Dysuria

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

• UTIs affect up to 50% of women in their lifetime, with almost half of these women experiencing a recurrence in 6–12 months

• Recurrent UTIs after menopause may be more likely since normally lower levels of estrogen lead to changes in the urogenital epithelium and subsequently the urogenital microbiome

• 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

• 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

  • Pelvic floor myofascial pain

  • Pelvic congestion syndrome (dilated and refluxing pelvic veins)

• 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

  ...