Dysuria (men)

1.  A man presents with acute dysuria.  Obtain a UA for Leukocyte Esterase:
  • Pyuria and STD risk:    Test, & Tx empirically, for GC & CT
  • Pyuria, 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, “6 weeks of antibiotic is the most anyone should take.”
  • Provide psychological support