Dysuria – Causes, Symptoms, Diagnosis, Treatment

Harun
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Dysuria is a symptom of pain or discomfort, pain and/or burning sensation, stinging, or itching of the urethra or urethral meatus during the time of passes urination. It is one of the most common symptoms that may be experienced by most people at least once over their lifetimes or more. Dysuria usually happens due to urinary bladder muscle contraction and of the urethra, which ends up causing the urine to come in contact with the inflamed mucosal lining tissue, which in turn stimulates pain receptors of your urinary tract and causes to feel pain and/or burning. Primarily, causes of dysuria can be divided broadly into many categories, infectious and non-infectious.

Causes of Dysuria

Most cases of urinary tract infections and burning sensations or dysuria, prostatitis, urethritis, vaginitis, of the urinary tract are due to the colonization of the urogenital tract with rectal and perineal flora. The most common organisms include Escherichia coli, Enterococcus, Klebsiella, Pseudomonas, and other Enterococcus or Staphylococcus species. Residential care patients, diabetics, and those with indwelling catheters or any form of immunocompromise can also colonize with Candida Albicans.

In these scenarios, one can always find protective factors that failed to prevent infection or risk factors that lead to poor resolution of sepsis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, higher morbidity, treatment failures, and reinfection.

  • Neisseria gonorrhea – It is the leading cause of urethritis and dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Neisseria gonorrhea is a gram-negative bacteria transmitted through sexual intercourse. The incubation period is 2-5 days. Patients are commonly co-infected with Chlamydia trachomatis.
  • Chlamydia trachomatis – It is the most common nongonococcal cause of urethritis, dysuria, urinary tract infection, prostatitis, vaginitis, and is also transmittable through sexual intercourse. Chlamydia trachomatis is one of the smallest gram-negative obligate intracellular parasitic bacteria. The incubation period is usually 7-14 days even it becomes more. It is commonly associate or co-infected with Mycoplasma genitalium and Neisseria gonorrhea.
  • Complicated – Anatomical or systemic factors that increase the chance of infection like male gender, diabetes, immunosuppression, polycystic kidney, hospital-acquired, bladder outflow obstruction, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, (prostate hypertrophy, urethral stricture), neuropathic bladder (multiple sclerosis, diabetes mellitus), catheterization or ureter stent, ureterolithiasis, genitourinary surgery or malignancy, vesicoureteral reflux
  • Mycoplasma genitalium a –  Its cause of recurrent or persistent urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and is commonly a causative agent in men with nongonococcal urethritis. This organism is small self-replicating bacteria lacking a cell wall synthesis. This organism can be difficult to detect to identifying or given its slow-growing nature.
  • Trichomonas vaginitis – It is a flagellated parasitic protozoal STI, is a common infection affecting the urogenital tract of both men and women in most commonly.
  • Herpes Simplex virus – It is a double-stranded DNA virus, can cause genital dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, infection involving the urethra.
  • Adenovirus – is an uncommon cause of urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in men. However, it should be considered in all males presenting with dysuria, mastitis, and associated conjunctivitis or constitutional symptoms.
  • Treponema pallidum – It may cause urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, from an endourethral syphilitic chancre; uncommon.
  • Haemophilus influenza – It is an uncommon cause of dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, transmitted through oral sex from respiratory secretions.
  • Neisseria meningitides – It is a gram-negative diplococcus that colonizes the nasopharynx. Transmission of this organism is through oral sex is most common and is a less common cause of urethritis.
  • Ureaplasma urealyticum and ureaplasma parvum – In some scientific studies show uncommon links to urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.  In patients that have tested positive, it is usually in younger men and men with fewer sexual partners.  This causative agent should be of suspicion when other identifiable nongonococcal urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, is absent.
  • Candida – species are a common fungal yeast that can cause infections and irritation to the urogenital tract, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.

