What are the likely causes, diagnostic work‑up, and treatment options for dysuria in a married adult male?

Dysuria in a Married Adult Male: Diagnostic Approach and Management

In a married adult male presenting with painful urination, the most critical first step is to obtain a midstream urine culture to distinguish between bacterial infection (urethritis, prostatitis, or cystitis) and non-infectious causes, while simultaneously performing a digital rectal examination to assess for prostatic tenderness that would indicate acute bacterial prostatitis. 1, 2

Initial Diagnostic Workup

Essential History Components

• Duration and severity of dysuria, associated symptoms (frequency, urgency, hesitancy, weak stream), and degree of bother using validated questionnaires like the International Prostate Symptom Score (IPSS) 1, 2
• Sexual history including recent partners, condom use, and symptoms in partner(s), as sexually transmitted infections are common causes of urethritis in sexually active men 1, 3
• Urethral discharge presence, color, and timing (morning vs. throughout day) to differentiate gonococcal from non-gonococcal urethritis 1
• Fever, chills, perineal pain, or obstructive symptoms suggesting acute bacterial prostatitis versus chronic conditions 1, 4

Critical Physical Examination Findings

• Digital rectal examination (DRE) to assess prostate size, consistency, nodularity, and most importantly, tenderness—a tender, boggy prostate indicates acute bacterial prostatitis and contraindicates prostatic massage 1, 2
• Suprapubic examination for bladder distention suggesting urinary retention 1, 2
• External genitalia inspection for urethral discharge, meatal erythema, or lesions 2
• Neurological assessment of perineum and lower extremities to exclude neurogenic bladder 1

Laboratory Testing Algorithm

For all men with dysuria:

• Midstream urine dipstick checking nitrites and leukocytes 1
• Midstream urine culture to guide antibiotic selection—this is mandatory as all UTIs in men are considered complicated 2, 3
• Urinalysis with microscopy to detect pyuria, hematuria, or proteinuria 2

If sexually active or age <35 years:

• First-void urine for nucleic acid amplification test (NAAT) for Chlamydia trachomatis and Mycoplasma genitalium 1
• Urethral swab/smear if urethral discharge is present, testing for Neisseria gonorrhoeae 1

If prostatitis suspected (perineal pain, obstructive symptoms, tender prostate):

• Blood culture and complete blood count if acute bacterial prostatitis with systemic symptoms 1
• Meares-Stamey 2- or 4-glass test only in chronic bacterial prostatitis, not acute phase 1, 4

Differential Diagnosis Framework

Most Likely Causes by Age and Presentation

Younger men (<35 years, sexually active):

• Urethritis from STIs (C. trachomatis, N. gonorrhoeae, M. genitalium)—presents with urethral discharge and dysuria without frequency 1, 3
• Treatment: Ceftriaxone 1000 mg IM/IV single dose PLUS doxycycline 100 mg twice daily for 7 days (covers both gonorrhea and chlamydia) 1

Older men (>50 years) or those with obstructive symptoms:

• Acute bacterial prostatitis—presents with dysuria, frequency, urgency, perineal/suprapubic pain, fever, and tender prostate on DRE 1, 4, 5
• Chronic bacterial prostatitis—recurrent UTIs with same organism, pelvic pain, voiding symptoms, painful ejaculation 4, 5
• Benign prostatic hyperplasia (BPH)—dysuria with hesitancy, weak stream, incomplete emptying, nocturia in men >50 years 1, 6

Any age with negative cultures:

• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)—pelvic pain >3 months, urinary symptoms, painful ejaculation without documented bacterial infection 4, 7

Treatment Algorithms

For Confirmed Bacterial Infections

Acute Bacterial Prostatitis:

• Fluoroquinolone (ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily) for 4 weeks as first-line, given excellent prostatic penetration 5, 3
• Alternative: Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 4 weeks 5
• Hospitalization with IV antibiotics if severe infection with systemic symptoms 1, 4

Chronic Bacterial Prostatitis:

• Fluoroquinolone for 6-12 weeks minimum duration required for cure 4, 5, 8
• Cure rates are suboptimal (50-70%), and relapses are common 4, 5
• Long-term suppressive therapy may be needed for recurrent cases 5

Uncomplicated Cystitis in Men:

• Trimethoprim-sulfamethoxazole for 7 days or nitrofurantoin for 7 days as first-line 3
• Note: Men require 7 days (not 3 days as in women) due to higher complication risk 3

Urethritis (STI-related):

• Gonorrhea likely: Ceftriaxone 1000 mg IM/IV single dose PLUS antibiotic active against Chlamydia (doxycycline 100 mg twice daily for 7 days) 1
• Gonorrhea unlikely: Single antibiotic or combination active against Chlamydia and Enterobacterales 1

For Non-Bacterial Causes

BPH-related dysuria:

• Alpha-blockers (tamsulosin 0.4 mg daily, alfuzosin 10 mg daily) as first-line for most men with moderate symptoms 1, 6, 2
• 5-alpha reductase inhibitors (finasteride 5 mg daily, dutasteride 0.5 mg daily) for prostates >30 cc 1, 6
• Assess response at 2-4 weeks for alpha-blockers, 3 months for 5-ARIs 1, 2

Chronic Prostatitis/Chronic Pelvic Pain Syndrome:

• Trial of fluoroquinolone for 4-6 weeks provides relief in 50% of men, especially if prescribed early 4, 7
• Alpha-blockers for urinary symptoms 4
• NSAIDs for pain symptoms 4
• Pelvic floor physical therapy/biofeedback is potentially more effective than medications 4, 7

Behavioral and Lifestyle Modifications (All Patients)

• Target approximately 1 liter urine output per 24 hours—excessive fluid intake worsens symptoms 2
• Reduce evening fluid intake to minimize nocturia 2
• Avoid bladder irritants (caffeine, alcohol, spicy foods) 2
• Maintain physical activity and avoid prolonged sitting 2

Follow-Up Strategy

• Evaluate at 4-12 weeks after initiating treatment to assess response using IPSS or similar validated questionnaire 1, 2
• Repeat urine culture if symptoms persist or worsen to detect treatment failure or resistant organisms 3
• Annual follow-up for patients with successful treatment to detect progression or complications 2

Mandatory Urologist Referral Criteria

Refer immediately before initiating treatment if:

• Neurological disease affecting bladder function 1, 2
• Severe obstruction (peak flow <10 mL/second on uroflowmetry) 2
• Abnormal PSA or suspicious DRE findings suggesting prostate cancer 2
• Recurrent infections despite appropriate therapy 2
• Hematuria (visible or microscopic) 2
• Acute urinary retention requiring catheterization 1
• Suspected prostatic abscess on imaging 1

Critical Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis—this can precipitate bacteremia and sepsis 1
• Do not assume infection based solely on pyuria—sterile pyuria occurs in CP/CPPS and requires different management 1, 4
• Do not treat asymptomatic bacteriuria in men—pyuria accompanying asymptomatic bacteriuria is not an indication for antibiotics 1
• Do not use 3-day antibiotic courses in men—all UTIs in men require minimum 7 days due to higher complication risk 3, 8
• Do not overlook STI testing in sexually active men—urethritis from Chlamydia or Gonorrhea requires specific testing and treatment 1, 3
• Do not initiate BPH treatment without documenting symptom severity—use IPSS to quantify symptoms and guide treatment decisions 1, 2
• Do not continue ineffective antibiotics beyond 4-6 weeks in CP/CPPS—shift to non-antibiotic strategies (pelvic floor therapy, alpha-blockers) 4, 7