generic name), who has a negative urinalysis (UA) and refuses a genital examination?

Management of Adolescent Male with Dysuria, Negative UA, and Refusal of Genital Examination

The most critical next step is to obtain nucleic acid amplification testing (NAAT) on a first-void urine sample for Chlamydia trachomatis and Neisseria gonorrhoeae before initiating any further treatment, as sexually transmitted urethritis is the most likely diagnosis in this clinical scenario. 1

Diagnostic Approach

Why STI Testing is Essential

• Urethritis from sexually transmitted infections is the primary concern in an adolescent male with dysuria and a negative urinalysis, particularly when genital examination is refused 1
• The European Association of Urology strongly recommends performing validated NAAT on first-void urine samples or urethral smears before empirical treatment to diagnose chlamydial and gonococcal infections 1
• NAAT testing on first-void urine eliminates the need for genital examination or urethral swabs, making it ideal for this patient who refuses physical examination 1

Critical Clinical Context

• Fosfomycin was inappropriate initial treatment for this presentation, as it is indicated only for uncomplicated cystitis in women, not for urethritis or UTIs in males 2, 3
• A negative urinalysis does not rule out urethritis, as pyuria may be absent in STI-related urethritis, and the pathogens (C. trachomatis, N. gonorrhoeae) are not detected on standard urine culture 1
• The patient's age (13 years) and symptom pattern (penile pain with urination) are consistent with urethritis rather than cystitis or pyelonephritis 1

Immediate Management Steps

Testing Protocol

• Collect first-void urine (initial 10-20 mL of urination) for NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae 1
• If NAAT results will be delayed and symptoms are severe, the European Association of Urology recommends delaying treatment until NAAT results are available in patients with mild symptoms 1
• However, if symptoms are moderate to severe or the patient is unlikely to follow up, empirical treatment may be warranted 1

Empirical Treatment Considerations (If Necessary)

If treatment cannot be delayed pending NAAT results:

• For non-gonococcal urethritis (unidentified pathogen): Doxycycline 100 mg twice daily orally for 7 days 1
• Alternative: Azithromycin 500 mg orally on day 1, then 250 mg orally for 4 days 1
• For suspected gonococcal infection: Ceftriaxone 1 g intramuscularly or intravenously as a single dose PLUS azithromycin 1 g orally as a single dose 1

Important Clinical Pitfalls to Avoid

• Do not repeat fosfomycin or use it for urethritis, as it has no role in treating STI-related urethritis and is not indicated for males with UTIs 2, 3
• Do not assume the negative UA rules out infection—urethritis often presents with negative standard urinalysis 1
• Do not delay STI testing due to examination refusal—first-void urine NAAT is highly sensitive and specific without requiring genital examination 1
• Do not treat empirically without planning for NAAT testing, as antimicrobial resistance patterns (particularly for gonorrhea) require culture-based confirmation and susceptibility testing 1

Follow-Up and Partner Management

Post-Treatment Monitoring

• Perform urethral swab culture before treatment initiation in patients with positive NAAT for gonorrhea to assess antimicrobial resistance profiles 1
• If empirical treatment is given, ensure NAAT results are followed up to confirm pathogen identification and guide any necessary treatment modifications 1
• Sexual partners should be treated while maintaining patient confidentiality 1

Counseling Considerations

• Given the patient's age (13 years), confidential sexual history and risk assessment are essential 1
• Discuss the importance of partner notification and treatment to prevent reinfection 1
• Provide education about STI prevention and the need for follow-up testing 1

Alternative Diagnoses to Consider

If NAAT testing is negative for C. trachomatis and N. gonorrhoeae:

• Consider Mycoplasma genitalium or Ureaplasma urealyticum as causes of non-gonococcal urethritis 1
• Evaluate for Trichomonas vaginalis, though less common in males 1
• Consider non-infectious causes such as chemical irritation, trauma, or anatomical abnormalities 1
• If symptoms persist despite negative testing, referral to urology or adolescent medicine may be warranted for further evaluation 1