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Home Books The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e

Chapter 40. Dysuria

Sara L. Swenson, MD

You receive a telephone call from a 32-year-old woman who complains of burning with urination over the past 12 hours. She also feels an intense need to urinate but reports difficulty voiding more than a small amount. She has experienced similar symptoms in the past and requests that you call in a prescription for antibiotics to her pharmacy.

  • What additional questions will you ask her?
  • What aspects of the patient history will enable you most efficiently to differentiate between benign and serious diagnoses?
  • Which questions, if any, can help you determine whether it is safe to treat her over the telephone?

Dysuria is defined as pain, burning, or discomfort experienced during or immediately after urination. Although it has a broad differential diagnosis, dysuria usually results from infection or inflammation of the bladder and/or urethra.1 The patient's age, sex, and sexual history can help the clinician quickly delineate the most likely causes of dysuria. When infection seems less likely, the characteristics and duration of the pain, associated symptoms, and the patient's medical comorbidities can effectively narrow the differential diagnosis.

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Acute dysuriaDysuria of less than 1 week in duration.
Internal dysuriaDysuria that is localized to the internal genital structures (urethra, bladder, suprapubic area).
External dysuriaDysuria that is localized to external genital structures (labia minora and majora) and occurs as urine exits the body.
UrgencyA sudden, compelling need to urinate that is often accompanied by bladder discomfort and the inability to void more than a minimal quantity of urine.
FrequencyUrinating more frequently than usual without an increase in total urine volume due to the bladder's decreased capacity to hold urine.
NocturiaWaking up to urinate 2 or more times during the night.
Voiding symptomsSymptoms that occur at the time of urination. These include a slow or intermittent urine stream, difficulty initiating urination (hesitancy), prolonged termination of urination (dribbling), and dysuria.
Storage symptomsSymptoms that occur during bladder storage and filling. These include urinary urgency or frequency, nocturia, and incontinence.
Urinary tract infection (UTI)An infection of the urethra, bladder, prostate, or kidney. Lower UTI implies infection of the urethra and/or bladder (ie, urethrocystitis or cystitis). Upper UTI usually indicates infection of the kidney (ie, pyelonephritis).
Complicated UTIUTI in individuals with functional or structural abnormalities of the urinary tract. Such individuals are at higher risk of treatment failure.
Positive likelihood ratioThe increase in the odds of a diagnosis if a given clinical factor is present.
Negative likelihood ratioThe decrease in the odds of a diagnosis if a given clinical factor is absent.

Dysuria usually reflects irritation or inflammation of the external genitalia (urethral meatus, labia majora/minora) or the lower (urethra, bladder) or upper (ureters, kidneys) genitourinary tract. Less commonly, referred pain from other pelvic or abdominal organs can lead to dysuria. Infection of the urinary tract (including the urethra, bladder, or prostate) ...

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