All Dysuria Is Local

OBJECTIVE:  To determine the cost‐effectiveness of management strategies for dysuria in different office settings. DESIGN:  Decision and cost‐effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies. SETTING:  Hypothetical primary care practice. PATIENTS:  Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency. INTERVENTIONS:  All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim‐sulfamethoxazole. RESULTS:  The cost‐effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim‐sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost‐effectiveness ratio of $4 to $32 per symptom‐day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim‐sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA). CONCLUSIONS:  In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria.