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Key Features

Essentials of Diagnosis

  • Inquire about

    • Fever; new back or flank pain; nausea or vomiting

    • Vaginal discharge

    • Pregnancy risk

    • Structural abnormalities

    • Instrumentation of urethra or bladder

General Considerations

  • An inflammatory process (eg, infection; autoimmune disorder) underlies most causes of dysuria

  • In women, cystitis

    • Will be diagnosed in up to 50–60% of cases

    • Has an incidence of 0.5–0.7% per year in those who are young and sexually active

  • In evaluating women with dysuria, the key objective is to exclude

    • Serious upper urinary tract infection (UTI), such as acute pyelonephritis

    • Sexually transmitted diseases

  • In younger men, urethritis accounts for most cases of dysuria

  • In elderly men, dysuria may be a symptom of prostatitis

Clinical Findings

Symptoms

  • An increased likelihood of cystitis is present when women report

    • Multiple irritative voiding symptoms (dysuria, urgency, frequency)

    • Fever

    • Back pain

  • It is imperative to inquire about symptoms of vulvovaginitis

  • Gross hematuria in women with voiding symptoms

    • Usually represents hemorrhagic cystitis

    • Can also be a sign of bladder cancer (particularly in older patients) or upper tract disease

  • Chlamydial infection should be strongly considered among women age 25 years or younger who are sexually active and seeking medical attention for a suspected UTI for the first time or who have a new sexual partner

  • Because fever and back pain, as well as nausea and vomiting, are considered harbingers of (or clinical criteria for) acute pyelonephritis, women with these symptoms should be examined prior to treatment to exclude coexistent urosepsis, hydronephrosis, or nephrolithiasis

  • Presence of UTI during pregnancy is strongly associated with preeclampsia (particularly during the third trimester)

Physical Examination

  • Fever, tachycardia, or hypotension suggest the possibility of urosepsis and need for hospitalization

  • A focused examination in women, in uncomplicated circumstances, could be limited to ascertainment of costovertebral angle tenderness and to a lower abdominal and pelvic examination, if the history suggests vulvovaginitis or cervicitis

Differential Diagnosis

  • In women

    • Acute cystitis

    • Acute pyelonephritis

    • Vaginitis (Candida, bacterial vaginosis, Trichomonas, herpes simplex)

    • Urethritis/cervicitis (Chlamydia, gonorrhea)

    • Interstitial cystitis/painful bladder syndrome

  • In men

    • Urethritis (eg, Mycoplasma genitalium)

    • Prostatitis (eg, Enterobacteriaceae)

Diagnosis

Diagnostic Studies

  • Nucleic acid amplification tests from first-void urine or vaginal swab specimens are highly sensitive for detecting chlamydial infection

  • Urinalysis

    • Most helpful in atypical presentations of cystitis

    • Dipstick detection (> trace) of leukocytes, nitrites, or blood supports a diagnosis of cystitis

    • Urine dipstick test results in older patients

      • A positive urine dipstick test should be interpreted cautiously if UTI symptoms are absent

      • A negative dipstick result for leukocyte esterase and nitrites excludes infection in older patients with equivocal cystitis symptoms

    • Microscopy of unspun urine may also be helpful in diagnosis and reduces unnecessary use of antibiotics

  • Urine culture

    • Should be considered ...

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