Dysuria

Dysuria: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Lower urinary tract infection

❑ Acute pyelonephritis

❑ Urethritis

❑ Vaginitis

❑ Acute prostatitis

❑ Urethral calculus

❑ Reiter syndrome

Diagnostic Approach

In women, ask whether burning is internal (urinary tract infection) or external (vaginitis). Women who have had a prior urinary tract infection are more than 90% accurate in identifying recurrences.

The urine dipstick is a useful diagnostic adjunct for determining the presence of pyuria. Leukocyte esterase and nitrate tests are complementary, increasing the overall sensitivity.

Always consider a sexually transmitted infection, especially with minimal pyuria and/or a new sexual partner.

The combination of symptoms of dysuria and frequency without vaginal discharge or irritation has an overall likelihood ratio of 24.6 in predicting acute urinary tract infection.

Clinical Findings

Lower urinary tract infection  In women, infection is experienced as acute onset of urinary urgency, urinary frequency, and an internal burning sensation with passage of urine. There is often suprapubic tenderness and visible hematuria. In men, frequency and urgency are more prominent than burning. Bacterial bladder or upper tract infections are uncommon in young men unless a structural urinary tract abnormality is present. In older men, an infection often accompanies a high postvoid residual in bladder outlet obstruction.

Acute pyelonephritis  Dysuria is not always present. Fever, chills (even rigors), nausea, flank pain, and costovertebral angle percussion tenderness are indicators of upper tract infection.

Urethritis  It is distinguished from cystitis as sharp burning with urination but with little to no bladder-irritative symptoms. There may be a purulent (gonococcal) or clear mucoid (chlamydial) urethral discharge. Often, the patient has a new sexual partner. In women, cervicitis with mucopurulent discharge may accompany urethritis, and the discharge may be seen issuing from the urethra or cervical os.

Vaginitis  It is characterized by external burning with urination along with vaginal discharge and itching. There is no urinary frequency. A pelvic examination with a visible discharge and erythema will confirm signs of infection. Severe external burning and rawness should suggest herpes simplex.

Acute prostatitis  Burning during urination may occur, along with frequency, deep perineal pressure or aching, and pain with ejaculation or defecation. The sine qua non is a tender prostate on rectal exam, which may also be boggy. With a prostatic abscess, the prostate will be extremely tender, hot, and fluctuant.

Urethral calculus  Sharp pain in the urethra will accompany passage of a calculus. In men, the calculus may at times be palpated in the urethra on the underside of the penis.

Reiter syndrome  It presents with urethral burning along with conjunctivitis or iritis, acute symmetrical polyarthritis, mucosal ulcerations, and/or circinate balanitis.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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