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Dysuria

By

Geetha Maddukuri

, MD, Saint Louis University

Last full review/revision Jan 2021| Content last modified Jan 2021
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Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom in women, but it can occur in men and can occur at any age.

Pathophysiology of Dysuria

Etiology of Dysuria

Overall, the most common causes of dysuria are

Table
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Evaluation of Dysuria

History

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 Cystoscopy Cystoscopy is insertion of a rigid or flexible fiberoptic instrument into the bladder. Indications include the following: Helping diagnose urologic disorders (eg, bladder tumors, calculi in... read more Cystoscopy , catheterization Bladder Catheterization Bladder catheterization is used to do the following: Obtain urine for examination Measure residual urine volume Relieve urinary retention or incontinence Deliver radiopaque contrast agents or... read more , 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 Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more 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 a history of kidney stones Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more . As with any potentially infectious illness, a history of an immunocompromised state (including HIV/AIDS) or recent hospitalization is important.

Physical examination

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 Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more 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 Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include vaginal discharge, vaginal bleeding, and cervical erythema and friability. Women are tested for infectious... read more Cervicitis ). Swabs for testing for sexually transmitted diseases (STDs) 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.

Red flags

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

Interpretation of findings

Some findings are highly suggestive (see table Some Causes of Dysuria Some Causes of Dysuria Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom... read more ). 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 STD Overview of Sexually Transmitted Diseases Sexually transmitted diseases (STDs), also termed sexually transmitted infections (STIs), can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and symptoms... read more . Thick purulent material is usually gonococcal; thin or watery discharge is nongonococcal. Vaginitis Overview of Vaginitis Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema... read more Overview of Vaginitis and the ulcerative lesions of herpes simplex virus infection Genital Herpes Genital herpes is a sexually transmitted disease caused by human herpesvirus 1 or 2. It causes ulcerative genital lesions. Diagnosis is clinical with laboratory confirmation by culture, polymerase... read more Genital Herpes are typically apparent on inspection. In men, a very tender prostate suggests prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more , and a tender, swollen epididymis suggests epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more Epididymitis . Other findings also are helpful but may not be diagnostic; eg, women with findings of vulvovaginitis may also have a urinary tract infection Introduction to Urinary Tract Infections (UTIs) Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys (pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra... read more (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 Chronic Pyelonephritis Chronic pyelonephritis is continuing pyogenic infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities. Symptoms may be absent or may include fever... read more . 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.

Testing

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 STD 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 STD Overview of Sexually Transmitted Diseases Sexually transmitted diseases (STDs), also termed sexually transmitted infections (STIs), can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and symptoms... read more , vulvovaginitis Overview of Vaginitis Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema... read more Overview of Vaginitis , prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more , tuberculosis Genitourinary TB Tuberculosis outside the lung usually results from hematogenous dissemination. Sometimes infection directly extends from an adjacent organ. Symptoms vary by site but generally include fever... read more Genitourinary TB (TB), tumor, interstitial nephritis Tubulointerstitial Nephritis Tubulointerstitial nephritis is primary injury to renal tubules and interstitium resulting in decreased renal function. The acute form is most often due to allergic drug reactions or to infections... read more Tubulointerstitial Nephritis , or other causes. Red blood cells detected with urinalysis in patients with no WBCs and sterile cultures may be due to cancer, calculus Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more , foreign body, glomerular abnormalities, or recent instrumentation of the urinary tract.

Treatment of Dysuria

Treatment is directed at the cause. Many clinicians do not treat dysuria in women without red flag findings if no cause is apparent based on examination and the results of a urinalysis. If treatment is decided upon, a 3-day course of trimethoprim/sulfamethoxazole, nitrofurantoin, or fosfomycin is recommended. Because they can cause tendinopathy, fluoroquinolones should not be used for uncomplicated urinary tract infections (UTIs) whenever possible; to avoid resistance, fluoroquinolones should be used only if other drugs cannot be used or for serious infection. Some clinicians give presumptive treatment for a sexually transmitted disease (STD) in men with similarly unremarkable findings; other clinicians await STD test results, particularly in reliable patients.

Acute, intolerable dysuria due to cystitis Cystitis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more can be relieved somewhat by phenazopyridine 100 to 200 mg orally 3 times a day for the first 24 to 48 hours. This drug turns urine red-orange and may stain undergarments; patients should be cautioned not to confuse this effect with progression of infection or hematuria. Complicated UTI requires 10 to 14 days of treatment with an antibiotic that is effective against gram-negative organisms, particularly Escherichia coli.

Key Points

  • Dysuria is not always caused by a bladder infection.

  • STDs and cancer should also be considered.

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