Dysuria in Men

Aka: Dysuria in Men, Urethitis in Men

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II. Causes

  1. Infection
    1. Urinary Tract Infection (E. coli >75% of cases, and the rest Enterobacteriaceae)
      1. Pyelonephritis
      2. Acute Cystitis
    2. Urethritis
      1. Neisseria gonorrhoeae or Gonorrhea (213 cases per 100,000 U.S. men in 2018)
      2. Chlamydia trachomatisUrethritis (381 cases per 100,000 U.S. men, most common cause of Urethritis)
      3. Mycoplasma Genitalium (1-3% of Non-Gonococcal Urethritis, esp in Gay Men, younger, smokers, multiple partners)
      4. Trichomonas vaginalis (0.5% in men, but up to 10% in high STD Prevalence areas, older men, jail, multiple partners)
      5. Genital Herpes or HSV II infection (Meatitis and Urethritis)
    3. Prostatitis (Enterobacteriaceae)
    4. Epididymitis and Orchitis (Enterobacteriaceae, Mumps)
    5. Balanitis
  2. Obstructive Uropathy
    1. Benign Prostatic Hypertrophy
      1. May also predispose to Urinary Tract Infection
    2. Urethral Stricture
      1. Urethral instrumentation
      2. Prior Gonorrhea infection
  3. Miscellaneous Causes
    1. Prostadynia
  4. Non-gender specific causes
    1. See Dysuria
    2. Trauma

III. Findings: Symptoms and Signs

  1. See related conditions
    1. Urinary Tract Infection
      1. Hematuria, frequency, nitrite positive
    2. Pyelonephritis
      1. Fever, Flank Pain, White Blood Cell Casts
    3. Prostatitis
      1. Prostatic tenderness
    4. Epididymitis or Orchitis (consider Testicular Torsion)
      1. Unilateral tenderness, swelling at epididymis
  2. Mucopurulent Urethral discharge suggests STD Urethritis
    1. Gonorrhea
      1. Oropharygeal exudates, anal sex
      2. Symptomatic in 90% of cases
    2. Chlamydia
      1. Slightly more than half are symptomatic
  3. Penile Lesion present
    1. Vesicles: Genital Herpes
    2. Ulcer: See Genital Ulcer
      1. Chancroid (painful ulcer, associated inguinal adenopathy)
      2. Genital Herpes (painful ulcer)
      3. Syphilis (painless ulcer)
    3. Glans irritation: Balanitis
  4. Scrotal Pain
    1. Epididymitis
    2. Orchitis
  5. Perineal or Rectal Pain or Prostate pain on palpation
    1. Prostatitis
    2. Prostadynia

IV. Evaluation

  1. Labs in all patients
    1. Urinalysis with microscopy
    2. Urine Culture
  2. Sexually active patient
    1. If obtaining STD testing via PCR probe from urine
      1. Void into non-sterile cup (without cleaning tip of penis)
      2. Stop, clean tip of penis with wipe
      3. Void into sterile cup for Urinalysis and Urine Culture
    2. Routine PCR swab for Gonorrhea and Chlamydia (from "dirty" urine or Urethra)
    3. Urethral discharge
      1. Urethral smear for diplococci (Gonococcus)
      2. Urethral culture
    4. Offer other STD Testing (blood testing)
      1. Rapid plasmin reagin (RPR) or VDRL
      2. Human Immunodeficiency Test (HIV)
      3. Hepatitis B Testing (HBsAg)
  3. Symptoms of Prostatitis
    1. Consider Expressed Prostatic Secretion exam (rarely done)
    2. Do not perform Prostatic Massage in Acute Prostatitis

V. Management: General Approach when STD unlikely

  1. Treat underlying condition
  2. Antibiotic selection based on likely source of infection
    1. Urinary Tract Infection
      1. Treat Urinary Tract Infections for 7 days in men
      2. If Prostatitis is considered a possible source, avoid Nitrofurantoin, fosfomycin and beta-lactams
    2. Acute Prostatitis
    3. Epididymitis
  3. Consider topical or systemic genitourinary irritants (see Dysuria and Dysuria in Men)
  4. Consider imaging and/or Consultation
    1. Persistent Hematuria without pyuria (e.g. CT Urogram, Cystoscopy)
    2. Urine Culture confirmed Urinary Tract Infection (e.g. post-void residual, renal/Bladder Ultrasound)
  5. Recurrent Urinary Tract Infection
    1. Consider BPH as cause of Recurrent UTI (related to Urethral obstruction)
    2. Consider Chronic Prostatitis as cause of Recurrent UTI with same organism

VI. Management: Empiric for sexually active patients with risk of STD

  1. Chlamydia management
    1. Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
    2. Azithromycin 1 g orally for 1 dose
  2. Gonorrhea management
    1. Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
    2. Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
    3. Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
  3. Recurrent symptoms with same partner (cover Trichomonas and Ureaplasma)
    1. Drug 1: Metronidazole 500 mg orally daily for 5 days AND
    2. Drug 2: Choose one of the following
      1. Azithromycin 500 mg orally once daily for 5 days or
      2. Doxycycline 100 mg once daily for 7 days
  4. References
    1. Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
      1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm

VII. References

  1. (2019) Sanford Guide, accessed on IOS 9/22/2019
  2. Brill (2010) Am Fam Physician 81(7): 873-8 [PubMed]
  3. Kurowski (1998) Am Fam Physician 57(9): 2155-64 [PubMed]
  4. Michels (2015) Am Fam Physician 92(9): 778-86 [PubMed]
  5. Roberts (1999) Am Fam Physician 60(3): 865-72 [PubMed]
  6. Sell (2021) Am Fam Physician 103(9): 553-8 [PubMed]

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