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190 Cystitis, urethritis, and prostatitis
as a pain reliever. Phenazopyridine does not appear to have untoward effects
on antibiotic efficacy, and the urinary tract anesthetic actually increases
bioavailability of ciprofloxacin in the setting of cystitis. 17
Phenazopyridine’s urinary tract anesthetic effects do not extend to relief of
pain caused by bladder distension, as shown in an RCT demonstrating the
agent’s failure to alleviate pain of bladder filling necessary for ultrasoundguided
embryo transfer. 18
The major disadvantages of phenazopyridine are the side effects (e.g.
methemoglobinemia, hemolysis, skin discoloration), which can be particularly
prominent in overdose or renal insufficiency (which can also be caused
by phenazopyridine). 19,20 Urinary changes such as discoloration, while not
constituting major problems, should be mentioned to patients in order to
prevent unwarranted concern.
Ibuprofen does not reduce the dysuria or rectal pain associated with
radiation therapy for prostatic cancer. 21 However, there is some evidence
for occasional NSAID utility in relieving noninfectious chronic prostatitis. 22
Given the absence of other evidence for NSAIDs or other analgesics,
patients with refractory pain from infectious cystitis, urethritis, or prostatitis
may require opioids for relief.
For the occasional patient with external (noninfectious) irritation causing
urethritis, a small amount of a topical protective preparation may improve
pain. The best example of such an approach is soap-induced urethral pain. In
these cases, bathing can be rendered painless with the prebath application of
a small amount of petrolatum jelly. 23
n Summary and recommendations
First line: phenazopyridine 200 mg PO TID (for two or three days only)
Reasonable:NSAIDs(e.g.ibuprofen400–600 mg PO q6–8 h) if phenazopyridine
is contraindicated or fails as monotherapy
Pregnancy: phenazopyridine (200 mg PO TID for two or three days) is
probably safe in pregnancy in terms of the fetus, but the risk of masking
ongoing or complicated infection is particularly worrisome in this