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Infectious causes of dysuria in adult men
Authors
Heidi Swygard, MD, MPH
Myron S Cohen, MD
Arlene C Seña, MD, MPH
Section Editor
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor
Barbara H McGovern, MD
Literature review current through: Jun 2012. |This topic last updated:Ιαν 14, 2011.
INTRODUCTION — Dysuria in men (described as pain, tingling, or burning during or just after urination) may be localized to the urethral meatus, the distal portion of the penis, or anywhere along the penile shaft. Dysuria in men may be a presenting complaint of urethritis, prostatitis, epididymitis, or urinary tract infections.
Urethritis is more commonly seen in young sexually active men, whereas urinary tract infections occur in older men with prostatic hypertrophy or history of prior catheterization. Dysuria is also reported in the majority of men with symptomatic gonorrhea and over half of patients with nongonococcal urethritis (NGU).
Both acute and chronic prostatitis can occur in young and middle-aged men. Chronic prostatitis can occur as a complication of acute prostatitis or without any recognized initial infection. Urethral instrumentation and prostatic surgery are known causes of prostatitis, but many patients have no history of a precipitating event.
Isolated acute cystitis does not commonly occur in men. The much lower incidence of cystitis is men, compared to women, has been attributed to less frequent colonization around the urethra due to the drier periurethral environment, increased length of the urethra, and antibacterial substances in prostatic fluid. Most men with acute cystitis have a functional or anatomic abnormality. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
Acute bacterial epididymitis is a relatively rare disease, but can cause serious illness. It can be seen in conjunction with acute prostatitis, particularly in older men who may have underlying prostatic obstruction or recent instrumentation as a risk factor. Acute epididymitis can also be due to a sexually acquired infection.
HISTORY — A thorough sexual history should be obtained from all patients with dysuria. (See "Screening for sexually transmitted diseases", section on 'Taking a sexual history'.)
Painful urination is usually the chief complaint in men with urethritis. They may also complain of pruritis or discharge at the urethral meatus. Discharge may be present throughout the day or may be scanty and only present on the first morning void.
Some general principles can suggest different etiologies of urethritis secondary to sexually transmitted diseases:
   Since the incubation period for gonorrhea is shorter (less than two weeks) than for chlamydia (which has a variable onset of 2 to 35 days), a urethral discharge that is described as acute and frankly purulent is suggestive of gonorrhea.
   Patients with dysuria alone are more likely to have chlamydial infection.
   Dysuria that is accompanied by painful genital ulcers is probably due to genital HSV; patients with primary HSV infection may also complain of fever, tender local inguinal lymphadenopathy, and headache.
Detailed information regarding these infections is available elsewhere. (See "Genital Chlamydia trachomatis infections in men" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Diagnosis of gonococcal infections" and "Treatment of urogenital gonococcal infections".)
The typical signs and symptoms of acute bacterial prostatitis are similar to upper urinary tract infection and include fever, chills, malaise, myalgia, dysuria, and cloudy urine. In addition, swelling of the acutely inflamed prostate can cause obstructive symptoms, ranging from dribbling and hesitancy to anuria.
Patients with chronic prostatitis may have complaints of typical cystitis such as frequency, dysuria, and urgency. However, other subtle symptoms may include perineal discomfort, discomfort during ejaculation, deep pelvic pain, or pain radiating to the back. The diagnosis of prostatitis should be considered in men who have a history of recurrent UTIs in the absence of risk factors, such as bladder catheterization. (See "Acute and chronic bacterial prostatitis".)
Patients with acute epididymitis often complain of irritative voiding symptoms (dysuria, frequency, urgency) and pain in one testicle. These localizing symptoms are often accompanied by a history of high fever and rigors.
Acute cystitis is indicated by dysuria and other complaints of urinary frequency, urgency, suprapubic pain, and cloudy or bloody urine. The presence of upper tract infection is suggested by systemic symptoms such as fever, chills, and malaise. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
PHYSICAL EXAMINATION — The physical examination should include measurement of temperature and assessment of the general well-being of the patient. Specific attention should be given to a full genital and rectal examination and assessment of tenderness in the costovertebral region.
