UBC Objectives: Care of Men, Priority Topic: Dysuria, Priority Topic: Prostate, & Priority Topic: Sexually Transmitted Infections

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Screen, diagnose and treat sexually transmitted infections, including managing or referring for contact tracing and supportive counselling
  

Dysuria

Key Feature 1: In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis

Key Feature 2: When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Key Feature 3: Consider non-urinary tract infection related etiologies of dysuria (ex: prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 4: When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (ex: pregnancy, children, diabetes, urolithiasis).
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation

Key Feature 5: In patients with recurrent dysuria, look for a specific underlying cause (ex: post-coital urinary tract infection, atrophic vaginitis, retention).
Skill: Clinical Reasoning
Phase: Hypothesis generation

Prostate

Key Feature 7a: In patients presenting with specific or non-specific urinary symptoms: Identify the possibility of prostatitis.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 7b: In patients presenting with specific or non-specific urinary symptoms: Interpret investigations (ex: urinalysis, urine culture-and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.
Skill: Clinical Reasoning
Phase: Diagnosis, Investigation

Sexually Transmitted Infections

Key Feature 2a: In a patient with symptoms that are atypical or non-specific for STIs (ex: dysuria, recurrent vaginal infections): Consider STIs in the differential diagnosis.
Skill: Selectivity, Clinical Reasoning
​Phase: Hypothesis generation

Key Feature 2b: In a patient with symptoms that are atypical or non-specific for STIs (ex: dysuria, recurrent vaginal infections): Investigate appropriately.
Skill: Clinical Reasoning, Selectivity
Phase: Investigation

UTIs are extremely common, and quite frankly the discomfort is sucky. Usually they're uncomplicated, presenting with the classic symptoms of dysuria with increased urinary frequency and urgency along with suprapubic pain. Sometimes there is also hematuria. What would make such a presentation "complicated" would be any of the following 3 things:

1. The patient is pregnant
2. The patient has constitutional symptoms
3. The patient has flank pain

In such a classic presentation, all it takes is a urine dipstick test, easily done in real-time in the office, to confirm this diagnosis (or raise the question about other etiologies instead; if you are unsure based on history whether a patient is pregnant, you can also dip the urine for B-hCG at this time). Positive indicators in keeping with a presumed diagnosis of UTI would be a urine dipstick result that is (+) for nitrites +/or leukocyte esterase. If the urine dip is not positive for either of these, this does not absolutely rule out a UTI, but it does make it less likely, and the urine should be sent for culture and sensitivity to confirm or refute a diagnosis of uncomplicated UTI. 

I have pretty well always seen the doctors I work with in clinic do a urine dip to look for the above supporting evidence for a UTI when clinically suspected. According to UpToDate, it is not always necessary, if patients presents with very classic symptomatology and are a healthy female with no other risk factors, to do any testing at all, including a urine dipstick test in the clinic. Testing is typically low yield in this situation. In such a setting, empiric treatment and follow-up if there is not quick improvement can be totally appropriate, but again, this is when it is uncomplicated and the suspected likelihood of something else on the differential is very low. Patient with risk factors for complications for whom you should always get a urinalysis and urine culture and sensitivity include children and patients with diabetes mellitus. In any case, even if a urine dip is done and suggests UTI +/- the urine being sent for culture (which should be done if the dip is not supportive of a clinically suspected UTI, in patients with risk factors for unusual infectious causes, when the possibility of different diagnoses responsible for the symptoms are on the table, or when symptoms have not completely responded to empiric antibiotics), treatment is empirically initiated when suspected clinically. 

The reason we test the urine is to confirm our suspected diagnosis, or find out that perhaps there is something else going on. Dysuria doesn't necessarily mean a patient has a UTI, even though this is certainly the most common reason. Other reasons for dysuria include sexually transmitted infection*, non-infectious urinary tract inflammation (ex: chemical irritation), and causes of dysuria that are outside the urinary tract (ex: vaginitis). Also, the patient could have a UTI, but a more complicated type, such as prostatitis in a male (urinalysis would also suggest UTI, urine C&S/NAAT/swab of any discharge would also be expected to grow a microbial isolate, but DRE would be expected to reveal a boggy and tender prostate, unlike with a simple UTI in which you would expect prostate examination to be fairly unremarkable), or as a complication of urolithiasis. Reasons on history for which you would consider these other diagnoses may be a complaint of genital discharge or pruritus, risk factors for an STI, a failure of empiric antibiotic therapy or relapsing symptoms, or any other features that are outside of the classic uncomplicated UTI symptomatology, such as colicky flank pain or pain at the tip of the penis (symptoms that raise suspicion for urolithiasis). Also consider other diagnoses if the patient appears unwell, is febrile, or has costovertebral tenderness on examination, all features that go beyond what we would expect in a patient with  an uncomplicated UTI. If a patient has risk factors and has a presentation in keeping with a possible STI, empiric treatment should strongly be considered while awaiting results of confirmation. If confirmed, public health needs to be notified, and follow-up is warranted for further counselling. It is also prudent to screen patients for STIs regardless of whether or not they are symptomatic if they continue to have sexual risk factors for acquiring an STI.

If a patient does have an uncomplicated UTI, and if it is part of a pattern of recurrent UTI (defined as 2 or more UTIs within 6 months, or 3 or more episodes within a year), it is important to asses why this might be happening, and to offer up some strategies to try to prevent recurrence going forward. This is largely informed by the demographic the patient falls within, with  common reasons being common, as well as by individual patient factors such as known disease that may suggests a reason for the recurrence, such as urinary retention from benign prostatic hypertrophy in an older male. In females who are sexually active, sexual activity is a common precipitating factor for UTI, so they should be given advice to void urine after sex. Postmenopausal changes also lead to an increased frequency of UTI, so a trial of vaginal estrogen may be offered for these women. All people should be counselled to drink enough fluid such that they are voiding urine regularly (a rule of thumb I've heard a doctor tell people was to drink enough so that your urine is clear), which helps to flush out bacteria that sit around for too long and start to multiply and lead to infection. Sometimes people want to know if there are any natural supplements they can take. There is some evidence that cranberry can help (some women will swear by the fact that drinking cranberry juice significantly helps with the symptoms of a UTI), so taking prophylactic cranberry pills is an option. Another option, albeit with even less evidence but little risk of harm (expect to the wallet) is to try prophylactic probiotic supplements. However, if a patient continues to have recurrent UTIs, it's probably safe to say it's a waste of their money. For those patients who continue to have recurrent UTIs despite the recommendations above, and who have no known reversible reason to address, they may be considered for prophylactic antibiotics, such as a one-time dose taken immediately after sex, or on daily basis. Given concern for antibiotic resistance, however, this would be a last resort.

*Diagnostic investigations for chlamydia and gonorrhea:

• Patients can collect a self-swab of discharge if present and feasible, which is sent for culture and sensitivity
• When there is no overt discharge (ex: in a patient whose presenting complaint is dysuria without associated discharge), then a cervical swab can be collected in women, which is sent for culture and sensitivity
• A dirty first-catch urine sample (meaning the patient hasn't cleaned the area first, and the urine captured should be what comes out first) can also be collected for screening purposes, but diagnostically it isn't as useful because it doesn't provide an antibiotic sensitivity profile, which is useful if there is a failure of therapy