I am an otherwise healthy adult experiencing dysuria; what is the appropriate evaluation and management?

Evaluation and Management of Dysuria in Otherwise Healthy Adults

In an otherwise healthy adult with dysuria, perform urinalysis first; if symptoms are typical for uncomplicated cystitis (frequency, urgency, suprapubic pain without vaginal discharge), treat empirically with nitrofurantoin for 5 days, fosfomycin single dose, or trimethoprim/sulfamethoxazole for 3 days without requiring urine culture. 1

Initial Diagnostic Approach

For Women with Dysuria

• Self-diagnosis with typical symptoms (frequency, urgency, burning, nocturia, suprapubic pain) WITHOUT vaginal discharge is accurate enough to diagnose uncomplicated UTI and initiate treatment without urinalysis or culture. 1
• If vaginal discharge or irritation is present, perform a pelvic examination to evaluate for vaginitis rather than treating for UTI. 2
• Reserve urine culture for recurrent infections, treatment failure, history of resistant organisms, or atypical presentations. 1

For Men with Dysuria

• All men with dysuria require urinalysis AND urine culture before treatment, as UTIs in men are considered complicated. 1, 3
• Perform digital rectal examination to assess prostate size, consistency, and tenderness to distinguish benign prostatic hyperplasia from prostatitis. 4
• In men under 35 years, consider sexually transmitted urethritis (Chlamydia trachomatis) as the primary etiology. 3
• In men over 35 years, coliform bacteria predominate, often secondary to urinary stasis from prostatic hyperplasia. 3

Key History Elements to Obtain

• Duration and character of dysuria (burning during vs. after urination suggests urethral vs. bladder pathology). 2
• Associated symptoms: frequency, urgency, hematuria, suprapubic pain, flank pain, fever, or vaginal/urethral discharge. 2
• Sexual activity and new partners (increases risk of sexually transmitted infections). 2
• Recent urologic procedures or catheterization (defines complicated UTI). 2
• Medication review for agents causing urethral irritation or inflammation. 2

Physical Examination Priorities

• Suprapubic palpation to detect bladder distention suggesting retention. 4
• Costovertebral angle tenderness to identify pyelonephritis requiring different management. 2
• External genital examination for lesions, discharge, or signs of trauma. 4
• Digital rectal exam in men to assess prostate and rule out prostatitis. 4, 3

Urinalysis Interpretation

• Negative nitrite AND negative leukocyte esterase strongly argues against bacterial UTI. 5
• Nitrites are more specific than leukocyte esterase for detecting bacteriuria, particularly in elderly patients. 6
• Pyuria alone is NOT diagnostic of infection—it commonly occurs without infection, especially in older adults with lower urinary tract symptoms. 6
• In symptomatic patients with high pretest probability, negative dipstick does NOT rule out UTI; proceed with culture if clinical suspicion remains high. 6

First-Line Antibiotic Treatment

For Uncomplicated Cystitis in Women

• Nitrofurantoin 100 mg twice daily for 5 days (preferred due to minimal resistance). 1, 6
• Fosfomycin 3 g single dose (convenient single-dose option). 1, 6
• Trimethoprim 100 mg twice daily for 3 days (if local resistance <20%). 1
• Trimethoprim/sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%). 1, 6
• Avoid fluoroquinolones as first-line due to increasing resistance and collateral damage. 6

For Men with Uncomplicated UTI

• Treat for 7 days (longer than women due to higher risk of prostatic involvement). 1
• First-line options: trimethoprim, trimethoprim/sulfamethoxazole, or nitrofurantoin for 7 days. 1
• Adjust antibiotics based on culture and susceptibility results. 1, 3

When to Obtain Urine Culture

Obtain urine culture in the following scenarios:

• All men with dysuria (UTIs in men are complicated by definition). 1, 3
• Women with recurrent UTI (≥2 episodes in 6 months or ≥3 in 12 months). 1
• Treatment failure after initial empiric therapy. 1
• Atypical presentation or unclear diagnosis. 1, 6
• History of resistant organisms. 1
• Pregnancy (urine culture is the test of choice). 6
• Adults ≥65 years (to guide antibiotic adjustment after empiric treatment). 1

Red Flags Requiring Immediate Urologic Referral

• Hematuria (microscopic or gross) accompanying dysuria. 5, 4
• Recurrent UTIs (≥2 in 6 months or ≥3 in 12 months). 7, 4
• Suspected anatomical abnormalities or urethral stricture. 5
• Neurological disease affecting bladder function. 4
• Persistent symptoms despite appropriate antibiotic therapy. 5
• Findings suspicious for malignancy on examination. 4

Alternative Diagnoses to Consider When Urinalysis is Normal

• Urethritis from sexually transmitted infections (Chlamydia, gonorrhea)—obtain urethral swab or first-void urine for nucleic acid amplification testing. 2, 3
• Vaginitis—perform pelvic examination with vaginal pH, wet mount, and cultures. 2
• Interstitial cystitis/bladder pain syndrome—consider if chronic symptoms (>6 weeks) with negative cultures. 2
• Urethral trauma from recent sexual activity, catheterization, or instrumentation. 2
• Medication-induced urethritis (cyclophosphamide, ketamine). 2
• Dermatologic conditions (lichen sclerosus, contact dermatitis). 2
• Urethral or bladder calculi—obtain imaging if hematuria present. 2

Common Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria—it is common in older women and does not require antibiotics; treatment increases resistance without improving outcomes. 6
• Do NOT assume all dysuria is UTI—in women with vaginal symptoms, vaginitis is more likely than cystitis. 2
• Do NOT use fluoroquinolones empirically—reserve for complicated infections or documented resistance to first-line agents. 6
• Do NOT obtain routine imaging (ultrasound, CT) in uncomplicated dysuria without red flags. 2
• Do NOT defer evaluation in men—all male UTIs warrant culture and consideration of prostatic involvement. 1, 3

Follow-Up Strategy

• Women with uncomplicated cystitis do NOT require routine follow-up if symptoms resolve completely. 1
• Re-evaluate at 2–4 weeks if symptoms persist or recur to obtain urine culture and consider alternative diagnoses. 5
• For recurrent UTIs, consider prophylactic strategies (increased fluids, cranberry products, methenamine hippurate) rather than continuous antibiotics. 1