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CHIEF COMPLAINT

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PATIENT Image not available.

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

Image not available. What is the differential diagnosis of dysuria? How would you frame the differential?

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CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

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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. A pelvic exam should be performed in any woman with 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 to the genitourinary tract is helpful for organization.

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  1. Skin: rash causing irritation with urination

    1. Herpes

    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. Benign prostatic hypertrophy (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 (men or patients with any of the following: urinary obstruction; pregnancy; neurogenic bladder; concurrent kidney stone; immunosuppression; indwelling Foley catheter; systemic infection, such as bacteremia or sepsis)

    2. Interstitial cystitis

  6. Kidney: pyelonephritis

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Image not available.

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 not available. 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?

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PRIORITIZING THE DIFFERENTIAL DIAGNOSIS

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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 (Table 16-1).

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Table Graphic Jump Location
Table 16-1.Diagnostic hypotheses for Ms. D.

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