Dysuria in Men

Vastly different from last post (Dysuria in Women), because men rarely get typical UTIs from E. coli or other enteric bacteria.  But they do get genital tract illness, which in males is shared with the urinary tract.  You can schematize the differential anatomically:

            •  Urethra                    •  Testis           •  Bladder
            •  Epididymis              •  Prostate        •  Kidney
 

Since pathogens are the same, I find it more useful to distinguish among:

  • STD
  • E. coli / other enteric UTI
  • “Prostatitis”

WARNING —  In my experience, it’s not unusual for men to present with intermittent burning on urination that doesn’t seem compatible with any pathology.  They describe it as occurring perhaps 1-2 times a day at most, or not every day.  No infection of any kind happens as such.

An uncircumcised male might have smegma temporarily stick to the meatus; anyone might have a drop of ejaculate remain.  I bet there’s a certain male fear that any sense of dysuria might be an STD (especially among those with reason to worry), or portend imminent impotence.  If an initial dipstick UA is negative for leukocyte esterase (i.e. no pyuria), I reassure them by saying, “Burning on urination is common; lots of men get it now & then.”

So let’s say a man complains of recent onset persistent dysuria.  In terms of the intricacies of interpreting the UA & the C&S, see prior posting “Dysuria in Women.”

Pyuria

Assuming the patient doesn’t look sick [see below], send him for a dipstick UA.  If it’s positive for Leukocyte Esterase, assume an STD.  This is because 1) men rarely get typical E. coli UTIs; and 2) there’s no concern that vaginal contamination is interfering.

Confirm your suspicion of likely STD by history.  Test by urine probes, & treat empirically, for Gonorrhea (GC) and Chlamydia trachomatis (CT).  Note that I obtain the UA before exploring a sexual history.  If I seek the latter first, I occasionally obtain a “false-negative history,” which is harder to reverse than if I have a UA in hand (“The urine shows an infection; it could well be an STD.  Who have you had sex with…?”).

What if the patient adamantly denies any risks for STDs?  Test anyway, explaining that the germs can linger asymptomatically for a long time.  Certainly send a standard Urine C&S too; there’s pyuria, after all.  Treat empirically with Doxycycline 100 mg B.I.D. x7 days:

  • CT is much more likely to present late than is GC
  • Doxy also covers lots GC (non-resistant strains)
  • Doxy also covers lots of E. coli

Men can present quite ill from the very rare acute orchitis or prostatitis.  They usually require hospitalization for IV antibiotics.  But these patients hurt all over the perineum; they don’t come in just complaining of “dysuria” per se [today’s topic].

No Pyuria

What if the initial UA is negative for pyuria?  Still test for the STDs, but don’t treat empirically.  Maybe obtain a urine C&S for bacteria (poor specificity in the absence of pyuria, but possible in prostate infections).

And if all your tests are negative, and the dysuria persists?  There are some rare, stretch-of-the-imagination possibilities like:

  • passage of renal / bladder stones (should see hematuria, or crystaluria on microscopic UA; the dysuria is definitely penile, not suprapubic)
  • penile masses (palpate the penis; inquire about new focal symptoms during erection)
  • meatal / urethral lesions (examine the meatus; seek very localized penile pain)
  • reactive arthritis [formerly Reiter’s Syndrome] (oligoarthritis is a main complaint)

Supposing none of the above seem likely, we enter the realm of…

“Chronic Prostatitis”

In quotes, because there’s no gold standard for the condition, and it may even have nothing to do with the prostate.  As such, some sources combine the diagnosis as “Chronic Prostatitis / Chronic Pelvic Pain Syndrome”.  An older term, “prostadynia,” sounds embarrassingly archaic.  Still, the entity may be common, with major quality-of-life implications.

Since this diagnosis is “Chronic,” its definition implies symptoms persisting >6 weeks.  Studies, including cultures of prostate secretions & biopsies, have found no association with any bacteria, including Ureaplasma or Mycoplasma.  As such, I try real hard to avoid giving antibiotics.

However, there is some suggestion that combining an antibiotic (specifically ciprofloxacin) plus an alpha blocker (doxazosin, terazosin, tamsulosin, etc.) is modestly statistically helpful for Chronic Prostatitis.  The conventional course is 6 weeks.  Long-term antibiotics make me uncomfortable, but I’m willing to bite the bullet, because I know Urology will start right out with it.  However, I do delay until I see that dysuria has persisted a full 6 weeks to justify the diagnosis.

Then we’re stuck with the dilemma of what to do at the end of therapy, when symptoms may inconveniently recur.  Certainly don’t continue the antibiotic (6 weeks is more than enough), but keep the alpha-blocker going indefinitely.  Bail out to Urology if the patient insists “only the Cipro works,” or if treatment hadn’t helped in the first place.

In men >50, of course there’s LUTS.  This is such a nice abbreviation that I’ve announced it before defining it: “Lower Urinary Tract Symptoms.”  It’s being used in place of “BPH” (formerly “Benign Prostatic Hypertrophy”, with the “H” now changed to mean “Hyperplasia”).  LUTS is so neat & all-encompassing that nobody can argue with it.

But Dysuria is a minor feature of LUTS, overshadowed by other voiding symptoms such as hesitancy, straining to urinate, slow stream, and dribbling at end of void.  If these are present, also inquire about nocturia, frequency, & urge incontinence, which suggest possibility of retention.  Standard treatment for LUTS (or BPH, if you will) involves an alpha-blocker, maybe a 5-alpha reductase inhibitor (e.g. finasteride) if the prostate is palpably enlarged (but can take up to a year to work, and impairs fertility).

SUMMARY

1.  A man presents with acute dysuria.  Obtain a UA for Leukocyte Esterase:
  • Pyuria and STD risk: Test, & Tx empirically, for GC & CT
  • Pyuria but no STD risk:  Test for GC, CT, & Urine C&S.  Give Doxycycline
  • No Pyuria, but yes for STD risk:  Test for GC & CT
  • No Pyuria:  Reassure there’s “no infection”
2.  Patient returns with persistent Dysuria (above tests, if done, are negative)
  • Repeat the UA (still no pyuria)
  • Examine genitals, perineum, & prostate carefully for focal lesions (none)
  • Send a Urine C&S, GC & CT if haven’t yet
  • Suggest an NSAID (“anti-inflammatory”)
  • Return in 2 weeks if not better (telephone results if positive)
3.  Dysuria persists, tests are negative (it’s 3-4 weeks now)
  • Repeat the UA (still no pyuria)
  • Reassure “no infection!”
  • Give an alpha-blocker
  • Return in 2-3 weeks
4.  Dysuria persists (now 6 weeks = “Chronic Prostatitis”)
  • Add ciprofloxacin to the alpha-blocker
  • Promise a Urology referral if it doesn’t work
  • Explain that Urology would simply try the same Tx
  • Casually mention that “6 weeks of antibiotic is the most anyone should take.”
  • Provide psychological support

And that’s it for the burning issue of “dysuria”.

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