The physical examination should include lymph node palpation and inspection and palpation of the testicles and penis. The skin of the entire pubic area, scrotum, groin, and penis should be examined for lesions or genital ulcers. The testes, epididymides, and spermatic cords should be palpated for masses or tenderness. The foreskin should be completely retracted and the urethral meatus should be inspected for crusting, redness, or discharge.
In patients with suspected urethritis, penile discharge may be mucoid, mucopurulent, or purulent in appearance. If there is no apparent urethral discharge noted on physical examination, the urethra should be milked from the base to the meatus by placing the gloved thumb along the ventral surface of the base of the penis and the forefinger on the dorsum and applying gentle pressure. The hand is moved slowly toward the meatus to expel any discharge for specimen collection [1]. (See "Genital Chlamydia trachomatis infections in men" and "Diagnosis of gonococcal infections".)
The typical signs of acute prostatitis notable upon examination include high fevers and chills. The finding of an edematous and tender prostate on physical examination should lead to a presumptive diagnosis of acute prostatitis. The digital rectal examination should be performed in a gentle fashion when acute prostatitis is suspected since vigorous examination can induce bacteremia. (See "Acute and chronic bacterial prostatitis".) The physical exam in patients with chronic prostatitis may be unremarkable.
In patients with epididymitis, physical examination is usually notable for induration and swelling of the involved epididymis in association with exquisite tenderness. Urologic consultation for possible torsion might be necessary if the onset of pain was sudden and severe [2]. (See "Evaluation of the acute scrotum in adults".)
Patients with an upper urinary tract infection are often febrile and uncomfortable in appearance; in severe cases, physical examination may be notable for hypotension and flank pain. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
MICROBIOLOGY
Urethritis — Gonorrhea is a common cause of urethritis in the United States and Europe, especially in urban areas and STD clinics. In 2004, rates of positive urethral gonorrhea tests were higher in HIV-positive MSM compared to HIV-negative MSM. (See "Diagnosis of gonococcal infections".)
In addition, up to 25 to 30 percent of men with gonococcal urethritis also have concurrent chlamydia infection [2]. When N. gonorrhoeae cannot be detected, the term "nongonococcal urethritis" (NGU) is used. Although most cases of NGU are due to C. trachomatis, other etiologies include T. vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum [3-7]. In some areas of Africa, T. vaginalis is the most common cause of urethritis [5] and is also identified in 10 to 20 percent of urethral swabs from asymptomatic men presenting to STD clinics [5-7]. (See "Genital Chlamydia trachomatis infections in men".) Urethritis can also occur secondarily to primary genital herpes simplex virus infection. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)
Prostatitis — Acute prostatitis is most commonly bacterial in origin and caused by gram-negative rods (eg, Enterobacteriaceae, Pseudomonas, Proteus) and gram-positive organisms (Enterococcus, S. aureus). Gonorrhea and chlamydia can also cause acute prostatitis. In the absence of instrumentation or anatomic abnormalities, isolation of S. aureus should prompt the clinician to consider hematogenous spread and the possibility of underlying endocarditis.
Chronic prostatitis may be due to some of the same bacterial organisms especially the gram-negative rods, as well as some fungi (depending on the host immune status). (See "Acute and chronic bacterial prostatitis".)
Epididymitis — In men under the age of 35, C. trachomatis is the most common organism responsible for bacterial epididymitis, although gonococcal infection can also contribute to some cases. Sexually transmitted organisms may also be responsible for epididymitis in older men, but bacteriuria secondary to obstructive urinary disease (eg, prostatic hyperplasia) is more common, involving organisms such as E. coli and other coliforms. Men who engage in anal insertive intercourse are at increased risk for epididymitis due to coliform bacteria [2]. (See "Evaluation of the acute scrotum in adults".)
Urinary tract infection — As seen in women, the most common causes of urinary tract infection in men are enteric gram-negative pathogens, such as E. coli. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
DIAGNOSIS — Sexually active men with dysuria should be evaluated for urethritis and its associated pathogens. The presence of urethritis can be confirmed by one of the following findings [8]:
   Mucopurulent or purulent discharge on examination
   >5 polymorphonuclear cells (PMNs) per oil immersion field from the Gram's stain of a urethral swab
   Positive leukocyte esterase ("dipstick") on first-void urine or the presence of >10 WBCs per high power field of the first-void urine.
