NO DRUG THERAPY IN PRIMARY CARE (ASSESS FIRST)
Dysuria is a symptom, not a diagnosis. In a non-pregnant woman with frequency and urgency and no vaginal discharge, cystitis is likely enough to treat on the history. Otherwise think again: vaginal discharge points to vaginitis or a sexually transmitted infection, flank pain and fever to pyelonephritis, and in a man dysuria is urethritis or prostatitis until proved otherwise. Ask about pregnancy every time. - Assess, then decide
Dysuria in an infant under 3 months, or with fever at any age, needs urgent assessment. Send the urine for culture before starting antibiotics, not after, and remember that urinary infection in a young child warrants thought about reflux.
No dose - assessment step, no medicine given
Treating every dysuria as cystitis is how chlamydia is missed in young women and how pyelonephritis gets sent home with a short course of tablets.
- Pregnancy changes the whole approach: asymptomatic bacteriuria is treated, a culture is always sent, and nitrofurantoin is avoided at term.
- Fever, rigors, flank pain or vomiting is pyelonephritis, not cystitis. That needs a culture and a different, longer antibiotic course.
- In a man, and in recurrent infection in a woman, send a urine culture rather than treating blind.
- Dysuria with a new sexual partner, urethral or vaginal discharge, or pelvic pain: test for chlamydia and gonorrhoea, and treat the partner.
- Visible blood in the urine that persists after the infection has been treated needs investigating for bladder cancer, particularly in a smoker over 45.
- Sterile pyuria - white cells with no growth - should raise chlamydia, and in Egypt also urinary tuberculosis and schistosomiasis.
- RED FLAG - Hematuria accompanying dysuria can signal urological obstruction from a stone or tumor and warrants further evaluation rather than empiric antibiotic treatment alone.