II. Causes

  1. Infection
    1. Urinary Tract Infection (E. coli >75% of cases, and the rest Enterobacteriaceae)
      1. Pyelonephritis
      2. Acute Cystitis
    2. Urethritis (Gonorrhea and Chlamydia)
    3. Prostatitis (Enterobacteriaceae)
    4. Epididymitis and Orchitis (Enterobacteriaceae, Mumps)
    5. Meatitis and Urethritis (HSV II infection)
    6. 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

III. 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. Penile discharge suggests Urethritis (STD)
    1. Gonorrhea
      1. Oropharygeal exudates, anal sex
    2. Chlamydia
  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 coverage
    1. Azithromycin 1 gram orally for 1 dose or
    2. Doxycycline 100 mg orally twice daily for 7 days
  2. Gonorrhea coverage (consider waiting for results if low Prevalence in community)
    1. Ceftriaxone 250 mg IM
    2. Cefixime (Suprax) is not recommended due to increasing resistance
      1. Previously dosed at 400 mg orally for 1 dose
  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

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