Dysuria

History of present illness should cover duration of symptoms and whether they have occurred in the past. Important accompanying symptoms include fever, flank pain, urethral or vaginal discharge, and symptoms of bladder irritation (frequency, urgency) or obstruction (hesitancy, dribbling). Patients should be asked whether the urine is bloody, cloudy, or malodorous and the nature of any discharge (eg, thin and watery or thick and purulent). Clinicians should also ask whether patients have recently engaged in unprotected intercourse, have applied potential irritants to the perineum, have had recent urinary instrumentation (eg, cystoscopy, catheterization, surgery), or might be pregnant.

Review of systems should seek symptoms of a possible cause, including back or joint pain and eye irritation (connective tissue disorder) and gastrointestinal symptoms, such as diarrhea (reactive arthritis). Review of food or drink that can cause symptoms is also necessary.

Past medical history should note prior urinary infections (including those during childhood) and any known abnormality of the urinary tract, including congenital urinary tract anomalies or a history of kidney stones. As with any potentially infectious illness, a history of an immunocompromised state (including HIV/AIDS) or recent hospitalization is important.

Examination begins with review of vital signs, particularly to note the presence of fever.

Skin, mucosa, and joints are examined for lesions suggesting reactive arthritis (eg, conjunctivitis, oral ulcers, vesicular or crusting lesions of palms, soles, and around nails, joint tenderness). The flank is percussed for tenderness over the kidneys. The abdomen is palpated for tenderness over the bladder.

Women should have a pelvic examination to detect perineal inflammation or lesions and vaginal or cervical discharge (see Cervicitis). Swabs for testing for sexually transmitted infections (STIs) and wet mount should be obtained at this time rather than doing a 2nd examination.

Men should undergo external inspection to detect penile lesions and discharge; the area under the foreskin should be examined. Testes and epididymis are palpated to detect tenderness or swelling. Rectal examination is done to palpate the prostate for size, consistency, and tenderness.

The following findings are of particular concern:

• Fever

• Flank pain or tenderness

• Recent instrumentation

• Immunocompromised patient

• Recurrent episodes (including frequent childhood infections)

• Known urinary tract abnormality

• Male sex

Some findings are highly suggestive (see table Some Causes of Dysuria). In young, healthy women with dysuria and significant symptoms of bladder irritation, cystitis is the most likely cause. Visible urethral or cervical discharge suggests an STI. Thick purulent material is usually gonococcal; thin or watery discharge is nongonococcal. Vaginitis and the ulcerative lesions of herpes simplex virus infection are typically apparent on inspection. In men, a very tender prostate suggests prostatitis, and a tender, swollen epididymis suggests epididymitis.

Other findings also are helpful but may not be diagnostic; eg, women with findings of vulvovaginitis may also have a urinary tract infection (UTI) or another cause of dysuria. Diagnosis of UTI based on symptoms is less accurate in older patients.

Findings suggestive of infection are more concerning in patients with red flag findings. Fever, flank pain, or both suggest an accompanying pyelonephritis. History of frequent UTIs should raise concern for an underlying anatomic abnormality or compromised immune status. Infections following hospitalization or instrumentation may indicate an atypical or resistant pathogen.

No single approach is uniformly accepted. Many clinicians presumptively give antibiotics for cystitis without any testing (sometimes not even urinalysis) in young, otherwise healthy women presenting with classic dysuria, frequency, and urgency and without red flag findings. Others evaluate everyone with a clean-catch midstream urine sample for urinalysis and culture. Urine culture is recommended in patients with risk factors for multidrug-resistant infections. Some clinicians defer culture unless dipstick testing detects white blood cells (WBCs). In women of childbearing age, a pregnancy test is done (UTI during pregnancy is of concern because it may increase the risk of preterm labor or premature rupture of the membranes). Vaginal discharge warrants a wet mount. Many clinicians routinely obtain samples of cervical (women) or urethral (men) exudate for STI testing (gonococcus and chlamydia culture or polymerase chain reaction [PCR]) because many infected patients do not have a typical presentation.

A finding of > 10⁵ bacteria colony-forming units (CFU)/mL suggests infection. In symptomatic patients, sometimes counts as low as 10² or 10³ CFUs indicate UTI. WBCs detected with urinalysis in patients with sterile cultures are nonspecific and may occur with an STI, vulvovaginitis, prostatitis, tuberculosis (TB), tumor, interstitial nephritis, or other causes. Red blood cells detected with urinalysis in patients with no WBCs and sterile cultures may be due to cancer, calculus, foreign body, glomerular abnormalities, or recent instrumentation of the urinary tract.

Cystoscopy and imaging of the urinary tract may be indicated to check for obstruction, anatomic abnormalities, cancer, or other problems in patients who have no response to antibiotics, recurrent symptoms, or hematuria without infection. Rectovesicular fistula should be considered in men with recurrent lower urinary tract infections or those with polymicrobial infections. Pregnant patients, males, older patients, and patients with prolonged or recurrent dysuria need closer attention and a more thorough investigation.