Non-infectious etiologies associated with urethritis include

  • Trauma – It is less commonly the cause of dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. However, inflammation and irritation may occur with intermittent catheterization and surgical problems, after urethral instrumentation, or from a foreign body or any particle insertion.
  • Irritation – of the genital area may also result in urethritis from

    • Rubbing or pressure resulting from tight clothing or sex and associate system.
    • Physical activity including activities such as bicycle riding, cricket playing, running, stairs climbing.
    • Irritants including various soaps, body powders, fungal infection, protozoa, and spermicides.
    • Menopausal females with insufficient estrogen levels in the body may develop dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, due to the tissues of the urethra and bladder becoming thinner and dryer, causing irritation. This is a very common cause of urethritis with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in older women.
  • Vaginitis – It is one of the presence of vaginal discharge, odor, pruritus, dyspareunia. No frequency/urgency.
  • Urethritis – Urinalysis shows dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, but no bacteria. Common in sexually active women.
  • Painful bladder syndrome – It is also found in the diagnosis of exclusion. Dysuria, frequency, urgency, but no evidence of infection in some cases.
  • Pelvic inflammatory disorder – It causes lower abdominal/ pelvic pain, fever, cervical discharge, cervical motion tenderness.
  • Prostatitis – It is considered in men. May present with pain during ejaculation and tender prostate on digital and manual rectal examination.
  • Anatomical defects – It leads to stasis, obstruction, urinary reflux all result in an increased predisposition to recurrent urinary tract infections, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Vesicoureteric reflux (VUR) is identified in up to 40% of women being investigated for a first UTI. Cystocele is also an important risk factor for recurrent dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in women.
  • Functional defects – like overactive bladder and urinary incontinence also lead to recurrent infections with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.
  • Recurrent urinary tract infections – It may be commonly seen in sexually active women without any identifiable structural abnormality or another associated condition. Older men can often develop urinary tract infections due to obstruction or neurogenic bladder in urinary stasis dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and an increased risk of recurrent infection.
  • Several other lesions – It may indicate to recurrent dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, including intraluminal (bladder stones, neoplasms, indwelling catheter), intramural (ureteral stenosis/strictures), and extramural lesions (inflammatory mass, fibrosis, or neoplasm).

Examples of a complicated UTI include

  • Infections occurring despite the presence of anatomical protective measures (dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in males are by definition considered complicated UTI)
  • Infections occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal tract calculi, or colovesical fistula  with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections occurring due to an immune-compromised state, for example, steroid use, post-chemotherapy, tumor, neoplasm, diabetes, elderly population, HIV)
  • Atypical organisms causing dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.
  • Recurrent infections adequate treatment (multi-drug resistant organisms)
  • Infections are occurring in pregnancy or non-pregnant women (including asymptomatic bacteriuria)
  • Infections are occurring after instrumentation, nephrostomy tubes, ureteric stents, suprapubic tubes, or Foley catheters, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections in renal transplant patients with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections are occurring with impaired renal function
  • Infections following dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,or radiotherapy

Inflammation and irritation

A range of problems may lead to inflammation or irritation dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, of the urinary tract or genital area, leading to the symptom of a painful urination. Besides infections, other reasons that area may be irritated or inflamed that are included

  • Stones in the urinary tract, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Irritation of the urethra from sexual activity or after
  • Interstitial cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, a condition caused by bladder inflammation
  • Vaginal changes or vaginal discharge related to menopause
  • Activities such as horseback riding or bicycling, bike riding.
  • Vaginal sensitivity or irritation related to the use of scented unqualified soaps or bubble baths, toilet paper, or other products such as douches or spermicides.
  • Side effects from certain medications, supplements, and treatments, cosmetic use.
  • Tumor, neoplasm in the urinary tract

Symptoms of Dysuria

Patient with cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis may present with the following symptoms

  • Frequency, dysuria, urgency, suprapubic pain, abdominal pain, cloudy urine, hematuria, nausea, vomiting, and fever
  • Similar symptoms of  cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis but usually will have flank pain, fever, and other systemic symptoms
  • Apart from a typical presentation, they tend to have altered mental status, lethargy, and, mental, emotional weakness.
  • Recurrent or resistant with urinary tract infection
  • Irritative urinary symptoms like frequency, dysuria, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and urgency
  • Flank pain, the renal mass, tumors may be present in the case of renal TB.
  • Testicular mass, perineal pain, abdominal or lower abdominal, and urethral discharge may be seen in genital TB.
  • Menstrual irregularity, abdominal pain, infertility, or pelvic inflammatory cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis disease in case of female genital involvement
  • Unexplained infertility in both sexes man and women.
  • Non-specific symptoms in some cases like fever, weight loss, and backache

Associated symptoms include

  • Flank pain is more common in cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis
  • Lower abdominal pain
  • Painful urination and burning sensation.
  • Urinary urgency or frequency with cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis
  • Fever
  • Active menstruation
  • Passing stone or grits
  • Recent throat or skin infection, skin rash
  • Joint pains, oral ulcers in the mouth and another organ, rash
  • Hemoptysis
  • Leg swelling
  • Hearing loss
  • Flank mass
  • Constitutional associate symptoms like weight loss, anorexia, cachexia
  • Back pain and chronic lower back pain, sciatica.

Diagnosis of Dysuria

History

History is the most important clue for the diagnosis of acute uncomplicated cystitis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis and it should be supported by a focused examination and urinalysis. It also is important to identify a more serious, complicated UTI. The new onset of frequency and dysuria, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis with the absence of vaginal discharge, has a positive predictive value of 90% of UTI.

Urethritis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis is commonly asymptomatic; if symptomatic, the symptoms vary based on the causative organism.

  • Urethritis – It may include dysuria, pruritus, burning sensation during urination, and discharge at the urethral meatus.  Frank purulent discharge suggests gonorrhea as the causative microorganism. Dysuria alone is common among chlamydia infections. If the patient has dysuria with painful genital ulcers, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis the causative organism is most likely herpes simplex virus.
  • Neisseria gonorrhea – It is often associated with copious purulent or mucopurulent urethral discharge in men or women can be asymptomatic.  In women, urethritis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis is often associated with cervicitis or may be asymptomatic. If symptoms are present, dysuria is the most common.  Other symptoms of cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis in women can include frequency and urgency in some cases.
  • Chlamydia trachomatis – It is most commonly asymptomatic. Symptomatic causes can have dysuria and urethral discharge in most cases. Females with urethritis usually also have cervicitis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Female patients may report dysuria, urgency, or frequency.  Symptoms of cervicitis include intermenstrual vaginal bleeding, post-coital bleeding, and changes in vaginal discharge cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Symptoms may be the reported chief complaint of females with urethritis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Males that are symptomatic may complain of mucoid or watery discharge and dysuria.  A small number of patients with chlamydial may develop a reactive urethritis triad.
  • Mycoplasma genitalium – It causes infections that are commonly asymptomatic, however; symptoms may include dysuria, or mucopurulent urethral discharge, urethral pruritus, balanitis, and cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. The urethral discharge is commonly associated with this micro-organism but, is not always evidence base in contrast to the Neisseria gonorrhea infections. It can cause acute, chronic and persistent urethritis in men.
  • Herpes simplex virus – It is usually presented with intense dysuria, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. On physical examination, a limited amount of discharge may be found or present and commonly mastitis and balanitis. The majority of patients may not have hepatic biliary lesions present at the time of examination but generally presents shortly after.
  • Adenovirus – It commonly presents with intense cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis instead of urethral irritation which helps differentiates it from other causes of urethritis. Usually transmitted by oral sex with upper respiratory tract infection symptoms generally during fall and winter months. The genitourinary examination usually shows scant, mal odor urethral serous discharge as well as mastitis and balanitis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. It is important to perform a complete physical examination as associated constitutional symptoms assist in the diagnosis.

