What is the best course of action for a sexually inactive patient presenting with penile ache, urinary frequency, and urgency, without dysuria, and with normal urine culture and analysis results?

Management of Penile Ache with Urinary Frequency and Urgency in a Sexually Inactive Patient

This patient most likely has overactive bladder (OAB), and you should initiate behavioral therapy followed by antimuscarinic medication if symptoms are bothersome and persist.

Diagnostic Reasoning

The clinical presentation of urinary frequency and urgency without dysuria, combined with normal urine culture and urinalysis, effectively rules out urinary tract infection and points toward a functional bladder disorder rather than an infectious or sexually transmitted etiology 1.

• Urgency is the hallmark symptom of OAB, defined as "a sudden, compelling desire to pass urine which is difficult to defer" 1.
• When urinary frequency (daytime and nighttime) and urgency occur in the absence of UTI or other obvious pathology and are self-reported as bothersome, the patient may be diagnosed with OAB 1.
• The absence of dysuria makes UTI highly unlikely, and the normal urine culture confirms this 2, 3.

Key Diagnostic Considerations

The penile ache requires careful evaluation to distinguish OAB from other conditions:

• Interstitial cystitis/bladder pain syndrome shares frequency and urgency symptoms with OAB, but bladder and/or pelvic pain is a crucial distinguishing component 1.
• Since this patient has penile ache (which could represent pelvic/bladder pain), you must determine if the pain is the predominant symptom or secondary to urgency 1.
• Prostatitis should be considered in men with pelvic/penile pain and urinary symptoms, even in sexually inactive patients 4.

Essential Workup

At your discretion, obtain the following to validate the OAB diagnosis 1:

• Post-void residual (PVR) to assess for bladder outlet obstruction or detrusor underactivity, which can present with both urgency and weak stream 5.
• Bladder diary (frequency-volume chart) to document voiding patterns and distinguish OAB from polydipsia-related frequency 1, 5.
• Symptom questionnaires to quantify baseline symptom severity and assess how bothersome symptoms are to the patient 1.

Physical examination should include 1:

• Abdominal exam to assess for bladder distention or masses
• Rectal/genitourinary exam to evaluate prostate size and tenderness
• Assessment of lower extremities for edema (which can contribute to nocturia)

Treatment Algorithm

First-Line: Behavioral Interventions

Begin with patient education and behavioral treatments 1:

• Educate about normal urinary tract function and the benefits/risks of treatment alternatives 1.
• Implement behavioral modifications including timed voiding, fluid management, and bladder training 1.
• If symptoms are not significantly bothersome to the patient, there is less compelling reason to treat pharmacologically 1.

Second-Line: Pharmacotherapy

If behavioral treatments are partially effective or ineffective, add antimuscarinic medication 1:

• Antimuscarinics are the standard pharmacologic treatment for OAB with active management of adverse events (dry mouth, constipation) 1.
• Consider dose modification or alternate antimuscarinic if effective but adverse events are intolerable 1.
• Mirabegron (a beta-3 agonist) is an alternative option 1.

For Specific Urinary Symptoms

If the patient has predominantly storage symptoms (urgency, frequency, nocturia):

• Consider anticholinergic medications such as oxybutynin for nocturia, frequency, or urgency 1.

If the patient has voiding symptoms (weak stream, difficulty emptying):

• Consider alpha-blockers such as tamsulosin for slow stream 1.
• This would be more likely if PVR is elevated, suggesting outlet obstruction 5.

When to Reassess or Refer

Reassess and/or refer to urology if 1:

• Treatment goals are not met despite behavioral and pharmacologic interventions
• Symptoms persist or recur after initial treatment
• There is concern for complicated OAB (neurologic disease, significant PVR, hematuria)
• The penile ache is the predominant symptom, suggesting possible chronic prostatitis/chronic pelvic pain syndrome

Follow-Up Strategy

Monitor for efficacy and adverse events 1:

• Reassess symptom severity using the same questionnaires/diaries at follow-up
• Adjust treatment based on response and tolerability
• If symptoms worsen or new symptoms develop, consider urodynamic studies or cystoscopy 5

Critical Pitfalls to Avoid

• Do not empirically treat with antibiotics when urinalysis and culture are negative, as this promotes antibiotic resistance without benefit 3.
• Do not assume this is prostatitis without evidence of prostatic tenderness on exam or elevated PVR, as OAB is more common and fits the presentation better 1.
• Do not ignore the penile ache—if pain becomes the predominant symptom rather than urgency, reconsider the diagnosis toward interstitial cystitis/bladder pain syndrome or chronic pelvic pain syndrome 1.
• Do not order urodynamic studies initially—these are reserved for when conservative and drug therapies fail or when considering more invasive treatments 5.