What is the appropriate workup and management for a young adult male presenting with dysuria, without discharge, fevers, or chills?

Workup and Management of Dysuria in Young Adult Males Without Discharge or Systemic Symptoms

In a young adult male with isolated dysuria and no discharge, fevers, or chills, obtain urinalysis with microscopy and nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae on first-void urine, as sexually transmitted urethritis is the most likely diagnosis in this age group. 1, 2

Initial Diagnostic Workup

Essential History Components

• Sexual history: Number of partners, recent new partners, condom use, and history of prior STIs, as C. trachomatis accounts for 30-40% of nongonococcal urethritis in men under 35 years 2
• Symptom characteristics: Onset, severity, timing during urination (beginning vs. throughout stream), and presence of urethral discharge even if minimal 1
• Urinary symptoms: Frequency, urgency, hesitancy, weak stream, or incomplete emptying to assess for lower urinary tract involvement 1
• Recent exposures: New sexual partners within the past 2-3 months, as STI incubation periods vary 2

Physical Examination Focus

• External genitalia: Inspect for urethral discharge (may require "milking" the urethra), meatal erythema, penile lesions, or testicular/epididymal tenderness 1, 2
• Suprapubic examination: Palpate for bladder distention or tenderness 1
• Digital rectal examination (DRE): Assess prostate size, consistency, and tenderness to evaluate for prostatitis, though less likely without fever 1, 2

Laboratory Testing Algorithm

For men <35 years with dysuria:

• First-void urine NAAT for N. gonorrhoeae and C. trachomatis (most sensitive test) 2
• Urinalysis with microscopy: Dipstick and microscopic examination to detect pyuria, bacteriuria, or hematuria 1, 2
• Urine culture: Obtain before antibiotics if UTI suspected, as all male UTIs are considered complicated and require culture-guided therapy 2
• Urethral Gram stain (if discharge present): >5 polymorphonuclear leukocytes per oil immersion field indicates urethritis 2

For men ≥35 years with dysuria:

• Urinalysis and urine culture are primary tests, as coliform bacteria (especially E. coli) predominate in this age group due to urinary stasis from benign prostatic hyperplasia 3, 4
• STI testing should still be considered based on sexual history 2

Differential Diagnosis by Age and Presentation

Young Men (<35 years) - STI-Related Urethritis Most Likely

• Chlamydia trachomatis: Leading cause (30-40% of cases), typically presents with mild-to-moderate dysuria and minimal or absent discharge 2
• Neisseria gonorrhoeae: Causes more pronounced symptoms with purulent discharge, though discharge may be absent in some cases 2
• Epididymitis: Usually accompanied by testicular pain and swelling, most commonly from C. trachomatis or N. gonorrhoeae in sexually active men 2

Older Men (≥35 years) - UTI More Likely

• Bacterial cystitis/prostatitis: E. coli and other coliforms predominate, often secondary to urinary stasis from benign prostatic hyperplasia 3, 4
• Benign prostatic hyperplasia (BPH): Can cause dysuria through inflammation and incomplete bladder emptying 1

Less Common Causes (Any Age)

• Urethral stricture: History of prior instrumentation or STI 1
• Renal calculus: Usually presents with flank pain, but small distal stones may cause isolated dysuria 3
• Reactive arthritis (Reiter's syndrome): Triad of urethritis, conjunctivitis, and arthritis following chlamydial infection 2

Management Based on Test Results

If NAAT Positive for C. trachomatis and/or N. gonorrhoeae

• Treat for both organisms empirically while awaiting results, as co-infection is common 2
• Dual therapy required: Ceftriaxone 500 mg IM once PLUS doxycycline 100 mg PO twice daily for 7 days (covers both organisms) 2
• Partner notification and treatment: All sexual partners within the past 60 days require evaluation and treatment 2
• Abstinence: Avoid sexual activity for 7 days after completing treatment and until partners are treated 2

If Urinalysis/Culture Positive for Bacterial UTI

• First-line antibiotic: Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days (not 7 days, as prostatitis cannot be excluded in most male presentations) 5, 2
• Alternative agents (if TMP-SMX contraindicated or local resistance >10%):
  • Ciprofloxacin 500 mg twice daily for 14 days 5
  • Levofloxacin 750 mg once daily for 14 days 5
  • Cefpodoxime 200 mg twice daily for 10-14 days 5
• Shorter duration (7 days) may be considered ONLY if patient becomes afebrile within 48 hours with clear clinical improvement, though recent evidence shows 7-day therapy is inferior to 14-day therapy in men (86% vs 98% cure rate) 5
• Obtain urine culture before starting antibiotics to guide therapy adjustments if needed 5, 2

If All Testing Negative (Non-Infectious Dysuria)

• Behavioral modifications: Reduce evening fluid intake, avoid bladder irritants (caffeine, alcohol, spicy foods), increase physical activity 1
• Frequency-volume chart: Complete 3-day voiding diary to identify patterns suggesting BPH or overactive bladder 1
• Consider alpha-blocker trial (e.g., tamsulosin 0.4 mg daily) if symptoms suggest BPH, with reassessment at 2-4 weeks 1
• Urologic referral if symptoms persist >4 weeks despite conservative management 1

Critical Pitfalls to Avoid

• Do not use fluoroquinolones as first-line empiric therapy without culture results, given FDA warnings about serious adverse effects and increasing resistance rates 5
• Do not treat for <7 days in male UTIs, as inadequate duration leads to recurrence, especially with unrecognized prostate involvement 5, 2
• Do not use amoxicillin-clavulanate (Augmentin) empirically, as resistance rates exceed 50% in E. coli and it is not a first-line agent 5
• Do not use cephalexin for male UTIs, as it has poor urinary concentration and limited efficacy against common uropathogens 5
• Do not fail to obtain pre-treatment urine culture in men, as all male UTIs are complicated and may require therapy adjustment based on susceptibility 2
• Do not assume absence of discharge rules out STI, as C. trachomatis frequently causes minimal or no visible discharge 2
• Do not overlook the need for partner treatment in STI cases, as reinfection rates are high without concurrent partner therapy 2

Mandatory Urologic Referral Criteria (Before Initiating Treatment)

• Severe obstruction: Qmax <10 mL/second on uroflowmetry 1
• Neurological disease affecting bladder function 1
• Recurrent UTIs despite appropriate treatment 2
• Hematuria (especially if >35 years) 1
• Abnormal PSA or concerning DRE findings 1
• Suspected structural abnormalities (history of stones, prior instrumentation) 2

Follow-Up Strategy

• Reassess at 4-12 weeks after initiating treatment to evaluate symptom resolution 1
• Repeat urine culture if symptoms persist or recur, as this may indicate treatment failure or resistant organism 2
• Test-of-cure NAAT is not routinely recommended for chlamydia/gonorrhea unless symptoms persist, but consider in high-risk patients 2
• Annual follow-up for patients with successful BPH treatment to monitor for progression 1