From the Guidelines
For patients presenting with dysuria and a negative urinalysis, the initial approach should focus on symptom management and ruling out underlying conditions such as interstitial cystitis/bladder pain syndrome (IC/BPS), urethritis, or other non-infectious causes, as indicated by the AUA guideline on diagnosis and treatment of IC/BPS 1.
Initial Management
- Increased fluid intake to help alleviate symptoms
- Over-the-counter pain relievers like ibuprofen (400-600mg every 6-8 hours) or acetaminophen (500-1000mg every 6 hours) for symptom relief
- If symptoms persist, consider empiric treatment for urethritis, especially in sexually active patients, with azithromycin 1g as a single dose plus ceftriaxone 500mg IM once
Specific Considerations
- For women with symptoms suggesting interstitial cystitis, phenazopyridine 100-200mg three times daily for 2-3 days can provide urinary tract analgesia, as per the management of IC/BPS symptoms 1
- Patients should avoid potential irritants like spicy foods, caffeine, and alcohol to reduce symptom exacerbation
- If vaginal irritation is suspected, especially in postmenopausal women, topical estrogen cream may be beneficial
Further Evaluation
If symptoms persist beyond 7-10 days despite initial management, further evaluation is warranted, including:
- STI testing
- Pelvic examination
- Urological referral for conditions like IC/BPS, which requires a careful history, physical examination, and laboratory examination to document basic symptoms and exclude infections or other confusable disorders 1
- Consideration of cystoscopy if there's suspicion of bladder cancer, bladder stones, or intravesical foreign bodies, as these conditions can mimic IC/BPS and require prompt diagnosis and treatment 1
From the Research
Treatment of Dysuria with Negative Urinalysis
- Dysuria, a feeling of pain or discomfort during urination, can be caused by various factors, including urinary tract infection, sexually transmitted infection, bladder irritants, skin lesions, and chronic pain conditions 2.
- A negative urinalysis does not rule out urinary tract infection, especially in patients with a high probability of infection based on symptoms 3.
- In cases with a moderate or unclear probability of urinary tract infection, urine culture should be performed to guide appropriate antibiotic use 3, 2.
- Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis, and evaluation and treatment of dysuria through a virtual encounter without laboratory testing may increase recurrent symptoms and antibiotic courses 2.
- The most common pathogen for uncomplicated cystitis and pyelonephritis is Escherichia coli, and first-line therapies for acute uncomplicated cystitis include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole 4, 5.
Diagnostic Approach
- History is most often useful for finding signs of sexually transmitted infection, complicated infections, lower urinary symptoms in males, and noninfectious causes of dysuria 2, 6.
- Urine culture is the gold standard for detection of urinary tract infection, and bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy 3.
- Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics 3.
Treatment Options
- Nitrofurantoin is at least comparable with other uncomplicated urinary tract infection treatments in terms of efficacy, and patients taking nitrofurantoin reported fewer side effects than other drugs 5.
- First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 3, 4.
- Decisions regarding antibiotic agents should be individualized based on patients' allergies, tolerability, community resistance rates, cost, and availability 4.