Management of Dysuria in Nonpregnant Women with Negative UA for UTI
Do not treat with antibiotics when the urinalysis is truly negative for UTI, as dysuria with a negative UA suggests an alternative diagnosis that requires targeted evaluation rather than empiric antimicrobial therapy.
Initial Diagnostic Approach
When a nonpregnant woman presents with dysuria but has a negative urinalysis, the key is recognizing that this presentation does not represent an uncomplicated UTI and requires investigation for alternative causes rather than reflexive antibiotic treatment.
Understanding "Negative UA" in Context
- Dipstick urinalysis has significant limitations: In patients with a high pretest probability of UTI based on symptoms, a negative dipstick does not definitively rule out infection 1
- Pyuria is commonly found in the absence of infection, particularly in women with lower urinary tract symptoms such as incontinence, and should not drive treatment decisions alone 1
- Bacteriuria is more specific and sensitive than pyuria for detecting true UTI 1
- If the clinical suspicion for UTI remains moderate or unclear despite negative dipstick, urine culture should be performed as it is the gold standard 1
Alternative Diagnoses to Consider
When dysuria occurs with negative UA findings, the differential diagnosis shifts away from bacterial cystitis:
- Urethritis (sexually transmitted infections including chlamydia and gonorrhea)
- Vaginitis (candida, bacterial vaginosis, trichomoniasis)
- Atrophic vaginitis in postmenopausal women 2
- Interstitial cystitis/bladder pain syndrome
- Chemical irritation (soaps, douches, spermicides)
- Urethral syndrome
Clinical Decision-Making Algorithm
Step 1: Verify the Negative UA
- Obtain urine culture if clinical suspicion remains high despite negative dipstick, as symptomatic women can have infection with bacterial counts as low as 10² CFU/mL 1
- Consider that nitrites are likely more sensitive and specific than other dipstick components for UTI 1
Step 2: Evaluate for Alternative Causes
- Assess for vaginal discharge: The presence or absence of vaginal discharge is one of the most diagnostic features distinguishing UTI from other causes 3, 1
- Sexual history and risk factors for sexually transmitted infections
- Menopausal status: Atrophic vaginitis due to estrogen deficiency is a common cause in postmenopausal women 2
Step 3: Targeted Treatment Based on Findings
For confirmed negative culture with persistent symptoms:
- Symptomatic treatment with NSAIDs can be considered for symptom relief, though NSAIDs alone (without antibiotics) probably result in less symptom resolution and longer duration of symptoms compared to antibiotic treatment when true UTI is present 4
- Do not prescribe antibiotics empirically when both UA and culture are negative, as this promotes antimicrobial resistance without addressing the underlying cause 3, 1
For postmenopausal women with atrophic vaginitis:
- Vaginal estrogen therapy is appropriate for prevention and management 2
Common Pitfalls to Avoid
- Do not treat asymptomatic bacteriuria if it is incidentally discovered, as this is common particularly in older women and should not be treated with antibiotics (pregnancy is the only exception) 1, 5
- Do not rely solely on pyuria to diagnose UTI, as it is frequently present without infection 1
- Do not assume all dysuria represents UTI: The combination of dysuria with negative UA should prompt investigation for non-infectious causes rather than empiric antibiotic treatment 3, 1
- Avoid fluoroquinolones and broad-spectrum agents when treatment is indicated, as resistance is increasing and these agents cause significant collateral damage 1
When Antibiotics ARE Indicated Despite Initial Negative UA
If urine culture subsequently grows ≥10² CFU/mL in a symptomatic woman, treatment is appropriate even with initially negative dipstick, as symptomatic women can have true infection at lower bacterial counts 1. In this scenario: