Painful Urination in Men — Full Text

We approach men completely differently from women, because men don’t often get typical urinary tract infections (UTIs) from common bacteria (we always abbreviate “Urinary Tract Infection” as “UTI,” pronounced letter-by-letter “You-Tee-Eye;” never โ€œYooteeโ€ nor โ€œOoteeโ€).  But they do get Genital Tract illness, which in males is shared with the urinary tract (see Diagram: Male Genital Anatomy).  We’d be more likely to suspect a typical UTI in an older man without new sex partners.

We can think of male anatomy (and the infections) in terms of:

โ€ข Urethra (penis)  (Urethritis)
โ€ข Bladder  (UTI)
โ€ข Testes  (Orchitis)
โ€ข Prostate  (ProstatitisAcute / Chronic)
โ€ข Epididymis  (Epididymitis)
โ€ข Kidney  (Pyelonephritis)

Since germs that might infect any of these parts are the same, I find it more useful to distinguish among:

  • STD germs
  • Regular UTI germs (E. coli & others from the bowel)
  • โ€œProstatitisโ€

Our first question is whether there is any discharge coming from the penis.  If so, it’s an STD for sure.  We test for gonorrhea & chlamydia, & treat while results are pending.

In my experience, itโ€™s not unusual for men to seek care for intermittent burning on urination, on & off, that doesnโ€™t seem possibly due to any disease.  They describe it as occurring perhaps 1-2 times a day at most, or not every day.  No infection of any kind happens as such.

An uncircumcised male might have non-specific gunk temporarily stick to the urinary opening (meatus).  Any man might have a drop of ejaculate stuck there.  There may be a certain male fear that any painful urination might be an STD (especially among those with reason to worry). 

If an initial Urinalysis (UA) shows no white blood cells (WBCs), there’s no typical UTI.ย  If the man has reason to fear an STD, however unlikely if the UA is normal, I might do a test for gonorrhea & chlamydia.

So letโ€™s say a man has a recent onset of persistent painful urination.  Assuming the patient doesn’t look ill (no fever, vomiting, severe pain), the first step is to obtain a clean catch urine specimen.  We give the following instructions:

  • We don’t want germs from the skin to get into the urine, soโ€ฆ
  • If uncircumcised, pull back the foreskin
  • Clean the head of the penis (with a towelette)
  • Start to urinate into the toilet
  • Without stopping, catch some in the cup
  • Then finish urinating into the toilet

Urinalysis (UA)

We perform this in the office with a dipstick, which tests for a variety of things like sugar, protein, blood, and Leukocyte Esterase, an enzyme in white blood cells (WBCs).

UA is Positive for Leukocyte Esterase (i.e. WBC’s)

We send the urine to the laboratory to test for gonorrhea & chlamydia, and also for a “Culture & Sensitivity” (C&S) which will identify other types of UTIs.ย  In young men, STDs are statistically the most likely, since men rarely get typical UTIs like women (that’s because the penis is long, so any germ working its way up toward the bladder invariably gets washed out before it can start an infection).

If a young man adamantly denies any risks for STDs, we test anyway, because the germs can linger asymptomatically for a long time.  We treat with an antibiotic that covers both chlamydia and regular UTIs.  If our patient does in fact suggest an STD is possible, we also give a shot for gonorrhea.

In a man over 60, we’d be more suspicious of a typical UTI (bladder or kidney infection).  We’d order a C&S of urine to identify both the exact bacteria, and also the best drug to treat it.  We’d start an antibiotic pending results, which can take a few days.  If there were potential STD risks, we’d test for gonorrhea & chlamydia also, maybe treat also if there’s a history of unprotected sex with a new partner.

Fever, or nausea / vomiting, suggests a kidney infection.ย  We’d have a lower threshold for hospitalizing a man with a kidney infection, because such cases are so unusual.ย  We might hospitalize the very old patient, to give IV antibiotics that are sure to cover all causes pending C&S results, since there’s risk for Sepsis.

Men can be quite ill from infections in the testes or prostate.  They usually require hospitalization for IV antibiotics.  But these patients hurt all over the genital area, they donโ€™t come in just complaining of simple โ€œpainful urinationโ€ [the topic here].

UA is Negative for Leukocyte Esterase

Infection without WBCs is highly unlikely.  We’d still test for the STDs, but wouldn’t treat until results are back.  Maybe we’d send the urine for a culture & sensitivity, because maybe a germ from the prostate would show up.

And if all our tests are negative, and the urinary pain persists?  There are some rare, stretch-of-the-imagination possibilities like:

  • kidney or bladder stones passing down the urethra (UA should show blood and/or crystals; pain would be in the penis, not the bladder area)
  • tumors of the penis (should be easy to find by palpating the penis for hard lumps; may cause pain with erection)
  • sores in the penis’s opening (pain would be felt just right at the tip)
  • Reactive Arthritis [previously called “Reiterโ€™s Syndrome”]:ย  includes 1) urethra inflammation, 2) arthritis of one or a few big joints, 3) eye inflammation

Supposing none of the above seem likely, we enter the realm ofโ€ฆ

โ€œChronic Prostatitisโ€

This is in quotes, because thereโ€™s no definite way to diagnose the condition, and it may even have nothing to do with the prostate.  As such, some authorities combine the diagnosis as โ€œChronic Prostatitis / Chronic Pelvic Pain Syndromeโ€.  Still, this may be common, and cause significant effect on a man’s quality-of-life.

Since this diagnosis is โ€œChronic,โ€ its definition implies symptoms lasting over 6 weeks.  Numerous studies have found no association with any bacteria, even obscure ones.  As such, I try real hard to avoid giving antibiotics.

However, there is some suggestion that combining an antibiotic (specifically ciprofloxacin) plus “alpha blocker” drugs like doxazosin [Carduraยฎ], terazosin [Hytrinยฎ], tamsulosin [Flomaxยฎ], etc., is slightly statistically helpful for Chronic Prostatitis.  The length of time in studies was 6 weeks.  Long-term antibiotics make me uncomfortable, because theyโ€™re the cause of wide-spread drug resistance (and then, the medication wonโ€™t work when you or someone else really needs it). So I usually begin with just the alpha blocker alone, raising to maximum dose over a month (for safety’s sake).  If that doesn’t help, I refer to Urology.

Some patients have it stuck in their minds that “only an antibiotic will help,” even if there’s no evidence of infection.  Since a study did find that one course might be successful, it’s not illogical to try.  Especially since that’s what a Urologist specialist would do if we refer. But if symptoms return afterwards, there is no evidence that the medication should be continued.  Long-term antibiotics aren’t good for people or society, except in very special circumstances (this isn’t one of them).

โ€œBenign Prostatic Hypertrophyโ€ (BPH)  (aka โ€œLUTSโ€)

Men over 50 yrs-old (usually older) commonly have what used to be called “Benign Prostatic Hypertrophy,” name changed to “Benign Prostatic Hyperplasia,” still called BPH, though now the  preferred term is LUTS (= “Lower Urinary Tract Symptoms”) (“Lower Tract” means “not the Kidneys,” which is “upper tract”).  So if a man tells me, “I have all these urinary symptoms,” I can diagnose him with LUTS (can’t argue with that one).

This is because nobody really knows what causes it, though non-cancerous enlargement of the prostate may certainly play a role.

Pain is a minor feature of LUTS.  It’s overshadowed by other symptoms such as straining to start urinate, slow stream, frequent urination, urgent need to urinate small amounts, and dribbling at end.  Diagnostically, we order a urinalysis to make sure there’s no infection.  We examine the prostate to see if it’s enlarged, but this doesn’t help us with diagnosis.  We’d also like to make sure there’s no prostate cancer, but effective screening here may be impossible (see Prostate Cancer).

We should order a regular Ultrasound of the bladder for “post-void residual” (how much urine remains after peeing), to see if so much accumulates as to be dangerous [a prostate ultrasound for cancer, done rectally by a Urologist, is a bit uncomfortable & never routine].ย  Anyway, there are various treatments for BPH / LUTS [or whatever we call it], some of which should probably not be given to younger men (see prostate medications).ย 

See also Painful Urination in Men for the clinicianโ€™s condensed thought-process when face-to-face with a patient.

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