Textbook of Urgent Care Medicine, Chapter 27, Dysuria and Urinary Tract Infections in the Adult Patient

Published on October 26, 2026

Original author: Kimberly Gibson

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

INTRODUCTION

Urinary tract infections (UTIs) are among the infections most frequently encountered in urgent care. Dysuria may be caused by bacterial cystitis, urethritis, genital tract disease, or a noninfectious process. The first task is to identify patients with systemic infection, pregnancy, or urinary obstruction who need more than routine outpatient treatment.

Findings from the patient’s medical history, physical findings, and initial urinalysis are used to distinguish between urethritis, cystitis, and pyelonephritis for successful diagnosis and initiation of treatment.

Current terminology emphasizes whether infection appears confined to the bladder or extends beyond it. In the 2025 IDSA classification, fever, rigors, flank pain, or costovertebral angle tenderness favor a complicated UTI; diabetes, male sex, or immunocompromise alone do not automatically establish that classification. Clinical judgment remains necessary for higher-risk patients. [1]

PRESENTATION

Dysuria is defined as pain, burning, or discomfort on urination. Patients present with

• Urinary frequency and urgency
• Back pain or flank pain
• Subjective fever and documentation of temperature
• Nausea, vomiting, or both

Suprapubic discomfort and hematuria may accompany cystitis. Fever, chills, flank pain, nausea, or vomiting suggest infection beyond the bladder. Vaginal discharge or irritation, urethral discharge, or genital lesions should prompt consideration of other causes of dysuria. [1,2]

TRIAGE PEARLS

Efficiently differentiate cystitis or urethritis from pyelonephritis. Inadequate treatment can lead to treatment failure, renal damage, or sepsis. Evaluate for the following:

• Flank pain
• Nausea or vomiting
• Fever >38°C
• Hypotension, tachycardia, altered mentation, rigors, or other signs of systemic illness
• Pregnancy with fever or flank pain (suspected pyelonephritis requires initial inpatient management)
• Severe pain with hematuria or reduced urine output suggesting an obstructing stone
• Inability to tolerate oral medications or maintain hydration

An infected obstructed urinary tract is a urologic emergency. Arrange ED transfer; activate EMS for shock, toxic appearance, or other instability. Do not delay transfer for send-out testing or imaging unavailable in urgent care. [1,3]

If any of the following are present, consider whether inpatient or outpatient management is appropriate:

• Pregnancy
• Severe illness
• Immunocompromised status
• Marked debilitation
• Inability to tolerate oral intake
• Signs of urinary obstruction or ureteral stone

These findings require individualized assessment; they do not all establish complicated infection in the newer IDSA classification. [1]

HISTORY PEARLS

• Diabetes
• Pregnancy
• Recent/prior history of UTI
• History of neoplasms of the bladder or renal tract or renal calculi
• Urinary catheter or recent urinary tract instrumentation
• Recent changes in sexual activity, including unprotected sex, multiple partners, or increased frequency or intensity

Ask about prior urine culture results, recent antibiotics, drug allergies, renal function, and resistant organisms. Determine whether urinary symptoms are acute or have been present between apparent infections. [1,4]

• Women:
  • Unusual vaginal discharge, odor, or vulvodynia
  • Vaginal atrophy or dryness secondary to menopause
  • Sensitivity to scented creams, sprays, toilet paper
• Men:
  • Urinary frequency, nighttime urination, or leakage due to prostate enlargement
  • Urethral discharge
  • Urethral irritation or a tickling sensation

In men, ask about fever, perineal or pelvic pain, urinary retention, and prior prostatitis. Acute bacterial prostatitis requires a different antibiotic selection and treatment course. [1,2]

PHYSICAL EXAM PEARLS

• Temperature, pulse, and blood pressure to assess severity of infection (i.e., tachycardia is worrisome in elderly patients)
• Abdominal exam
  • Suprapubic tenderness
  • Assess for right lower quadrant or left lower quadrant tenderness or rebound.
• Assess tenderness of the costovertebral angle.
• A pelvic exam is indicated if the patient has vaginal discharge or irritation.
• Examination of the testicles and urethral meatus and a prostate exam if indicated

Avoid vigorous prostatic massage when acute bacterial prostatitis is suspected. Check for bladder distention when retention is a concern. An absence of costovertebral angle tenderness does not completely exclude pyelonephritis. [1]

TESTING AND DIAGNOSIS PEARLS

A dipstick urinalysis is a simple test waived under the Clinical Laboratory Improvement Amendments.

