Dysuria

For further information, see CMDT Part 2-12: Dysuria

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

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)

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

• 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

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