What is the appropriate workup and treatment for a patient presenting with dysuria?

Workup for Dysuria

In patients presenting with dysuria, immediately obtain urinalysis (dipstick and microscopic examination) and urine culture before initiating any antibiotics, and only start empiric treatment if additional symptoms such as frequency, urgency, fever, or flank pain are present. 1

Initial Clinical Assessment

History - Key Elements to Elicit

• Recent-onset dysuria with accompanying symptoms: frequency, urgency, new incontinence, fever, chills, or flank pain 1, 2
• Sexual history in younger patients, as sexually transmitted organisms (particularly Chlamydia trachomatis) are common causes in this age group 3
• Age and gender considerations: Older men (>35 years) typically have coliform bacteria related to prostatic hyperplasia, while younger women have higher rates due to sexual activity 4, 3
• Risk factors for complicated UTI: male sex, pregnancy, urologic obstruction, recent procedures, immunosuppression 5
• Vaginal or urethral symptoms in women, as vaginal discharge decreases likelihood of UTI and suggests alternative diagnoses 6, 5
• Bladder irritants: certain foods, beverages, or medications 2
• Red flag symptoms: hematuria, flank pain, fever, altered mental status (especially in elderly), functional decline 7, 1

Physical Examination - Focused Components

• Vital signs including temperature and blood pressure 1
• Abdominal examination for suprapubic tenderness or masses 1
• Costovertebral angle tenderness to assess for pyelonephritis 7, 1
• Digital rectal examination in men to evaluate prostate size, tenderness, or abnormalities 1, 3
• Pelvic examination in women when vaginal symptoms present, to evaluate for vaginitis or cervicitis 5

Laboratory Workup

Mandatory Initial Testing

Urinalysis is mandatory in all patients with dysuria and should include: 1, 2

• Dipstick testing for leukocyte esterase and nitrite 2
• Microscopic examination for white blood cells (pyuria ≥10 WBCs/high-power field), red blood cells, bacteria, and casts 2
• Negative nitrite AND negative leukocyte esterase has good negative predictive value and makes UTI unlikely 7, 2

Important caveat: In elderly patients, urine dipstick specificity is only 20-70%, so clinical correlation is essential 7, 8

Urine Culture - When to Obtain

Urine culture with susceptibilities must always be obtained before starting antibiotics, particularly in: 1

• All men (UTI in males is considered complicated) 1
• Presence of pyuria or positive leukocyte esterase/nitrite 2
• Recurrent or suspected complicated UTI 6, 9
• Elderly patients to guide targeted therapy 8
• Treatment failures or persistent symptoms 1, 6

Additional Testing Based on Clinical Scenario

For suspected sexually transmitted infections (especially in younger patients with urethritis or cervicitis): 6, 5

• Urethral and vaginal smears and cultures 4
• Mycoplasma genitalium testing if persistent urethritis/cervicitis with negative initial testing 6
• Testing for Chlamydia trachomatis and Neisseria gonorrhoeae 3

For elderly or frail patients with atypical presentations: 7

• Basic metabolic panel to assess renal function and electrolyte abnormalities 7
• Blood cultures if systemic signs present (fever, rigors, delirium) 7

Imaging Studies - When Indicated

Upper urinary tract imaging (renal ultrasound or CT urography) is indicated when: 1

• History of upper urinary tract infection 1
• Hematuria present 7
• Urolithiasis suspected 1
• Renal insufficiency 1
• Recent onset nocturnal enuresis 1
• Recurrent infections with suspected anatomical abnormalities 5, 9
• Hydronephrosis or structural concerns 7

Cystoscopy is warranted in patients with: 7

• Persistent hematuria after initial evaluation 7
• Risk factors for bladder malignancy (age >40, smoking, occupational exposures) 7
• Recurrent unexplained symptoms 7

Treatment Approach

Empiric Antibiotic Therapy - When to Initiate

Start empiric antibiotics only if dysuria is accompanied by: 1

• Frequency, urgency, or new incontinence 1
• Fever or systemic symptoms 1
• Costovertebral angle tenderness 1

Do NOT treat with antibiotics if: 7

• Urinalysis shows negative nitrite AND negative leukocyte esterase 7
• Asymptomatic bacteriuria in elderly (approximately 40% of institutionalized elderly have this and it should not be treated) 8

Antibiotic Selection

First-line options for uncomplicated UTI (7-14 days in males): 1

• Trimethoprim-sulfamethoxazole 1
• Nitrofurantoin 1
• Fosfomycin 3g single dose (particularly recommended for elderly patients due to low resistance rates) 8
• Pivmecillinam 1

Avoid fluoroquinolones if local resistance is high or in elderly patients with recent exposure due to increased risk of tendon rupture, CNS effects, and QT prolongation 1

For complicated UTI in elderly males: 7-14 days treatment, with 14 days recommended when prostatitis cannot be excluded 8

Follow-Up and Monitoring

• Evaluate clinical response within 48-72 hours of initiating therapy 1, 8
• Adjust antibiotics based on culture results and susceptibility patterns 1, 8
• Refer to urology if red flag symptoms present, treatment fails, recurrent infections occur, or anatomical abnormalities suspected 1

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria in elderly patients—it causes neither morbidity nor mortality 8
• Do not rely solely on virtual encounters without laboratory testing, as this may increase recurrent symptoms and unnecessary antibiotic courses 6
• Do not assume UTI in elderly with altered mental status alone—use the algorithm requiring dysuria PLUS systemic signs (fever, rigors, clear-cut delirium) before prescribing antibiotics 7
• Do not skip urine culture in men—all UTIs in males are considered complicated and require culture-guided therapy 1
• Do not ignore vaginal symptoms in women—vaginal discharge decreases likelihood of UTI and requires evaluation for alternative diagnoses 6, 5