Some data indicate that enteric micro-organisms are causative and infective agents of urethritis from rectal exposure — gram-negative rods from urinary tract infections cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, or anal sex. Haemophilus species, Neisseria meningitides, Moraxella catarrhalis, and Streptococcus pneumonia are associated with oral sex causing NGU.

Physical Exam

A physical examination with acute uncomplicated cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis is typically normal except in 10% to 20% of women with suprapubic tenderness. Acute pyelonephritis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis may be suspected if the patient is ill-appearing and seems uncomfortable, particularly if she has a concomitant fever, tachycardia, or costovertebral angle tenderness.

  • Tender scrotal swelling – irregular/nodular prostate, genital ulcer, and perineal sinus/ fistula.
  • Ureteral – involvement is usually seen at the junction and may lead to ureteral strictures, and severe cases may cause hydronephrosis.
  • Bladder TB – usually starts at the ureteral orifice, in the form of superficial inflammation with granulation, which may also lead to ureteral and complications. The complication may manifest as fibrosis cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and involvement of the muscle layers leading to the thick fibrous bladder.
  • Epididymal – It is induration and beading of great deferences and rarely draining sinus.
  • Testicular – It is beading and nodular appearance is characteristic of cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis and helps differentiate it from other mass lesions of the testis.
  • The affected prostate – It may feel nodular in appearance and non-tender on palpation. In severe cases, it may lead to cavitation infection formation. Decreased semen volume may be observed during sexual life.
  • Urethral – It involvement and genial area cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis penis presents with a superficial ulcer. It occurs due to penile ulcers extending to the urethra with time. It may also involve the fallopian tubes, leading to strictures.

A complete physical examination can contribute to making a valid differential diagnosis. Important signs to look for are

  • Febrile
  • Hypertension
  • Periorbital edema
  • Presence of pallor, icterus, oral thrust, oral ulcers, or skin rash
  • Hearing impairment may be found
  • Generalized lymphadenopathy and edema
  • Joints swellings
  • The flank mass may be present
  • Palpable enlarged cystic kidneys, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis
  • Costovertebral angle tenderness, swelling
  • Pubic tenderness may be present
  • Urethral discharge or tear also found in some case
  • Lower extremity edema, swelling, tenderness.

Self Diagnosis and Diagnosis by Telephone

  • Two recent studies suggest that women who self-diagnose cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis may be treated safely via telephone management. Women who are treated with acute uncomplicated cystitis are usually determining when they are having another episode.

Lab Tests

The convenience and cost-effectiveness of a urine dipstick test make it a common diagnostic tool. It is an appropriate alternative to urinalysis and urine microscopy in the diagnoses of acute cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Nitrite and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis in symptomatic women.

