Treatment of Dysuria (Assuming Urinary Tract Infection)
For women with classic dysuria, frequency, and urgency without vaginal discharge, start empiric antibiotic therapy immediately without waiting for urinalysis or culture, using nitrofurantoin (100 mg twice daily for 5 days), fosfomycin (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) as first-line options. 1, 2
When to Obtain Urine Culture Before Treatment
You must obtain urine culture before starting antibiotics in these specific situations:
- Suspected acute pyelonephritis (fever, flank pain, costovertebral tenderness) 1, 3
- Symptoms that don't resolve or recur within 4 weeks after treatment completion 1, 2
- Women presenting with atypical symptoms 1, 4
- Pregnant women 1, 2
- Recurrent UTIs (≥3 UTIs/year or 2 UTIs in 6 months) 1, 2
- Men with dysuria (all cases should be considered complicated) 1
- Patients with diabetes, structural abnormalities, or immunosuppression 4
First-Line Antibiotic Regimens for Uncomplicated Cystitis in Women
Nitrofurantoin is the preferred first-line agent:
- Dose: 100 mg twice daily for 5 days 1, 2, 3
- Alternative formulations: 50-100 mg four times daily for 5 days 1
Fosfomycin trometamol:
Trimethoprim-sulfamethoxazole (if local E. coli resistance <20%):
Alternative agents (if resistance patterns permit):
- Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days) if local E. coli resistance <20% 1
- Trimethoprim 200 mg twice daily for 5 days 1
Treatment Duration and Follow-Up
- Keep treatment duration as short as reasonable, generally no longer than 7 days 2
- For men with dysuria, treat for 7 days minimum with trimethoprim-sulfamethoxazole 160/800 mg twice daily 1
- Reassess symptoms after 48-72 hours of treatment 4
- Do not perform routine post-treatment urinalysis or cultures in asymptomatic patients 1
Symptomatic Treatment Alternative
For mild to moderate symptoms, consider ibuprofen as an alternative to antibiotics after discussing with the patient:
- This approach prioritizes symptom management but may delay bacterial clearance 1, 5
- The European Association of Urology supports this option for select patients willing to accept potential delayed clearance 5
- This is not appropriate for patients with fever, flank pain, or risk factors for complicated infection 1
When Initial Treatment Fails
If symptoms persist or recur within 2 weeks:
- Obtain urine culture and antimicrobial susceptibility testing 1, 4
- Assume the organism is not susceptible to the original agent 1
- Retreat with a 7-day regimen using a different antibiotic class 1
- Consider imaging studies if structural abnormalities are suspected 7
Critical Pitfalls to Avoid
Do not treat asymptomatic bacteriuria except in pregnancy or before urological procedures breaching the mucosa 2, 4
Do not use fluoroquinolones as first-line therapy:
- Reserve as second-line agents due to increasing resistance and collateral damage risk 2
- Avoid if used in the last 6 months due to resistance concerns 4
Do not diagnose UTI based solely on positive culture without symptoms:
- This leads to unnecessary antibiotic use and increased resistance 3
- Dysuria has >90% accuracy for UTI diagnosis in young women without vaginal symptoms 4, 8
Rule out alternative causes if vaginal discharge is present:
- Vaginal discharge decreases likelihood of UTI 8
- Consider cervicitis, vaginitis, sexually transmitted infections, or vulvar lesions 9, 10
- Test for Mycoplasma genitalium if persistent urethritis with negative initial testing 8
Special Population Considerations
Elderly women:
- Genitourinary symptoms are not necessarily related to cystitis 1, 2
- Urinalysis may help differentiate UTI from other conditions 2
Men with dysuria:
- All cases should be considered complicated 1
- Treat for minimum 7 days 1
- Consider prostatitis in older men with prostatic hyperplasia 10
Complicated UTIs (structural abnormalities, immunosuppression):