Micturition just prior to examination may hamper detection of sexually transmitted infections. Generally, it should be avoided for at least two hours priors to obtaining specimens.
A Gram's stain specimen for examination of PMNs and any organisms can be collected from expressed penile discharge or from inside the urethra. A calcium alginate swab should be inserted gently at least 2 cm into the urethra and rotated 360 degrees, with care not to force the tip past an obstruction. The swab can then be rolled across a clean microscope slide for air drying and Gram's stain evaluation.
More than four PMNs per high power field is abnormal and is seen in 60 to 90 percent of patients with urethritis [9,10]. The presence of PMNs without any visible organisms is consistent with NGU, whereas gonococcal urethritis may be diagnosed by the demonstration of gram-negative intracellular or extracellular diplococci in the urethral exudate. Because of the specificity of the urethral Gram's stain, a confirmatory culture for gonorrhea is not necessary in men, as it is in women.

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Inspection for PMNs can also be performed on the first void urine by spinning 10 to 15 milliliters of urine and examining the sediment. All men with suspected urethritis (by symptoms or the above criteria) should be tested for gonorrhea and chlamydia, which can often be copathogens.
Due to the discomfort associated with collection of urethral specimens, the preferred diagnostic tests for gonorrhea and chlamydia in most centers is a nucleic acid amplification test (NAAT) from a urine sample. (See "Genital Chlamydia trachomatis infections in men" and "Diagnosis of gonococcal infections".)
Trichomoniasis and mycoplasma infections may cause symptoms of urethritis in men, but their diagnosis is more difficult. Although wet mount preparations for trichomonas can be useful in women, microscopy is very insensitive in men [2]. Endourethral culture and cultures of the first-void urine sediment can be considered. NAATs are more expensive than culture, but have superior sensitivity for T. vaginalis, and are the preferred methods for diagnosis of trichomoniasis in men.
Patients with genital ulcers should have cultures taken for HSV and have serologic testing for syphilis. Patients presenting with STD risk factors should also be routinely be offered screening for syphilis and HIV infection. (See "Screening for sexually transmitted diseases" and "Diagnostic testing for syphilis".)
In male patients with suspected urinary tract infections, a midstream urine culture is recommended to confirm the diagnosis. Microscopic or sometimes gross hematuria is occasionally seen in urinary tract infections: white cell casts are suggestive of pyelonephritis. In one study of 422 men with symptoms of dysuria, urinary frequency, and/or urgency, a positive nitrite test had a positive predictive value of 96 percent when compared to urine culture results [11].
Acute and chronic prostatitis require careful distinction from urinary tract infections in men. The majority of men with prostatitis are diagnosed based on their clinical presentations and rectal exam findings. A urinalysis should be performed to determine the presence of pyuria. A urine culture should also be obtained in all men suspected of having acute prostatitis; Gram's stain of the urine, if positive, can be used as a guide to initial therapy. Blood cultures are recommended in patients with a history of fevers and rigors to rule out bacteremia.
DIFFERENTIAL DIAGNOSIS — In male patients with dysuria, other diagnostic considerations include reactive arthritis with associated urethritis (formerly Reiter syndrome) or endourethral syphilitic chancre. (See "Reactive arthritis (formerly Reiter syndrome)".) Non-infectious causes of dysuria that should also be considered, include chemical irritation from spermicides or soaps.
A history of recurrent episodes of cystitis should prompt consideration of chronic prostatitis, which requires a longer duration of antibiotic therapy. (See "Acute and chronic bacterial prostatitis".)
TREATMENT — Initial treatment for dysuria is usually empiric and the choice of therapy will depend on the suspected diagnosis based on presenting signs, symptoms, and risk factors.
Treatment for NGU is usually targeted towards chlamydia as the most likely pathogen. Azithromycin (1 gram orally) is the current recommendation from the Centers for Disease Control and Prevention.