  • Urinalysis with microscopy  – Ideally mid-stream catch or catheter oriented to avoid contamination. However, at least two studies have shown significant infection differences in contaminated or unreliable results in specimens collected either with and without preliminary cleansing.
  • Nitrites Test- Bacteria reduction of nitrate to nitrite; typically by gram-negative organisms. Under normal circumstances, urine will have no nitrites. False positives result from air exposure, and false negatives can be the result of the non-nitrite-producing organism that are associate with cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, low nitrate diets such as (decreased vegetables), vitamin C, concentrated urine infection, and low pH. Sensitivity (19% to 48%) and specificity (92% to 100%) or may increase.
  • Leukocyte Esterase Test – It is the presence of intact or broken down neutrophils from your body. False negatives can be the result of an early infection, vitamin C, concentrated urine, ketonuria, hematuria, and proteinuria. False positives can be caused by contamination of the urine by normal skin flora. Sensitivity (62% to 98%) and specificity (55% to 96%) or may increase.
  • Pyuria – It more than five white blood cell count (WBC) per HPF = Sensitivity (90% to 96%) and specificity (47% to 50%) or may increase.
  • WBC Casts – It is the coagulum of Tamm Horsfall mucoprotein and leukocytes from renal tubular lumen which test can indicate pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Other causes glomerulonephritis, interstitial nephritis.
  • Clean-catch urine examination – For clean-catch urine examination should have a colony count of more than 100,000 CFU/mL for a single organism. 20% to 40% of women presenting with cystitis, pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis or have 100-10,000 CFU/mL
  • Urine culture – Indication for culture is complicated infections, pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis., and prior antimicrobial treatment. Routine post-treatment urine microscopic analysis or urine cultures in asymptomatic patients are not necessary.
  • Urinalysis – It is the initial and most useful test to identify infection. Although urine dipstick is widely available and can be performed quickly, it can give false-positive or false-negative results and warrants urinalysis and urine microscopy to establish the diagnosis the pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. The presence of 3 or more WBC per High Power Field on urine sediments is defined as microscopic hematuria although there is no safe lower limit of hematuria. Urine appearance, pH, the presence of proteins, WBCs, nitrites, leukocyte esterase, crystals, bacteria infection, and casts are helpful. A dirty urine specimen with significant WBCs and positive nitrites and leukocyte suggests urinary tract infection and a likely cause of hematuria. The presence of excessive proteins with hematuria, pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.  glomerulonephritis.
  • Urine microscopy -It is essential to examine urine sediments for RBC morphology, and RBC casts are the single most significant test which can differentiate between glomerular and non-glomerular bleeding and infection.
  • Dysmorphic RBCs  – >25% per High-Power Field is highly specific (>96%) with a high positive predictive value (94.6%) but not much sensitive (20%) for pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, Glomerulonephritis.
  • RBC casts -It is rare to find but almost diagnostic of pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.

Imaging Test

Renal parameters should be obtained to rule out acute kidney injury.

  • Imaging – Initial imaging could be in the form of an ultrasound of the kidneys, ureters, and bladder pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. It can assist in diagnosing anatomical causes of hematuria such as a kidney stone or bladder or renal mass. It can also detect renal cysts.
  • Abdominopelvic CT scan –  with or without contrast is the preferred modality to detect renal stones and other morphological abnormalities of kidneys. MRI abdomen and pelvis is another useful modality if CT scan is contraindicated or not helpful.
  • Cystoscopy – After ruling out urinary tract infection and having negative imaging of kidneys and ureters to detect any abnormality, cystoscopy by a urologist is the next step in the evaluation of hematuria pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. It can detect urothelial carcinoma, bladder wall inflammation, or mucosal thickening. It can also be therapeutic to remove bladder stones.
  • Urine Cytology – can be performed to detect malignant cells or to detect urothelial carcinoma, pyelonephritis, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. , but it is not a substitute for a cystoscopy.
  • UTI biopsy – The gold standard to diagnose a glomerular cause of hematuria is a kidney biopsy by a nephrologist or radiologist. The presence of dysmorphic RBCs and RBC casts should be followed by a kidney biopsy. As it is an invasive test, it can lead to complications such as life-threatening bleeding, but the frequency of occurrence is low. An adequate renal sample is 2-3 biopsy cores with a sufficient number of glomeruli. Light microscopy, electron microscopy, and immunofluorescence are performed to look at glomerulus structure to diagnose glomerulonephritis and detect a specific type.
  • Ultrasound – can evaluate for hydronephrosis or abscess. CT can help you evaluate for kidney stones, hydronephrosis, emphysematous changes, and abscess.

Treatment of Dysuria

There are many things to consider when treating cystitis. The choice between agents should be individualized and depends on the duration of treatment as well as the possible organism involved. According to guidelines, there is no single, best agent to treat acute uncomplicated cystitis. Choosing an antibiotic depends on its effectiveness, the risk of adverse effects, resistance rates, and propensity to cause collateral damage; furthermore, physicians should consider cost, availability, and patient factors, such as allergy history. On average, patients will experience symptom relief within 36 hours of the beginning treatment.

