What is the appropriate work‑up and management of dysuria in a man who has recently completed treatment for prostate cancer?

Management of Dysuria After Prostate Cancer Treatment

Begin by determining whether the dysuria represents irritative symptoms from radiation-induced mucositis/edema versus obstructive symptoms from urethral stricture or bladder neck contracture, as this distinction fundamentally changes management. 1

Initial Assessment

Obtain a focused history targeting:

• Timing of symptom onset relative to treatment completion (acute vs. late effects) 1
• Character of dysuria: burning/pain during urination (irritative) versus hesitancy, weak stream, or incomplete emptying (obstructive) 1
• Associated symptoms: frequency, urgency, nocturia, hematuria, or urinary retention 1
• Type of treatment received: surgery, external beam radiation, brachytherapy, or combination therapy 1
• History of instrumentation: transurethral resection of prostate (TURP), rectal procedures, or biopsies post-radiation 2, 3

Physical examination should assess for:

• Suprapubic fullness suggesting retention 1
• Urethral meatal stenosis on inspection 2
• Digital rectal exam to evaluate for rectal pathology or fistula if severe symptoms present 3

Diagnostic Work-Up Based on Symptom Pattern

For Irritative Symptoms (Frequency, Urgency, Dysuria)

These symptoms are common after radiation therapy, affecting up to 50% of men during acute treatment phases 1:

• Trial of anticholinergic medications (e.g., oxybutynin) for presumed overactive bladder, which occurs in up to 48% of post-treatment patients 1
• Urinalysis and culture to exclude urinary tract infection 1
• Consider urodynamic testing if symptoms persist despite medical therapy 1
• Follow the AUA Overactive Bladder guideline for refractory cases 1

For Obstructive Symptoms (Weak Stream, Hesitancy, Incomplete Emptying)

These symptoms suggest urethral stricture or bladder neck contracture, particularly in post-radiation patients 1:

• Post-void residual measurement to quantify retention 1
• Trial of alpha-blocker therapy (e.g., tamsulosin) 1
• Cystourethroscopy is mandatory before any surgical intervention to directly visualize urethral pathology (stricture, bladder neck contracture, or fistula) 1, 2
• Urethral stricture occurs in up to 2% of post-radiation patients, with higher rates after prior TURP 1

Treatment Algorithm

Conservative Management (First-Line)

For irritative symptoms:

• Anticholinergic medications 1
• Behavioral modifications per AUA Overactive Bladder guidelines 1

For obstructive symptoms:

• Alpha-blocker trial 1
• Monitor post-void residuals 1

Escalation for Refractory Cases

If obstructive symptoms persist despite medical therapy:

• Refer to urology for cystourethroscopy 1
• Stricture management may require dilation, direct vision internal urethrotomy, or urethroplasty 2
• Critical caveat: Post-radiation strictures are more difficult to treat with slower recovery and lower success rates compared to post-surgical strictures 2

If severe dysuria with hematuria or constitutional symptoms:

• Urgent urology referral to exclude fistula, particularly if history of rectal procedures or biopsies post-radiation 3
• 81% of patients with rectourethral fistulas had prior instrumentation (rectal biopsy, TURP, argon beam therapy) 3

Key Clinical Pitfalls

• Do not assume all post-treatment dysuria is benign cystitis: Radiation-induced complications can be severe and progressive, including strictures and fistulas 2, 3
• Avoid instrumentation in recently radiated tissues when possible: TURP after radiation carries high incontinence risk, and rectal procedures increase fistula risk 1, 3
• Radiation effects can manifest late: Urethral stricture and other complications may appear months to years after treatment completion 1
• Combined therapy (surgery + radiation) carries highest risk: Up to 26% develop bladder outlet obstruction with combination treatment 4

When to Refer to Urology

Immediate referral for:

• Urinary retention requiring catheterization 1
• Gross hematuria with dysuria 1
• Suspected fistula (pneumaturia, fecaluria, recurrent UTIs) 3
• Failed conservative management after 4-6 weeks 1

Routine referral for:

• Persistent obstructive symptoms despite alpha-blocker therapy 1
• Bothersome irritative symptoms refractory to anticholinergics 1