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Approach to the Patient with Dysuria - Case 1



Ms. D is a 33-year-old woman who complains of dysuria for 4 days.

image What is the differential diagnosis of dysuria? How would you frame the differential?


Dysuria is pain or burning with or after urination. Most patients with dysuria have a urinary tract infection (UTI). When considering this symptom, pivotal points are history and physical exam findings that suggest more serious or complicated etiologies. Important historical features include vaginal or penile discharge, flank pain, rectal/perineal pain, nausea or vomiting, fever, hematuria, urinary hesitancy, urinary urgency, nocturia, and urinary frequency. On the physical exam, vital signs including temperature and sometimes orthostatics are important as are abdominal and costovertebral-angle (CVA) tenderness. Except in a few situations, a pelvic exam should be performed in any woman with a vaginal discharge. A prostate exam should be performed in any man in whom cystitis is suspected, especially those with symptoms of nocturia, hesitancy, or rectal pain. When approaching the differential diagnosis for dysuria, an anatomic approach is helpful for organization. Below is a list of diagnoses, organized by anatomic location, that can cause dysuria. Many of these diagnoses (eg, bladder cancer and benign prostatic hypertrophy [BPH]) usually present with symptoms other than dysuria.

  1. Skin: rash causing irritation with urination

    1. Herpes simplex

    2. Irritant contact dermatitis

    3. Syphilitic chancre

    4. Erosive lichen planus

  2. Urethra (urethritis from sexually transmitted infections [STIs])

    1. Gonorrhea

    2. Chlamydia

    3. Trichomoniasis

  3. Male genital structures

    1. Epididymis: epididymitis

    2. Testes: orchitis

    3. Prostate

      1. BPH

      2. Acute prostatitis

      3. Chronic prostatitis

  4. Female genital structures

    1. Vagina

      1. Trichomoniasis

      2. Bacterial vaginosis

      3. Candidal infections

      4. Atrophic vaginitis

    2. Uterine/bladder prolapse

    3. Cervix

      1. Neisseria gonorrhoeae infection

      2. Chlamydia trachomatis infection

  5. Bladder

    1. Acute cystitis

      1. Uncomplicated (healthy women with no urinary tract abnormality)

      2. Complicated (patients with any of the following: urinary obstruction; pregnancy; neurogenic bladder; concurrent kidney stone; immunosuppression; indwelling urinary catheter; male sex; systemic infection, such as bacteremia or sepsis)

    2. Interstitial cystitis

    3. Bladder cancer (with hematuria)

  6. Kidney

    1. Pyelonephritis

    2. Renal cancer (with hematuria)


Ms. D noted the gradual onset of dysuria 4 days ago. She also has increased urinary frequency. She denies flank pain, fever or chills, nausea or vomiting, vaginal discharge, genital rash, or hematuria. Her last menstrual period ended 5 days ago, and she takes an oral contraceptive pill regularly for contraception.

image At this point what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?


Ms. D is a healthy young woman with symptoms consistent with cystitis. The pivotal points in this case are the absence of flank pain, vaginal discharge, nausea, vomiting, or fever. Vaginitis is a common disease that can cause similar symptoms, and pyelonephritis is a must not miss diagnosis. These diagnoses must be explored as part of the limited differential diagnosis ...

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