Broad-spectrum, empiric antibiotics should always be switched to a targeted narrow-spectrum antibiotic, if possible, once culture results are available. Initial broad-spectrum choices tend to be penicillins or beta-lactams, cephalosporins, fluoroquinolones, and carbapenems (especially if dealing with an extended-spectrum beta-lactamases (ESBL) organism). The specific choice will depend on the individual hospital’s microbiological spectrum and antibiogram.

The first line options for empiric antibiotic therapy are

  • Nitrofurantoin 100 mg twice daily orally for 5 to 7 days. It should be avoided in suspected pyelonephritis or if creatinine clearance <60 mL/min.
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily orally for three days. It should be avoided if the local resistance rate exceeds 20%.
  • Fosfomycin as a single oral dose of 3 grams. Overuse may result in increased rates of resistance.
  • Pivmecillinam. Not available in the US but is the agent of choice for UTI in Nordic countries. Avoid suspected pyelonephritis.

Second line 

If the above options cannot be used, oral beta-lactams are the next best choice.

  • Amoxicillin-clavulanate 500 mg twice daily,
  • cefdinir (300 mg twice daily),
  • cefadroxil (500 mg twice daily), and
  • cefpodoxime (100 mg twice daily), each given for five to seven days.
  • Ampicillin or amoxicillin should be avoided due to high rates of resistance.
  • If the beta-lactams cannot be used, fluoroquinolones such as levofloxacin (250 mg daily) and ciprofloxacin (250 mg twice daily), for three days, are good alternatives. Fluoroquinolones are contraindicated in pregnancy.

Third line 

For inpatient management of patients with risk factors for multi-drug resistant (MDR) pathogen infection,

  • carbapenems (imipenem 500 mg intravenously (IV) six-hourly, or
  • meropenem 1 gram IV eight-hourly, or doripenem 500 mg eight hourly) are used.
  • If no risk factors for MDR are present, ceftriaxone (1 gram IV daily)
  • piperacillin-tazobactam (3.375 grams IV six hourly) can be used.
  • Fluoroquinolones (ciprofloxacin or levofloxacin), both oral and parenteral, are also good alternatives. For critically ill patients, carbapenems (as above) along with vancomycin are typically used.

or

Gentamycin solution.

  • The recommended dosage is to instill 30-60 cc’s of a solution of 480 mg of Gentamycin in 1 Liter of Normal Saline after initially draining the bladder.
  • Gentamycin has no significant systemic absorption when used in this fashion so it can be used regardless of renal function.  Interestingly, heparin bladder installations have also shown some activity in reducing recurrent UTIs.

Uncomplicated Cystitis

  • Nitrofurantoin (Macrobid) 100 mg by mouth twice a day for 5 days
  • Trimethoprim-sulfamethoxazole 160 mg/800 mg twice a day for 3 days
  • Ciprofloxacin 250 mg twice a day or levofloxacin 250 mg twice a day for 3 days
  • Alternatives are B-lactams such as amoxicillin-clavulanate 500/125 mg twice a day for seven days or Cephalexin 250 mg four times per day for 3 to 7 days.

Complicated Cystitis

There is no absolute guideline for treatment that typically requires a longer duration (about seven days). Recommended treatments are listed below.

Nonpregnant women

  • Ciprofloxacin 500 mg by mouth twice a day 7 to 10 days
  • Nitrofurantoin Monohydrate/microcrystals 100 mg mouth twice a day for 7 days

Pregnant women

A shorter course of antibiotic therapy is preferred in pregnant patients. Fluoroquinolones are contraindicated during pregnancy. Nitrofurantoin is contraindicated in a pregnant patient at term, during labor, and delivery.

  • Amoxicillin-clavulanate 500 mg/12 mg by mouth twice a day for 7 days
  • Keflex 500 mg by mouth four times a day for 3 to 5 days
  • Cefpodoxime 100 mg twice a day for 5 to 7 days.

