What is the next step in managing a male patient with dysuria and a negative urinalysis (UA) result?

Management of Male Dysuria with Negative Urinalysis

In a male patient with dysuria and a negative urinalysis, the next step is to evaluate for non-infectious causes through focused history on sexual activity and lower urinary tract symptoms, perform digital rectal examination to assess the prostate, and consider a 3-day voiding diary to characterize urinary patterns, as UTI is unlikely with negative nitrite AND negative leukocyte esterase. 1, 2

Why Infection is Unlikely

A negative urinalysis (specifically negative nitrite AND negative leukocyte esterase) has excellent negative predictive value for excluding urinary tract infection in men. 1, 3 The European Urology guidelines explicitly state that this combination makes UTI unlikely and antibiotics should not be prescribed. 1 Recent data confirms that negative UA predicts absence of UTI with 99% accuracy in men, including those with catheters. 3

Differential Diagnosis to Pursue

Sexually Transmitted Infections (Younger Men <35 years)

• Urethritis from Chlamydia trachomatis or Neisseria gonorrhoeae is the most common cause in sexually active younger men. 4, 5
• Obtain urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia. 1, 5
• If initial STI testing is negative but symptoms persist, test for Mycoplasma genitalium. 5

Benign Prostatic Hyperplasia (Older Men >40 years)

• In older men, BPH with accompanying inflammation is a leading cause of dysuria, particularly when associated with urinary frequency, hesitancy, or weak stream. 6, 4
• Perform digital rectal examination to assess prostate size, consistency, and tenderness—this distinguishes BPH from prostatitis. 2
• Complete the International Prostate Symptom Score (IPSS) questionnaire to quantify severity: 0-7 mild, 8-19 moderate, 20-35 severe. 2, 7
• Request a 3-day frequency-volume chart to identify nocturnal polyuria, reduced bladder capacity, or excessive fluid intake patterns. 2, 7

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Consider this diagnosis when dysuria persists without evidence of acute infection or STI. 6
• The prostate may be tender on DRE but without acute infection findings. 2

Other Non-Infectious Causes

• Bladder irritants (caffeine, alcohol, spicy foods), medications (cyclophosphamide), urethral trauma, or interstitial cystitis should be explored through detailed history. 6, 5
• Renal calculi can present with dysuria and should be considered if there is hematuria or flank pain. 6, 4

Initial Management Strategy

Lifestyle Modifications (First-Line for BPH-Related Symptoms)

• Target approximately 1 liter of urine output per 24 hours, as excessive fluid intake worsens symptoms in older men. 2
• Reduce evening fluid intake to minimize nocturia. 2
• Avoid bladder irritants including alcohol, caffeine, and highly seasoned foods. 2
• Encourage physical activity to avoid sedentary lifestyle. 2

Pharmacological Treatment (If BPH Confirmed)

• Alpha-blockers (e.g., tamsulosin) are first-line pharmacological therapy for BPH-related lower urinary tract symptoms. 2, 7
• Assess treatment effectiveness after 2-4 weeks of alpha-blocker therapy. 2, 7
• For enlarged prostates (PSA >1.5 ng/mL or volume >40 mL), consider adding a 5α-reductase inhibitor (finasteride or dutasteride), with effectiveness assessed after 3 months. 7

When to Obtain Additional Testing

Uroflowmetry

• If available, obtain uroflowmetry—Qmax <10 mL/second indicates significant obstruction requiring urologic referral. 2, 7

Post-Void Residual (PVR)

• Measure PVR if obstructive symptoms are present, history of urinary retention, or neurologic disease. 2
• Elevated PVR (>100-200 mL) suggests significant obstruction. 7

Upper Tract Imaging

• Obtain renal ultrasound if there is history of upper UTI, hematuria, urolithiasis, renal insufficiency, or recent-onset nocturnal enuresis. 1

Mandatory Urologic Referral Criteria

Refer immediately to urology BEFORE initiating treatment if any of the following are present: 2, 7

• Neurological disease affecting bladder function
• Severe obstruction (Qmax <10 mL/second)
• DRE suspicious for prostate cancer
• Hematuria (especially if persistent or recurrent)
• Abnormal PSA
• Recurrent infections
• Palpable bladder or significant urinary retention

Follow-Up Timeline

• Evaluate clinical response within 48-72 hours if empiric STI treatment was initiated. 1
• For BPH treatment, reassess at 2-4 weeks for alpha-blockers and 3 months for 5α-reductase inhibitors. 2, 7
• If symptoms persist or worsen despite lifestyle modifications over 2-4 weeks, schedule follow-up for formal evaluation. 2
• Annual follow-up is recommended for patients with successful treatment to monitor for progression. 2, 7

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on dysuria when UA is negative—this leads to unnecessary antibiotic exposure and does not address the underlying cause. 1
• Do not assume all dysuria in older men is infection—BPH and chronic prostatitis are more common causes. 4
• Do not add antimuscarinics without first measuring PVR—men with elevated baseline PVR are at risk for acute urinary retention. 7
• Do not ignore sexual history in younger men—STIs are the predominant cause in this age group. 4, 5