What is the appropriate diagnosis and treatment for a 25-year-old male presenting with dysuria?

Dysuria in a 25-Year-Old Male

In a 25-year-old male with dysuria, the most likely diagnosis is urethritis from a sexually transmitted infection (STI), and you should obtain urinalysis, urine culture, and nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia before initiating empiric treatment with ceftriaxone 500 mg IM plus azithromycin 1 g PO or doxycycline 100 mg PO twice daily for 7 days. 1, 2, 3

Initial Diagnostic Approach

History and Physical Examination

The evaluation must focus on specific high-yield elements rather than generic assessment:

• Sexual history is critical: Document number of partners, type of sexual contact, condom use, and partner symptoms, as STIs are the predominant cause in men under 35 years 1, 3
• Symptom characterization: Determine if dysuria is external (suggests urethritis) versus internal (suggests cystitis), presence of urethral discharge, timing of symptoms relative to sexual activity 1, 2
• Physical examination specifics: Inspect external genitalia for lesions or discharge, palpate for urethral tenderness, perform digital rectal exam (DRE) to assess for prostate tenderness suggesting prostatitis 1, 3

Laboratory Testing

• Urinalysis and urine culture are mandatory for all men with dysuria to differentiate infectious from non-infectious causes 1, 2
• NAAT testing for Chlamydia trachomatis and Neisseria gonorrhoeae should be obtained from first-catch urine or urethral swab, as these are the most common pathogens in this age group 1, 2, 3
• If initial STI testing is negative but urethritis persists, test for Mycoplasma genitalium 2

Treatment Algorithm

For Suspected STI-Related Urethritis (Most Common in 25-Year-Olds)

Empiric treatment should be initiated immediately after obtaining specimens if clinical suspicion is high:

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g PO single dose OR doxycycline 100 mg PO twice daily for 7 days 1, 2
• This dual therapy covers both gonorrhea and chlamydia, which frequently co-exist 1, 2
• Partner notification and treatment is mandatory to prevent reinfection 1, 2
• Abstain from sexual activity for 7 days after treatment completion and until partners are treated 2

For Suspected UTI (Less Common in Young Men)

If the presentation suggests cystitis rather than urethritis (internal dysuria, no discharge, pyuria on urinalysis):

• All UTIs in men are considered complicated and require thorough evaluation 1
• Initiate empiric antibiotics based on local resistance patterns while awaiting culture results 1
• Consider underlying structural abnormalities or prostate involvement 1, 3

Symptomatic Relief

• Phenazopyridine 200 mg PO three times daily for up to 2 days can provide symptomatic relief while awaiting culture results 4
• Warn patients about orange-red urine discoloration and potential fabric/contact lens staining 4

Critical Follow-Up and Red Flags

Reassessment Timing

• Evaluate response at 2-4 weeks after treatment initiation 1, 2
• If symptoms persist despite appropriate treatment, consider alternative diagnoses including Mycoplasma genitalium, prostatitis, or non-infectious causes 1, 2

Mandatory Urologic Referral Criteria

Refer immediately to urology if any of the following are present:

• Hematuria (microscopic or macroscopic) 1
• Recurrent infections 1
• Abnormal DRE suspicious for malignancy 1
• Neurological disease affecting bladder function 1
• Symptoms persisting despite appropriate treatment 1, 2

Common Pitfalls to Avoid

• Do not treat empirically without obtaining specimens first - this compromises diagnostic accuracy and contributes to antibiotic resistance 1, 2
• Do not assume UTI is the cause in young sexually active men - STI-related urethritis is far more common in this demographic 1, 3
• Do not neglect partner treatment - failure to treat partners leads to reinfection rates exceeding 20% 2
• Do not order urine culture alone without STI testing in sexually active young men, as this misses the most common diagnoses 1, 2, 3
• Avoid virtual encounters without laboratory testing for dysuria, as this increases recurrent symptoms and unnecessary antibiotic courses 2

Alternative Diagnoses to Consider

If infectious workup is negative, consider:

• Urethral trauma from vigorous sexual activity or instrumentation 2, 5
• Chemical irritation from soaps, spermicides, or personal hygiene products 5
• Urethral stricture (less common in this age group) 3
• Renal calculus if flank pain or hematuria present 3, 5