Men

Acute cystitis is always recognized as complicated. Men with cystitis who do not have signs or symptoms of prostatitis can be treated with the following regimens.

  • Ciprofloxacin 500 mg by mouth twice a day for 7 days
  • Levofloxacin 750 mg by mouth f
  • our times a day for 7 days
  • Macrobid 100 mg by mouth twice a day for 7 days.

or

Acute cystitis

Acute cystitis is treated with antibiotic therapy. The selection of an antimicrobial agent depends on a patient’s risk factors for infection with a multidrug-resistant (MDR) organism. Patients who are at low risk for resistant etiologic organisms are treated with 1 of the first-line or preferred antimicrobial agents which include:

  • Nitrofurantoin 100 mg twice a day for 5 days
  • Trimethoprim-sulfamethoxazole (TMP-SMX) double-strength twice a day for 3 days
  • Fosfomycin 3 gm as a single oral dose
  • Pivmecillinam 400 mg twice a day for 5 to 7 days (if available)

Antimicrobial selection should be individualized based on patient factors which include allergy, adverse effects, tolerability, local resistance patterns, cost, or recent use of a specific antimicrobial agent within the preceding three months. Nitrofurantoin should not be used in patients with creatinine clearance of less than 30 mL per minute and TMP-SMX must be avoided in places with regional resistance greater than 20%. The suspicion for pyelonephritis or complicated UTI also precludes the use of nitrofurantoin, fosfomycin, and pivmecillinam because of poor penetration into the renal tissue.

Alternative or second-line antimicrobial agents are used in acute cystitis in patients with factors or circumstances that prevent the use of the first-line agents. A 5 to 7-day course of oral beta-lactams such as amoxicillin-clavulanate 500 mg twice daily, cefpodoxime 100 mg twice daily, cefdinir 300 mg twice daily, cefadroxil 500 mg twice daily, and cephalexin 500 mg twice daily (although this agent is less well-studied) is usually preferred. If beta-lactam agents are contraindicated, a fluoroquinolone such as ciprofloxacin or levofloxacin for 3 days may be used.

Acute pyelonephritis

Acute pyelonephritis can be managed as either outpatient or inpatient. Healthy, young, non-pregnant women who present with uncomplicated pyelonephritis can be treated as outpatients. Inpatient treatment is usually required for those who are very young, elderly, immunocompromised, those with poorly controlled diabetes, renal transplant, patients, patients with structural abnormalities of the urinary tract, pregnant patients, or those who cannot tolerate oral intake. The mainstay of treatment of acute pyelonephritis is antibiotics, analgesics, and antipyretics. Nonsteroidal anti-inflammatory drugs (NSAIDs) work well to treat both pain and fever associated with acute pyelonephritis. The initial selection of antibiotics will be empiric and should be based on the local antibiotic resistance. Antibiotic therapy should then be adjusted based on the results of the urine culture. Most uncomplicated cases of acute pyelonephritis will be caused by E. coli for which patients can be treated with oral cephalosporins or TMP-SMX for 14 days. Complicated cases of acute pyelonephritis require intravenous (IV) antibiotic treatment until there are clinical improvements. Examples of IV antibiotics include piperacillin-tazobactam, fluoroquinolones, meropenem, and cefepime. For patients who have allergies to penicillin, vancomycin can be used. Follow up for non-admitted patients for resolution of symptoms should be in 1 to 2 days.

Gonococcal urethritis

  • The recommended treatment of choice is a single dose of ceftriaxone 250mg intramuscular injection and a single dose of oral 1 gram of azithromycin to cover for coinfection with chlamydia. Neisseria meningitides urethritis is treated the same.