Some patients will have recurrent symptoms. While it is important to consider reinfection or antimicrobial resistance, other organisms should be considered. Emerging evidence suggests that nongonococcal nonchlamydial urethritis (NGNCU) is frequently associated with M. genitalium [12,13]. Fortunately, azithromycin is effective for this organism as well [14].
Current guidelines recommend that patients with persistent symptoms associated with NGU should also receive empiric treatment for trichomoniasis if diagnostic testing is not available. All patients with suspected gonococcal urethritis must also be empirically treated for chlamydia due to the likelihood of coinfection. Men with urethritis secondary to STIs should be advised to abstain from sex for one week following therapy, and to refer their sexual partners for evaluation and treatment. (See "Genital Chlamydia trachomatis infections in men" and "Treatment of urogenital gonococcal infections".)
Men with suspected acute or chronic bacterial prostatitis should be treated presumptively for gram-negative pathogens. A delay in therapy for acute prostatitis can lead to gram-negative sepsis, prostatic abscess, or metastasis infection. Men with acute prostatitis should be instructed to increase their hydration and bed rest. (See "Acute and chronic bacterial prostatitis" and "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".) Men with chronic prostatitis may require medical therapy over one to three months.
Medical management for epididymitis secondary to suspected STIs includes treatment for both gonorrhea and chlamydia. Bacterial epididymitis in men >35 years of age and men who engage in anal insertive intercourse should be directed towards gram-negative rods. As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided.
Men with suspected UTI should be treated presumptively for gram-negative pathogens until the culture results are available. Men with acute cystitis should also undergo further evaluation for underlying urologic abnormalities. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
The appropriate topic reviews should be consulted for recommended antibiotic regimens.
SUMMARY AND RECOMMENDATIONS
   Dysuria in men (pain, tingling, or burning during or just after urination) may be a presenting complaint of urethritis, prostatitis, epididymitis, or urinary tract infections. Distinction between the syndromes should be attempted in order to guide diagnosis and management. (See 'Introduction' above.)
   A careful history must determine the presence of irritative voiding symptoms; systemic manifestations, such as fever and chills; or subtle complaints, such as back pain. The constellation of symptoms will suggest different diagnoses. (See 'History' above.)
   Males with dysuria should have an appropriate physical examination with specific attention to the genital and rectal examination. (See 'Physical examination' above.)
   In the male patient with dysuria and purulent discharge, or suspected epididymitis secondary to STIs, we recommend a Gram's stain of a urethral swab specimen and specific testing for gonorrhea and Chlamydia with nucleic acid amplification testing (NAAT). (See 'Diagnosis' above.)
   In men with prostatitis and suspected urinary tract infection, a urinalysis and a midstream urine culture is recommended to confirm the diagnosis; white cell casts are suggestive of pyelonephritis. A urine culture should also be obtained in all men suspected of having acute prostatitis. Blood cultures are recommended in any patient with a history of fever and rigors. (See 'Diagnosis' above.)
   Urethritis is most commonly associated with gonococcal or chlamydial infections. Bacterial prostatitis and urinary tract infections are usually due to gram-negative pathogens, such as E. coli. Epididymitis in men younger than 35 years of age is most frequently due to Chlamydia trachomatis; in older men, E. coli, other coliforms, or Pseudomonas species are the likely pathogens. The choice of therapy for dysuria depends on the likely diagnosis based on presenting signs, symptoms, and risk factors, and suspected or confirmed pathogens. (See 'Microbiology' above.)
   Patients with risk factors for an STD should be offered screening for syphilis and HIV infection. (See 'Diagnosis' above.)
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REFERENCES
1.   McCormack W, Rein M. Urethritis. In: Principles and Practice of Infectious Diseases, Mandell, Douglas, and Bennett (Eds), 2006.
2.   http://www.cdc.gov/std/treatment/2010/default.htm (Accessed on January 03, 2011).
3.   Krieger JN, Jenny C, Verdon M, et al. Clinical manifestations of trichomoniasis in men. Ann Intern Med 1993; 118:844.
4.   Pépin J, Sobéla F, Deslandes S, et al. Etiology of urethral discharge in West Africa: the role of Mycoplasma genitalium and Trichomonas vaginalis. Bull World Health Organ 2001; 79:118.
