DYSURIA

Ask the following questions:

1. Is there fever? A significant fever would suggest either pyelonephritis, particularly in females, or acute prostatitis in males.
2. Is the urine grossly bloody or are there a significant number of red cells on microscopic examination? Grossly bloody urine in a young female should suggest acute cystitis, particularly if she has just returned from a honeymoon. In older patients it may indicate bladder carcinoma, but generally these patients have blood in their urine before they develop dysuria. Really significant blood in the urine may also indicate schistosomiasis or tuberculous cystitis. Dysuria and hematuria can occur in renal or vesicular calculi as well.
3. Is there a urethral or vaginal discharge? If either of these signs is present, one must consider that the patient may have gonorrhea until proven otherwise. Repeated negative smears and cultures for gonococcus should suggest that the patient may have female urethral syndrome or nonspecific urethritis due to chlamydia.
4. Are there systemic symptoms? If there are systemic symptoms, one must consider the possibility of Reiter's syndrome or collagen disease. One should not forget that systemic symptoms of arthritis and rash may also be present in gonorrhea.
5. Is the pain very severe? Severe pain, particularly a need to stay close to the restroom so one can empty one's bladder, may indicate tabes dorsalis, although this condition is rarely seen today.

DIAGNOSTIC WORKUP

Obviously, a urinalysis and Gram stain of the unspun urine should be done in all cases. If this is positive, treatment can be initiated. Urine cultures are only necessary for resistant or repeated episodes. I also recommend a urethral smear and a vaginal smear and culture if sufficient material can be obtained. This may mean massaging the prostate for an adequate specimen. Even four white cells per high-powered field on a urethral smear probably indicates urethritis. Cultures for both gonorrhea and chlamydia should be done. In persistent cases of dysuria, an intravenous pyelogram and a cystoscopy must be done. A urologist needs to be consulted before ordering these tests. Blood cultures should be done in cases of acute pyelonephritis. Cultures for anaerobic bacilli and tuberculosis may be necessary in persistent pyuria. It should go without saying that a rectal and vaginal examination should be done in all cases. However, this is frequently neglected.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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