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For further information, see CMDT Part 2-12: 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

  • 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


  • 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 in sexually active women age ≤ 25 years who seek medical attention for UTI symptoms for the first time or who have a new sexual partner

  • Women with suspected acute pyelonephritis

    • Clinical criteria are fever, back pain, nausea, and vomiting

    • Exclude coexistent urosepsis, hydronephrosis, or nephrolithiasis before initiation of treatment since it would affect management decisions

    • Risk factors for acute pyelonephritis in women 18- to 49-years-old

      • Relate to sexual behaviors (sexual intercourse at least three times a week, new sexual partner in previous year, recent spermicide use)

      • Diabetes

      • Recent UTI

      • Incontinence

  • 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

  • If uncomplicated, a focused examination in women includes

    • Costovertebral angle tenderness

    • 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

    • Pelvic floor myofascial pain

    • Pelvic congestion syndrome (dilated and refluxing pelvic veins)

  • In men

    • Urethritis (eg, Mycoplasma genitalium)

    • Prostatitis (eg, Enterobacteriaceae)


Diagnostic Studies

  • Urinalysis

    • Most helpful in atypical presentations of cystitis

    • Dipstick detection (> trace) of leukocytes, nitrites, or blood

      • Supports a diagnosis of ...

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