Dysuria

Dysuria: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

David M. Quillen

Approach

 Dysuria is defined as “painful urination.” Acute dysuria is a frequent problem seen in ambulatory practices, accounting for more than three million office visits a year. The most common diagnosis given for patients with dysuria is a urinary tract infection (UTI). Estimated cost for traditional management of acute UTIs approaches $1 billion per year in the United States. Although a UTI is the most common cause for dysuria symptoms, many other causes need to be accurately diagnosed. The differential diagnosis for patients with dysuria can be separated into broad categories. With a few notable exceptions, the differential diagnoses for men and women are similar, although the incidences are much different and change with age (1–2).

 A. Causes of dysuria—Female

1. Infectious

a. Cystitis, lower UTI, with or without pyelonephritis

 b. Urethritis caused by a sexually transmitted disease (STD): chlamydia, Neisseria gonorrhoeae, herpes simplex virus (HSV)

 c. Vulvovaginitis: bacterial vaginosis, trichomoniasis, yeast, genital HSV

 2. Noninfectious

a. Trauma, irritant, allergy, sexual abuse

B. Causes of dysuria—Male (3)

1. Infectious

a. Urethritis caused by chlamydia, N. gonorrhoeae, yeast (uncircumcised, balanitis), HSV (Chapter 10.9)

b. Cystitis (if culture positive, possible anatomic abnormality, further workup indicated)

c. Prostatitis, acute more common than chronic (4)

2. Noninfectious

a. Penile lesions, trauma, sexual abuse

History

A good general history is critical and can help direct further questions.

 A. Distinguishing between symptoms of “internal” dysuria and “external” dysuria is often helpful. Internal dysuria is where the discomfort seems to be centered inside the body and begins before or with the initiation of voiding. External dysuria is when the discomfort appears after voiding has initiated. Symptoms of internal dysuria suggest inflammation of the bladder or urethra, whereas those of external dysuria suggest vaginitis, vulvar inflammation, or external penile lesions.

 B. Careful questioning about other associated symptoms and risk factors is the key to sorting out the diagnosis. The history of a new sex partner may support an STD cause. Diaphragm usage may support a bladder infection as well as associated symptoms of frequency, urgency, voiding small volumes, hematuria, and abrupt onset. Gradual onset is more suggestive of urethritis and external causes. Other symptoms of suprapubic pain, costovertebral angle tenderness, fever, flank pain, and so on should be asked about and can direct the diagnostic workup.

Physical examination

 The physical examination is essential in narrowing the diagnosis. It helps to rule out pyelonephritis and other systemic infections in patients with dysuria, allowing the physician to search for the less severe causes. Fever, flank tenderness, and suprapubic tenderness are useful findings. A careful genital examination (speculum in women, foreskin retraction and prostate examination in uncircumcised men) can point to specific localized causes. The genital examination also allows collection of samples for testing. Attention to localized lesions (e.g., HSV lesions), discharge (yeast, bacterial vaginosis, gonorrhea, and trichomoniasis) and trauma also help make the diagnosis.

Testing

The history and physical examination usually suggests which tests are most appropriate. A urinalysis is the most common study performed. It is important also to gather samples for gonorrhea, chlamydia, and HSV, using wet preparations and potassium hydroxide testing when appropriate. Rapid tests on urine samples for the detection of bacteria and leukocytes can be done while patients wait. Direct microscopic examination of the urine can isolate bacteria and leukocytes. Rapid dipstick biochemical tests can isolate leukoesterase and nitrate, which are consistent with leukocytes and urea-fixing bacteria. Urine cultures require overnight to 48 hours of incubation to detect specific bacterial pathogens. Pyuria (defined as white blood cell count >10/mm³ of urine) is seen in more than 95% of patients with acute UTI but is uncommon in the absence of infection. Pyuria without bacteriuria suggests a chlamydia infection. Urine dipstick testing is generally less sensitive for pyuria than microscopic examination, but it is more convenient (5).

Diagnostic assessment

Given the many causes of dysuria, an accurate diagnosis can be difficult without a thorough approach to each patient. Because most causes have other associated symptoms and findings, a diagnosis can usually be made with a carefully taken history, a focused physical examination, and appropriate laboratory tests. Separating an uncomplicated UTI or STD from the more serious pyelonephritis and other possible diagnoses is the challenge in these patients.

References

1. Carlson KJ, Mulley AG. Management of acute dysuria. Ann Intern Med 1985;102:
244–249.

2. Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract infections. Infect Dis Clin North Am 1987;4(1):773–791.

3. Ainsworth JG, Weaver T, Murphy S, Renton A. General practitioners’ immediate management of men presenting with urethral symptoms. Genitourin Med  1996;72(6):427–430.

4. Roberts RO, Lieber MM, Rhodes R, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998;51(4):578–584.

5. Kurowiski K. The woman with dysuria. Am Fam Physician 1998;57(9):2155–2164, 2169–2170.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

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