Use symptoms and urinalysis together. Nitrite positivity supports bacteriuria but a negative nitrite result does not exclude UTI. Leukocyte esterase or pyuria is less specific and can occur with colonization or genital infection. Do not use a positive dipstick alone to diagnose UTI in a patient without compatible symptoms. [5,6]

For routine specimens, a midstream sample is usually appropriate. Clean collection technique may reduce contamination, but it is not an absolute prerequisite for a useful result; a catheterized specimen may be necessary in select cases. [3]

Obtain a urine culture if you suspect pyelonephritis or a complicated UTI.

Culture is also indicated for suspected UTI in pregnancy, recurrent infection, persistent symptoms after treatment, or suspected resistance. A culture is not routinely necessary for classic uncomplicated cystitis in a nonpregnant woman with no risk factors or prior treatment failure. [1,3,4]

Clinical situation	Urgent care approach
Typical acute dysuria/frequency in a nonpregnant woman without vaginal symptoms	Urinalysis as available; empiric treatment may be reasonable. Routine culture not always necessary.
Fever, flank pain, rigors, suspected pyelonephritis	Urinalysis and urine culture before therapy when feasible; assess transfer need immediately.
Pregnancy with urinary symptoms	Urinalysis and urine culture; use pregnancy-compatible treatment and review result.
Male patient, recurrent or nonresponsive symptoms, recent antibiotic use	Urinalysis and culture; assess prostatitis, retention, and resistance.
No urinary symptoms, incidentally positive urinalysis	Do not treat asymptomatic bacteriuria except pregnancy or before selected invasive urologic procedures.

In women, there is significantly decreased probability of UTI if dysuria is absent and there is a history of vaginal irritation, odor, or discharge.

This pattern is consistent with evidence that symptoms and dipstick findings should be interpreted together. [11]

In such cases, check for the following:

• Sexually transmitted infection, bacterial vaginosis, and yeast infection
• Genitourinary syndrome of menopause (atrophic vaginitis)
• Vulvovaginitis secondary to topical irritants

When urethritis or cervicitis is suspected, obtain gonorrhea/chlamydia nucleic-acid amplification testing (NAAT), generally through a send-out laboratory unless an appropriate onsite platform is available. Manage suspected STI according to current CDC recommendations rather than a cystitis regimen. [2]

In men, consider the following:

• If the patient is sexually active and has penile discharge, evaluate for gonorrhea, chlamydia, or Trichomonas infection.
• If the patient has a penile lesion, consider herpes or syphilis infection or balanitis.
• If the patient has perineal pain or prostate tenderness, consider prostatitis.

In patients with recurrent complaints of suprapubic pain, urgency, and increased daytime or nighttime frequency in the absence of proven infection, consider interstitial cystitis.

Asymptomatic bacteriuria should not be treated in most nonpregnant adults, including older adults and people with diabetes. Confusion alone with bacteriuria, in the absence of local urinary symptoms or systemic signs, is not sufficient to diagnose a UTI. Evaluate other causes of altered mental status. [6]

TREATMENT PEARLS

For acute cystitis confined to the bladder in a nonpregnant adult woman, select antibiotics according to likely organisms, allergies, renal function, local resistance, prior cultures, and pregnancy possibility. The following options remain useful. [5]

Drug	Usual regimen / clinical consideration
Nitrofurantoin monohydrate/macrocrystals	100 mg orally twice daily for 5 days. For bladder infection only; check renal function and avoid in G6PD deficiency.
Trimethoprim-sulfamethoxazole (TMP-SMX)	160/800 mg orally twice daily for 3 days, if organism susceptible or local E. coli resistance <20%; review allergy, drug interactions, potassium, and renal function.
Fosfomycin tromethamine	3 g orally once for susceptible acute cystitis; not for pyelonephritis.
Oral beta-lactam alternative	Amoxicillin-clavulanate or selected oral cephalosporins, typically 5–7 days depending on agent; selection should reflect local susceptibility.

The original nitrofurantoin and TMP-SMX regimens remain appropriate for selected patients; the new table summarizes these doses alongside other common choices. Fluoroquinolones should generally be reserved for patients without suitable alternatives to uncomplicated cystitis because of important adverse effects and resistance concerns. Nitrofurantoin and fosfomycin do not achieve adequate renal parenchymal concentrations and must not be used for pyelonephritis. [5,7]

Additional FDA-approved oral options for selected uncomplicated infections include pivmecillinam (approved 2024) and gepotidacin (approved 2025); sulopenem etzadroxil/probenecid was approved in 2024 for adult women with limited or no alternative oral options. These agents have specific organism, patient, and safety restrictions and are not routine substitutions for established first-line therapy. Consult current prescribing information and local formulary availability. [8–10]

In addition, consider recommending phenazopyridine, 200 mg three times a day for 2 days:

• May relieve dysuria through local analgesic effect
• Is available over the counter
• Adverse effects include urine color change, headache, gastrointestinal upset, and dizziness.
• Contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency because of risk for hemolysis

Phenazopyridine does not treat infection. Assess kidney function and product contraindications before recommending it; use for no more than 2 days with antibacterial therapy. [12]

Pyelonephritis

Patients with pyelonephritis who are treated on an outpatient basis should be able to tolerate oral antibiotics and maintain hydration with the following recommendations:

• Obtain urine culture and assess for sepsis, dehydration, obstruction, pregnancy, and treatment failure before choosing outpatient care.
• Transfer patients with instability, persistent vomiting, suspected infected obstruction, pregnancy-associated pyelonephritis, or unreliable follow-up.
• For a carefully selected, stable nonpregnant patient, initial ceftriaxone 1 g IM/IV can be considered if available and clinically appropriate while an effective oral regimen is arranged, based on susceptibility and local resistance. Do not delay necessary ED evaluation to give an injection.
• An oral fluoroquinolone may be used when appropriate and likely active; the updated 2025 IDSA guideline supports 5–7 days of effective fluoroquinolone or 7 days of effective non-fluoroquinolone therapy in clinically improving cUTI/pyelonephritis patients. Trial populations have exclusions; longer therapy may be needed for selected patients or suspected prostatitis.
• Arrange prompt review of culture results and reassessment if fever or pain fails to improve within 48–72 hours, sooner for worsening illness.

A urine culture is essential for treatment adjustment. The original routine 14-day TMP-SMX recommendation and blanket 7-day ciprofloxacin pathway have been replaced by clinical response- and susceptibility-guided durations. [1]

Pregnancy

• Always obtain a urine culture.
• Nitrofurantoin is a good antibiotic choice due to its high urinary concentration.
• Cephalexin is a good alternative.

Pregnancy changes the diagnostic and disposition threshold. Screen once early in prenatal care for asymptomatic bacteriuria using a urine culture; treat confirmed asymptomatic bacteriuria (usually ≥100,000 CFU/mL) and symptomatic cystitis with a targeted course, generally 5–7 days. A single dose of fosfomycin may be considered for appropriate lower UTI, but neither fosfomycin nor nitrofurantoin treats pyelonephritis. [3]

Nitrofurantoin and TMP-SMX may be reasonable during the first trimester if appropriate alternatives are unavailable; risks and alternatives should be assessed individually rather than applying an absolute trimester ban. Avoid nitrofurantoin in G6PD deficiency. Pregnancy-associated pyelonephritis requires initial inpatient management. [3]

Do not treat an isolated positive dipstick as confirmation of bacteriuria in pregnancy; obtain culture. Amoxicillin or ampicillin should not be selected empirically because E. coli resistance is common. [3]

Recurrent Infections

Recurrent UTI is commonly defined as at least two symptomatic infections within 6 months or three within 12 months. Confirm episodes with symptom history and urine culture; persistent irritative symptoms without bacteriuria suggest an alternate diagnosis. [4]

• A culture should be obtained to distinguish relapse from reinfection.

Use the narrowest effective treatment for the acute episode. Do not automatically start daily TMP-SMX or nitrofurantoin prophylaxis after treatment in urgent care; longitudinal prevention should be individualized with a primary care clinician or urologist. [4]

Risk factors for recurrent UTI include the following:

• Sexual intercourse
  • Use of spermicidal products
  • Having the first UTI at an early age
  • Maternal history of UTIs

Prevention options include:

• Avoiding spermicides when practical.
  • Vaginal estrogen for appropriately selected peri- and postmenopausal patients without contraindications.
  • Cranberry products, which may be offered as prophylaxis; preparations and proanthocyanidin content vary.
  • Methenamine hippurate as a nonantibiotic prophylactic option in selected women after assessment of contraindications and follow-up arrangements.
  • Increasing water intake for patients whose habitual fluid intake is low.

The 2025 AUA update does not recommend D-mannose alone as an effective preventive measure. Evidence is insufficient to present voiding before or after intercourse as proven prophylaxis. [4]

DISPOSITION PEARLS

Referrals

Patients unable to take oral antibiotics and maintain good hydration should be sent to an emergency department for evaluation.

Men with suspected cystitis should generally have urine testing with culture and follow-up appropriate to symptoms and risks; routine urology referral is not required for every male UTI. Refer promptly for retention, suspected prostatitis with systemic illness, recurrent infection, obstructive symptoms, or treatment failure.

Patients with recurrent UTIs should be referred to a primary-care provider or urologist.

Finding	Recommended disposition
Shock, hypotension, altered mentation with systemic illness, or other sepsis findings	Activate EMS; ED transfer without delay.
Fever/flank pain with pregnancy; suspected infected obstruction; persistent vomiting	ED evaluation and likely hospital-based treatment.
Stable suspected pyelonephritis without high-risk features	Selected outpatient management only if testing, appropriate therapy, culture review, and timely follow-up are available.
Typical uncomplicated cystitis; well appearing, able to take medication	Outpatient treatment and reassessment if symptoms do not improve.
Recurrent/persistent symptoms, gross hematuria after infection resolves, suspected retention	Timely primary care/urology evaluation as indicated.

Follow-Up

• Resolution of symptoms is indicative of cure.
• If symptoms are not resolved at the end of treatment, the patient should be reevaluated.

For uncomplicated cystitis, worsening symptoms, fever, vomiting, new flank pain, or failure to improve within approximately 48–72 hours merits earlier reassessment. Document the plan to review pending cultures and adjust treatment if resistance is identified. Routine test-of-cure culture is generally unnecessary after symptom resolution in nonpregnant adults. [1,4]

MEDICOLEGAL PEARLS

• Consider tubo-ovarian abscess, ovarian torsion, and ectopic pregnancy in all women of childbearing age with abdominal or pelvic pain.
• Pregnant women with urinary tract infections are at risk for preterm labor.

In older patients, confusion or a positive urinalysis does not by itself establish symptomatic UTI. A full assessment is needed to identify other causes and signs of systemic infection. [6]

• Remain aware of the risk for Stevens-Johnson syndrome with use of sulfa drugs.

Document vital signs, pregnancy status where relevant, flank/CVA findings, oral tolerance, drug allergies, renal considerations, culture follow-up arrangements, and the reasoning behind outpatient treatment or transfer. Do not let a positive urinalysis delay evaluation for appendicitis, pelvic emergencies, ureteral obstruction, or sepsis.

REFERENCES

1. Infectious Diseases Society of America. IDSA 2025 guideline update on complicated urinary tract infections. Published July 17, 2025. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/
2. Centers for Disease Control and Prevention. Urethritis and cervicitis. STI Treatment Guidelines. https://www.cdc.gov/std/treatment-guidelines/urethritis-and-cervicitis.htm
3. American College of Obstetricians and Gynecologists. Urinary tract infections in pregnant individuals. Clinical Consensus. August 2023. https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2023/08/urinary-tract-infections-in-pregnant-individuals
4. American Urological Association; Canadian Urological Association; Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Recurrent uncomplicated urinary tract infections in women. Guideline amended 2025. https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti
5. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by IDSA/ESCMID. Clin Infect Dis. 2011;52(5):e103–e120. https://doi.org/10.1093/cid/ciq257
6. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by IDSA. Clin Infect Dis. 2019;68(10):e83–e110. https://doi.org/10.1093/cid/ciy1121
7. U.S. Food and Drug Administration. FDA drug safety communication: fluoroquinolone antibiotics and disabling adverse effects. July 26, 2016. https://www.fda.gov/media/119537/download
8. U.S. Food and Drug Administration. FDA approves new treatment for uncomplicated urinary tract infections [pivmecillinam]. April 24, 2024. https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-uncomplicated-urinary-tract-infections
9. U.S. Food and Drug Administration. Drug Trials Snapshots: BLUJEPA (gepotidacin). Original approval March 25, 2025. https://www.fda.gov/drugs/drug-trials-snapshots/drug-trials-snapshots-blujepa
10. U.S. Food and Drug Administration. FDA approves new treatment for uncomplicated urinary tract infections in adult women who have limited or no alternative oral antibiotic treatment options [sulopenem etzadroxil/probenecid]. October 2024. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-new-treatment-uncomplicated-urinary-tract-infections-adult-women-who-have-limited-or-no
11. Giesen LGM, Cousins G, Dimitrov BD, van de Laar FA, Fahey T. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract. 2010;11:78. https://doi.org/10.1186/1471-2296-11-78
12. DailyMed. Pyridium (phenazopyridine hydrochloride) prescribing information. Accessed October 2026. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=165d01d4-a9f7-2293-e054-00144ff8d46c