Nongonococcal urethritis

  • the recommended treatment

Chlamydia trachomatis

  • The treatment of choice is a single dose of 1 gram of oral azithromycin or 100mg doxycycline twice a day for seven days.
  • Alternative treatment options are ofloxacin 300mg orally twice daily for seven days or levofloxacin 500mg orally once a day for seven days.
  • If coinfected with gonorrhea treatment with one dose of 250mg ceftriaxone intramuscular injection in addition to 1 gram oral single dose azithromycin.
  • In pregnant females, 1 gram orally of azithromycin is the recommended treatment. If pregnant females are unable to tolerate recommended treatment, these patients should have treatment with one of the following regimens:
  • Amoxicillin 500mg orally three times daily for seven days
  • Erythromycin base 500mg orally four times daily for seven days
  • Erythromycin base 250mg orally four times a day for 14 days
  • Erythromycin ethyl succinate 800mg orally four times daily for seven days
  • Erythromycin ethyl succinate 400mg orally four times a day for 14 days

In females who are pregnant or lactating the following medication treatment options are contraindicated

  • Levofloxacin,
  • Ofloxacin,
  • Erythromycin estolate, and
  • Doxycycline.
  • Azithromycin – All patients should undergo repeat testing three months after treatment and reinfection should receive therapy with azithromycin.
  • Mycoplasma genitalium – the recommended antibiotic of choice is azithromycin 1 gram orally as a single dose, similar to treating Chlamydia. For those patients’ infections resistant to treatment with azithromycin, moxifloxacin is a treatment alternative.
  • Trichomonas vaginalis – urethritis, including pregnant patients, should be treated with seven days of metronidazole 500 mg orally twice a day. Tolerance in pregnancy may be reduced due to significant nausea or vomiting so the length of treatment may be allowed to vary from five to seven days. 

WHEN SHOULD I REFER TO A SPECIALIST?

Referral to a specialist is recommended for these cases

All lower urinary tract symptoms in men, especially if they have the following characteristics

  • (a) bothersome lower urinary tract symptoms that have not responded to conservative management or drug treatment;
  • (b) lower urinary tract symptoms complicated by recurrent or persistent UTIs, retention, or renal impairment that is suspected to be caused by lower urinary tract dysfunction; and
  • (c) suspected urological cancer. ()

UTIs in the pediatric age group with the following characteristics

  • (a) infants aged under three months with a possible UTI, and
  • (b) infants and children aged three months or older with acute pyelonephritis/upper UTI.()

UTIs with the following characteristics

  • (a) severe symptoms;
  • (b) failed medical therapy (documented);
  • (c) evidence of retention (acute or chronic), and
  • (d) abnormalities detected on ultrasonography or cytology, such as calculi or bladder tumor. ()

Recurrent UTIs (defined as ≥ 3 UTIs in 12 months) with the following characteristics

  • (a) risk factors for complicated UTI are present;
  • (b) a surgically correctable cause is suspected, and
  • (c) a diagnosis of UTI is uncertain for recurrent lower urinary tract symptoms. ()

You prescribed a course of antibiotics and advised Yvonne to return if her symptoms did not improve after three days. Yvonne brought her mother to see you two weeks later for a cough and mentioned that your treatment for her cystitis had worked very well.

TAKE HOME MESSAGES

  • ABU does not require antibiotic therapy.
  • UTIs are one of the most common bacterial infections encountered by primary physicians and most uncomplicated UTIs can be treated in the outpatient setting with appropriate antibiotics.
  • Differentiating UTIs into simple (uncomplicated) and complicated using the European Association of Urology’s ORENUC classification aids inappropriate clinical management for better patient outcomes.
  • Simple lower-tract UTIs can be treated with appropriate oral antibiotics with no need for urine culture.
  • Outpatient treatment for acute pyelonephritis may be associated with a significant failure rate. Such patients should have a urine culture performed and require close follow-up.
  • A complicated UTI is an infection associated with a condition, such as a structural/functional abnormality of the genitourinary tract or the presence of an underlying disease, which increases the risk of the UTI having an outcome that is more serious than expected when compared to individuals without an identified risk factor; such patients would benefit from a urological review and close follow-up.
  • All males with a UTI and all infants aged under three months with a possible UTI should be reviewed by a urologist.

 

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