5.   Watson-Jones D, Mugeye K, Mayaud P, et al. High prevalence of trichomoniasis in rural men in Mwanza, Tanzania: results from a population based study. Sex Transm Infect 2000; 76:355.
6.   Hobbs MM, Kazembe P, Reed AW, et al. Trichomonas vaginalis as a cause of urethritis in Malawian men. Sex Transm Dis 1999; 26:381.
7.   Price MA, Miller WC, Kaydos-Daniels SC, et al. Trichomoniasis in men and HIV infection: data from 2 outpatient clinics at Lilongwe Central Hospital, Malawi. J Infect Dis 2004; 190:1448.
8.   http://www.cdc.gov/std/treatment/2010/ (Accessed on October 18, 2011).
9.   Bowie WR. Comparison of Gram stain and first-voided urine sediment in the diagnosis of urethritis. Sex Transm Dis 1978; 5:39.
10.   Root TE, Edwards LD, Spengler PJ. Nongonococcal urethritis: a survey of clinical and laboratory features. Sex Transm Dis 1980; 7:59.
11.   Koeijers JJ, Kessels AG, Nys S, et al. Evaluation of the nitrite and leukocyte esterase activity tests for the diagnosis of acute symptomatic urinary tract infection in men. Clin Infect Dis 2007; 45:894.
12.   Gaydos C, Maldeis NE, Hardick A, et al. Mycoplasma genitalium compared to chlamydia, gonorrhoea and trichomonas as an aetiological agent of urethritis in men attending STD clinics. Sex Transm Infect 2009; 85:438.
13.   Taylor-Robinson D, Renton A, Jensen JS, et al. Association of Mycoplasma genitalium with acute non-gonococcal urethritis in Russian men: a comparison with gonococcal and chlamydial urethritis. Int J STD AIDS 2009; 20:234.
14.   Mena LA, Mroczkowski TF, Nsuami M, Martin DH. A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Clin Infect Dis 2009; 48:1649.

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Πάντως από ό,τι έχω διαβάσει αν οι καλλιέργειες είναι αρνητικές διαρκώς, θα πρέπει να σκεφτείτε την πιθανότητα χλαμυδίων. Βέβαια σε άλλες δημοσιεύσεις λένε ότι τα χλαμύδια αμφισβητούνται ως αίτια χρόνιας προστατίτιδας, αλλά αυτό δεν είναι φυσικά οριστικό ούτε δεσμευτικό. Αν πάρετε vibramycin θα πρέπει να είναι για ένα μήνα τουλάχιστον.
Στην περίπτωση μου πάντα αρνητικές καλλιέργειες, όμως βελτιώνομαι εξαιρετικά με vibramycin. Είχα ξεκινήσει με ουρηθρίτιδα και το μόνο αίτιο που μπορεί να προκαλέσει στη συνέχεια προστατίτιδα είναι τα χλαμύδια και τα άτυπα που ουσιαστικά θεραπεύονται με τα ίδια φάρμακα και τα δύο. Βέβαια οι αντιβιώσεις και ιδιαίτερα οι κινολόνες και οι τετρακυκλίνες έχουν και ισχυρή αντιφλεγμονώδη δράση. Οπότε μπορεί να υποχωρεί ο πόνος διότι δρουν έτσι και τελικά το πρόβλημα να είναι ιδιοπαθές

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Available diagnostic tests for C. trachomatis include culture, direct immunofluorescence, ELISA, and nucleic acid amplification techniques (NAATs). The most sensitive and specific of these tests is NAATS, which can be performed on urethral specimens and on urine [28-30]. Urine based diagnostic testing decreases costs and time to test completion. They also avoid the patient discomfort associated with urethral sampling and may thereby improve patient acceptance of diagnostic testing

Η διάγνωση γίνεται με μοριακή μέθοδο ανίχνευσης των χλαμυδίων στα ούρα. Το κάνουν λίγα εργαστήρια, είναι αρκετά ακριβή εξέταση (ενώ στην Αμερική είναι φθηνότερη από τις καλλιέργειες!). για 15 ημέρες δεν θα έχετε πάρει αντιβίωση. Στην Ελλάδα το κάνουν στην Βιοιατρική και Ιατρόπολις