Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 2-12: Dysuria + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 In uncomplicated circumstances, a focused examination in women could be limited to ascertainment of costovertebral angle tenderness and, if the history suggests vulvovaginitis or cervicitis, to a lower abdominal and pelvic examination +++ 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 Download Section PDF Listen +++ +++ 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 for all women with upper tract symptoms (prior to initiating antibiotic therapy), as well as those with dysuria and a negative urine dipstick test In symptomatic women, a clean-catch urine culture is considered positive when 102–103 colony-forming units/mL of a uropathogenic organism is detected Renal imaging To rule out abscess or hydronephrosis, renal ultrasound or CT scanning should be done To exclude nephrolithiasis, noncontrast helical CT scanning is more accurate than intravenous urography and is now the diagnostic test of choice + Treatment Download Section PDF Listen +++ ++ Definitive treatment is directed to the underlying cause Antibiotic selection Guided by local resistance patterns Options for uncomplicated cystitis include Nitrofurantoin and cephalosporins Ciprofloxacin, fosfomycin, and trimethoprim-sulfamethoxazole can be considered, though there is increasing bacterial resistance to them 5 days of nitrofurantoin resulted in a significantly greater likelihood of clinical and microbiologic resolution than single-dose fosfomycin Options for women who are breastfeeding include Trimethoprim-sulfamethoxazole (unless G6PD deficiency is present) Amoxicillin Nitrofurantoin Ciprofloxacin Ofloxacin Phenazopyridine Can provide symptomatic relief Used in combination with antibiotic therapy (when a UTI has been confirmed) but for no more than 2 days Causes orange/red discoloration of urine and other bodily fluids and contact lens Rare cases of methemoglobinemia and hemolytic anemia have been reported, usually with overdoses or underlying kidney dysfunction Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been shown to be of symptomatic benefit but are less effective than antibiotic therapy Vaginal estrogen effectively relieves Urinary urgency Frequency Recurrent UTIs related to vulvovaginal atrophy of menopause (also known as genitourinary syndrome of menopause) In patients with recurrent UTIs and asymptomatic renal calculi, 50% may be rendered infection-free following stone extraction A 5-day course of fluoroquinolones in outpatient men with UTI is as effective as a 10-day course + Outcome Download Section PDF Listen +++ +++ When to Refer ++ Anatomic abnormalities leading to repeated UTIs Infections associated with nephrolithiasis Persistent interstitial cystitis/painful bladder syndrome +++ When to Admit ++ Severe pain requiring parenteral medication or impairing ambulation or urination (such as severe primary herpes simplex genitalis) Dysuria associated with urinary retention or obstruction Pyelonephritis with ureteral obstruction Symptoms and signs suggesting urosepsis + References Download Section PDF Listen +++ + +Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018 Feb 9;360:k341. [PubMed: 29438980] + +Dune TJ et al. Urinary symptoms and their associations with urinary tract infections in urogynecologic patients. Obstet Gynecol. 2017 Oct;130(4):718–25. [PubMed: 28885414] + +Gupta K et al. Urinary tract infection. Ann Intern Med. 2017 Oct 3;167(7):ITC49–64. [PubMed: 28973215] + +Hecht SL et al. Diagnostic work-up of lower urinary tract symptoms. Urol Clin North Am. 2016 Aug;43(3):299–309. [PubMed: 27476123] + +Huttner A et al. Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women: a randomized clinical trial. JAMA. 2018 May 1;319(17):1781–9. [PubMed: 29710295] + +Kang CI et al. Clinical practice guidelines for the antibiotic treatment of community-acquired urinary tract infections. Infect Chemother. 2018 Mar;50(1):67–100. [PubMed: 29637759] + +Köves B et al. Benefits and harms of treatment of asymptomatic bacteriuria: a systematic review and meta-analysis by the European Association of Urology Urological Infection Guidelines Panel. Eur Urol. 2017 Dec;72(6):865–8. [PubMed: 28754533] + +Kranz J et al. The 2017 update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1. Urol Int. 2018;100(3):263–70. [PubMed: 29342469] + +Kronenberg A et al. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. BMJ. 2017 Nov 7;359:j4784. Erratum in: BMJ. 2017 Nov 13;359:j5268. [PubMed: 29113968] + +Michels TC et al. Dysuria: evaluation and differential diagnosis in adults. Am Fam Physician. 2015 Nov 1;92(9):778–86. [PubMed: 26554471] + +Schaeffer AJ et al. Clinical Practice. Urinary tract infections in older men. N Engl J Med. 2016 Feb 11;374(6):562–71. [PubMed: 26863357] + +Waller TA et al. Urinary tract infection antibiotic resistance in the United States. Prim Care. 2018 Sep;45(3):455–66. [PubMed: 30115334]