Dysuria

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Dysuria

ABCs
  • check vitals
  • screen for systemic features: fever, tachycardia, hypotension → consider systemic infection / sepsis
red flags
upper tract / sepsis
  • fever, tachycardia, hypotension
  • flank pain, CVA tenderness, nausea / vomiting → pyelonephritis
HPI & examination
  • urinary symptoms
    • dysuria, urgency, frequency, suprapubic pain
    • hematuria, cloudy or malodorous urine
    • LUTS (especially in men): hesitancy, weak stream, dribbling
  • upper UTI features
    • flank pain, fever, nausea / vomiting
  • suggestive of STI / urethritis
    • discharge, pruritus, genital ulcers
  • 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 in males: tender prostate → prostatitis
workup
  • urine R/M and culture
  • CBC, CRP
  • blood cultures, serum lactate, RFT → if febrile or septic
  • β-hCG if indicated
  • STI testing if suspected
  • if catheter present → change catheter first, then send urine sample
imaging (if indicated)
  • CT KUB or renal ultrasound if: suspected nephrolithiasis, no improvement, red flags for pyelonephritis, recurrent UTIs, known anatomical abnormalities
management
  • encourage oral hydration; consider IV fluids if needed
  • empirical antibiotics
    • uncomplicated cystitis → nitrofurantoin 100 mg PO q12h ×5 d, OR fosfomycin 3 g PO single dose, OR TMP-SMX 960 mg PO q12h ×3 d
    • complicated UTI / pyelonephritis → levofloxacin 750 mg PO/IV q24h OR piperacillin-tazobactam 4.5 g IV q6h; oral switch when afebrile 48 h; 7–14 days
    • full empiric regimens → empiric antibiotics by source
  • symptomatic treatment: paracetamol 1 g PO/IV q6h ± NSAID; catheter present → change before sampling; prostatitis → longer course per urology
escalation / referral
  • persistent symptoms despite treatment
  • hemodynamic instability
  • consider: complicated UTI, pyelonephritis, prostatitis, nephrolithiasis, obstruction / urinary retention, anatomical abnormality
  • Urology consult if needed (stones, malignancy, instrumentation)
see also, MOC+ Volume 1: Acute Infections covers UTI, pyelonephritis and complicated urinary infections in depth. browse the library.
related hematuria · urinary retention · anuria / oliguria · fever
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

Last reviewed · May 2026

MOC