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

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 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)

Diagnosis

Diagnostic Studies

• Urinalysis

  • Most helpful in atypical presentations of cystitis

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

    • Supports a diagnosis of ...