Dysuria

What is dysuria?

Dysuria is the symptom of painful micturition (urination). It is a very common presentation in primary care. Treatment depends on identifying the underlying cause. See separate related articles on Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women.

Aetiology^{[1, 2]}

• Abdominal causes: dysuria can occur with emergency causes of abdominal pain such as appendicitis and ectopic pregnancy (due to irritation of nearby urinary structures).
• Urinary tract causes:
  • Urinary tract infection (UTI):
    • Bacterial UTI.
    • Urethritis - eg, chlamydia, gonococcus or non-gonococcal urethritis; in men aged <35, this is a common cause of dysuria.^[3]
    • Urinary schistosomiasis.
  • Interstitial cystitis.
  • Obstruction: prostatic enlargement (benign prostatic hyperplasia, prostate cancer), urethral stricture.
  • Stones (urolithiasis).
  • Malignancy - eg, carcinoma of the bladder or urethral tumours.
• Genital causes:
  • Urethral or vaginal trauma, including sexual abuse or a foreign body.
  • Genital herpes simplex.
  • Women: vaginitis - eg, vaginal candidiasis, atrophic vaginitis, bacterial vaginosis.
  • Men: prostatitis, epididymo-orchitis.
• Other disease:
  • Spondyloarthropathy - eg, reactive arthritis or Behçet's disease.
  • Compression from a pelvic mass.
• Irritants:
  • Drugs - eg, cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other non-steroidal anti-inflammatory drugs.^[4]
  • Chemical irritants: allergic or irritant reaction to soaps, vaginal lubricants, spermicides, contraceptive foams and sponges, tampons and toilet paper.
  • Mechanical irritation - eg, from a poorly fitting contraceptive diaphragm or vaginal ring pessary.
  • Radiation or chemical exposure.

Dysuria assessment

See also the separate Genitourinary History and Examination (Male) and Genitourinary History and Examination (Female) articles.

History

Depending on the situation, possible questions are:

• Pain symptoms:
  • Onset and duration of dysuria.
  • Whether there is abdominal pain. If it is present, consider abdominal pain causes - eg, appendicitis and ectopic pregnancy.
  • Radiation of pain (eg, to loin or back, suggesting upper urinary tract pathology).
• Other symptoms:
  • Fever, rigors or malaise - suggest pyelonephritis.
  • Haematuria - occurs with infection, stones, neoplasms and renal disease.
  • Urethral or vaginal discharge - consider genital tract infection.
  • Odour - suggests bacterial infection.
  • Pruritus - common with genital candidiasis.
  • Frequency and urgency - indicate bladder irritation.
  • Urine volume and flow - consider obstruction.
• Medical history:
  • Possible pregnancy.
  • Past history: previous UTI, other genitourinary disease, pelvic surgery or irradiation, other general illness, medication.
  • Recent sexual history; method of contraception; bear in mind the possibility of child sexual abuse.
  • Occupation: exposure to dyes and solvents is a risk factor for bladder cancer.

Examination

May not be required for simple situations - eg, if the history suggests uncomplicated lower UTI. If relevant, examine for:

• Fever, tachycardia and loin tenderness (pyelonephritis).
• Abdominal/pelvic tenderness, guarding, masses or adnexal tenderness; enlarged bladder.
• Vaginal discharge: candidiasis, genital herpes simplex or vaginitis.
• An enlarged prostate may be felt on rectal examination.
• If child sexual abuse is suspected, specialist assessment is required.

Investigations^{[5, 6]}

Consider the appropriate level of investigation for the clinical picture, or whether to treat empirically. Investigations are generally required for children and men with dysuria but not always for women.

Possible investigations for dysuria

Depending on the clinical picture, these include:

• Urine dipstick, microscopy and culture.
• Considering whether a pregnancy test is needed.
• Investigation for sexually transmitted infection (STI) - or referral to an STI clinic.
• Ultrasound of the urinary tract, pelvis or abdomen if there is suspicion of obstruction or masses.
• Plain kidney, ureters and bladder (KUB) X-ray if renal tract stones are suspected.
• Urodynamic studies.
• Urine cytology.
• Further tests (eg, cystoscopy) require a specialist setting.

See also the separate Urinary Tract Infection in Children, Urinary Tract Infection in Adults and Imaging of the Urinary Tract articles.