Dysuria

at the bedside

airway, breathing, circulation; full vitals; IV access if febrile or unwell
four questions → new or pre-existing dysuria; systemically unwell (fever, rigors, tachycardia, hypotension, new confusion); catheter, stent or nephrostomy in place; already on antibiotics, and what previous cultures grew
pregnancy test → when relevant and the status is uncertain, not automatic

escalate now if

fever with hypotension, tachycardia or confusion → urosepsis: antibiotics within the hour, treating team now → systemic UTI
fever with flank pain, CVA tenderness or vomiting → pyelonephritis
fever with known stones, hydronephrosis, a single or transplant kidney → infected obstructed kidney → urology now
pregnant with fever → urgent obstetric and medical assessment, IV antibiotics and monitoring → systemic UTI
man with fever and perineal or rectal pain → prostatitis
cannot void or suprapubic fullness (bladder scan), or urine output falling → urinary retention, anuria / oliguria

cystitis → dysuria, frequency, urgency, suprapubic pain; no fever
pyelonephritis → fever, flank pain, CVA tenderness, vomiting
catheter-related → spasm, traction, recent insertion or removal; CAUTI only with fever or flank pain, bacteriuria alone is not infection
prostatitis → fever, perineal pain, obstructive symptoms, tender boggy prostate
urethritis / STI, vaginitis → discharge, new partner, itch, external dysuria, pyuria with a negative culture
not infection → stones, interstitial cystitis, irritants, atrophic changes, cyclophosphamide

recent antibiotics and prior cultures → what is running and since when; antibiotics in the last 3 months; what grew before and its susceptibility (ESBL, Pseudomonas, Enterococcus)
symptoms and history → onset; hematuria, discharge, hesitancy in men; stones, instrumentation, diabetes, immunosuppression
catheter-related dysuria → recent insertion or removal, traction, bladder spasm, obstruction, local irritation: discomfort without infection
exam → suprapubic and flank tenderness, palpable bladder; genital exam if discharge or ulcers; gentle DRE if prostatitis is possible, no prostatic massage

stable new dysuria → urinalysis; culture by context and local policy (men, pregnancy, recurrence, recent antibiotics or ESBL history), before the first dose; NAAT if STI is possible
catheterized → aseptic sample from the sampling port or a new catheter, never the bag; dipstick alone does not diagnose CAUTI
fever, rigors or flank pain → CBC, RFT and electrolytes, CRP, lactate, blood and urine cultures: a sepsis work-up → fever
suspected obstruction or AKI → bladder scan and renal ultrasound tonight; CT KUB if stones are suspected or no cause on ultrasound
persistent dysuria on antibiotics → review the cultures, susceptibility, dose and route, the catheter, and the other diagnoses
pyuria or a positive culture without a compatible syndrome is not an antibiotic indication; a negative nitrite does not exclude UTI

complicated → IDSA 2025 treatment classification: spread beyond the bladder; a catheter, stent or nephrostomy still matters; diabetes, immunosuppression and male sex raise resistance risk, not the category

stable isolated dysuria

cystitis likely → after reviewing drugs, catheter history, urinalysis and prior cultures: one narrow-spectrum oral agent by renal function and prior susceptibility; nitrofurantoin 100 mg PO q12h × 5 d (not if CrCl < 30); TMP-SMX DS 1 tab PO q12h × 3 d if local resistance is low; fosfomycin 3 g PO once; men 7 days, culture first
paracetamol 1 g PO QDS, max 4 g/day, less if under 50 kg, frail or liver disease; NSAID only if renal function allows → analgesia

systemic UTI or pyelonephritis

start → sepsis assessment, blood and urine cultures, then ceftriaxone 1 g IV q24h; septic, prior ESBL or recent broad antibiotics → ceftriaxone is not the default: ertapenem 1 g IV q24h or piperacillin–tazobactam 4.5 g IV (over 4 h) q8h → empiric antibiotics
then → ultrasound tonight for obstruction (hydronephrosis with fever → urology now); IV to oral once improving, drinking and an active oral agent is on the culture; 5 to 7 days is usually enough if improving on effective therapy, individualize for prostatitis, obstruction, abscess or delayed response; nitrofurantoin and single-dose fosfomycin are inappropriate for systemic UTI
pregnant → as in escalate now; obstetrics guides the agent and duration

catheter-related symptoms

irritation, spasm, not draining → reposition and secure, treat the pain; bladder scan, flush or replace if blocked; no antibiotic → urinary retention
suspected CAUTI → fever, rigors, flank or suprapubic pain, or new confusion with no other cause: remove the catheter if no longer needed, replace it if in place > 7 days; sample from the port or the new catheter before antibiotics, without delaying antibiotics in sepsis for the replacement; treat as systemic UTI (a bladder-active oral only for selected lower CAUTI), reassess the IV route at 48 h; never treat bacteriuria alone

acute bacterial prostatitis

culture, then fluoroquinolone or TMP-SMX for 2–4 weeks, adjusted to the culture; septic → IV as for systemic UTI; no prostatic massage; retention → urology (suprapubic catheter preferred)

dysuria without convincing UTI

asymptomatic bacteriuria → no antibiotics (exceptions: pregnancy, before a urologic procedure); confusion or a fall with bacteriuria only → look for another cause → delirium
urethritis / STI → local STI guidance; vaginitis → gynecology; irritation, spasm, stones, interstitial or drug-induced cystitis → no antibiotic

urology now if

hydronephrosis with fever (decompression by nephrostomy or stent within hours, antibiotics alone are not enough); gas on imaging; renal, perinephric or prostatic abscess; infected obstructing stone; a single or transplant kidney; failed or traumatic catheterization; clots → hematuria

shock → hypotension, advanced: shock, ICU
reassess and hand over → symptom progression, vitals, urine output, response; pending cultures; the catheter plan; antibiotic review when susceptibilities return and IV to oral step-down for the treating team

source	type
IDSA 2025 · Complicated Urinary Tract Infections ↗︎	international guideline
NICE NG113 · Catheter-associated UTI ↗︎	national guideline
IDSA 2019 · Asymptomatic Bacteriuria ↗︎	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 Oct 2026file complaint/dysuria