Dysuria
ABCs
- check vitals
- systemic features: fever, tachycardia, hypotension → suspect sepsis
- β-hCG in reproductive-age women
upper tract / sepsis
- fever, tachycardia, hypotension
- flank pain, CVA tenderness, nausea/vomiting → pyelonephritis
- pregnancy with pyelonephritis → admit: IV antibiotics + monitoring
- fever + known obstruction → urological emergency: decompression + antibiotics
escalation / referral
- persistent symptoms despite treatment
- hemodynamic instability or sepsis → shock management
- male with systemic features → consider prostatitis, complicated UTI
- consider: complicated UTI, pyelonephritis, nephrolithiasis, obstruction, retention, anatomical abnormality
- Urology consult if needed (stones, malignancy, instrumentation, failed decompression)
HPI & examination
- urinary symptoms
- dysuria, urgency, frequency, suprapubic pain
- hematuria, cloudy or malodorous urine
- LUTS (especially men): hesitancy, weak stream, dribbling
- upper UTI features
- flank pain, fever, nausea/vomiting
- suggestive of STI / urethritis
- discharge, pruritus, genital ulcers
- consider vaginitis
- vaginal discharge, pruritus, or odor predominating over urinary symptoms → candidiasis, BV, atrophic vaginitis
- non-infectious causes
- interstitial cystitis, chemical irritants (douches, spermicides), postmenopausal atrophic changes
- PMH & risk factors
- recurrent UTIs, STIs, nephrolithiasis, GU instrumentation
- diabetes, immunosuppression, pregnancy, recent antibiotic use
- examination
- abdomen: suprapubic tenderness, flank tenderness
- CVA tenderness → suggests pyelonephritis
- genital exam (if indicated): discharge, ulcers, rash
- DRE if prostatitis suspected: tender, boggy prostate; do not massage in acute bacterial prostatitis
workup
- urine dipstick: typical cystitis + positive dipstick in non-pregnant woman may suffice without culture
- urine culture: send for pyelonephritis, complicated UTI, recurrent infections, pregnancy, men, treatment failure, atypical presentation
- CBC, CRP
- blood cultures, lactate, RFT → if febrile or septic
- NAAT for gonorrhea/chlamydia if STI suspected
- catheter present → change catheter first, then send sample
imaging (if indicated)
- CT KUB or renal ultrasound if: suspected nephrolithiasis, no improvement on antibiotics, pyelonephritis with fever beyond 48–72 h, recurrent UTIs, suspected obstruction
management
- oral hydration; IV fluids if needed
- is it complicated: complicated = spread beyond the bladder (fever, rigors, flank pain, CVA tenderness, systemic upset), not comorbidities
- diabetes, immunosuppression, or BPH with isolated cystitis = still uncomplicated
- catheter, stent, or nephrostomy does count as complicating
uncomplicated cystitis
- nitrofurantoin 100 mg PO q12h × 5 d
- fosfomycin 3 g PO single dose
- TMP-SMX 960 mg PO q12h × 3 d (avoid if local resistance high or used in last 3 months)
complicated UTI or pyelonephritis
- outpatient pyelonephritis: non-pregnant, non-septic, tolerating oral, no obstruction, reliable follow-up → oral antibiotics per culture; see empiric antibiotics
- admit if: septic, vomiting, pregnant, obstructed, immunocompromised, or uncertain diagnosis
- ceftriaxone 1–2 g IV daily as the usual empiric start; tailor by severity, recent antibiotics, previous cultures and any prior ESBL / resistant organism, healthcare exposure, obstruction, renal function, local antibiogram
- fluoroquinolone no longer automatic first choice: check local resistance and fluoroquinolone use in past 12 months
- IV → oral once all of: improving · hemodynamically stable · tolerating oral · active oral agent on susceptibility · source control adequate
- do not wait for an arbitrary afebrile period
- duration: total 5–7 days (7 d for non-fluoroquinolone regimens, including Gram-negative bacteremia)
- most improving patients do not need 10–14 days
- longer only for: undrained obstruction/abscess, inadequate source control, slow response, prostatitis, persistent bacteremia
- nitrofurantoin and fosfomycin do not treat complicated UTI or pyelonephritis: no renal parenchymal or blood penetration
- infected obstructed system → antibiotics alone insufficient: urgent decompression (Urology) required
prostatitis
- acute bacterial prostatitis: do not massage prostate (bacteremia risk)
- fluoroquinolone or TMP-SMX for 2–4 weeks (good prostatic penetration); guide by culture
- Urology referral if abscess suspected, or recurrent/chronic prostatitis
not a UTI, or special groups
- do not treat asymptomatic bacteriuria: positive culture without urinary symptoms or systemic signs is not a UTI
- exceptions: pregnancy, before endoscopic urologic procedure
- pyuria alone does not separate infection from colonization
- confusion or fall with bacteriuria alone → look for another cause
- pregnancy: asymptomatic bacteriuria must be treated (4–7 days); avoid TMP-SMX around the first trimester and near term; nitrofurantoin at term varies by local policy, cross-check
- STI / urethritis (NAAT sent above) → treat per local STI guidelines; sexual health referral + contact tracing
- symptomatic: paracetamol 1 g PO/IV q6h; NSAID if needed but avoid in renal impairment or AKI
- full empiric regimens → empiric antibiotics by source
evidence
| source | type |
|---|---|
| IDSA 2025 · Complicated Urinary Tract Infections ↗︎ | international guideline |
| IDSA/ESCMID 2010 · Uncomplicated Cystitis and Pyelonephritis ↗︎ | international guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
reviewed Aug 2026updated Sep 2026file complaint/dysuria