Evaluation of Dysuria in Adults
Evaluation of Dysuria in Adults
Evaluation of Dysuria in Adults
D
Members of various ysuria is the sensation of pain, percent of American women report acute
family practice depart- burning, or discomfort on dysuria every year.10 The symptom is most
ments develop articles
urination.1,2 Although many prevalent in women 25 to 54 years of age and
for “Problem-Oriented
Diagnosis.” This article physicians equate dysuria in those who are sexually active.11 In men,
is one in a series from with urinary tract infection dysuria and its associated symptoms become
the Department of (UTI), it is actually a symptom that has many more prevalent with increasing age.6
Family Practice at potential causes. Empiric treatment with
SUNY Health Science Causes of Dysuria
antibiotics may be inappropriate, except in
Center at Brooklyn
carefully selected patients.3-5 INFECTION AND INFLAMMATION
College of Medicine.
Guest coordinator of Dysuria most often indicates infection or Infection is the most common cause of
the series is Miriam inflammation of the bladder and/or urethra. dysuria and presents as cystitis, prostatitis,
Vincent, M.D. Other common causes of dysuria include pro- pyelonephritis, or urethritis, depending on the
statitis and mechanical irritation of the ure- area of the urogenital tract that is most
thra in men, and urethrotrigonitis and vagini- affected. The hollow or tubular structures of
tis in women. Dysuria can also result from the urinary system are vulnerable to infection
malformations of the genitourinary tract, by coliform bacteria. These bacteria are
neoplasms, neurogenic conditions, trauma, believed to gain access to the urethral meatus
hormonal conditions, interstitial cystitis, and through sexual intercourse or local contami-
psychogenic disorders6-8 (Table 1). nation and then ascend to the affected region.1
Dysuria accounts for 5 to 15 percent of vis- A community-based study10 found that
its to family physicians.9 Approximately 25 about two thirds of culture-proven UTIs are
caused by Escherichia coli. Other less frequent
pathogens include Staphylococcus saprophyticus
Infection is the most common cause of dysuria and presents (15 percent), Proteus mirabilis (10 percent),
Staphylococcus aureus (5 percent), Enterococ-
as cystitis, prostatitis, pyelonephritis, or urethritis, depending
cus species (3 percent), and Klebsiella species
on the area of the urogenital tract that is most affected. (3 percent).
Abnormalities in urinary anatomy or func-
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TABLE 1
Selected Causes of Dysuria
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Dysuria
whereas a history of internal dysuria (pain felt Longer duration and more gradual onset of
inside the body) suggests bacterial cystitis or symptoms may suggest C. trachomatis infec-
urethritis.1 Pain at the onset of urination is tion, whereas sudden onset of symptoms and
usually caused by urethral inflammation, but hematuria suggests bacterial infection.
suprapubic pain after voiding is more sugges- It is important to inquire about the presence
tive of bladder inflammation or infection. of other genitourinary symptoms. Dysuria is
Epididymitis
Urethral smear and culture or orchitis Inflammation, secretions
Painful Ulcer Irritation
vesicles of glans
Yes No
Herpes Chancroid, Balanitis
Positive Negative syphilis,
or LGV Prostatitis Prostatodynia
Gonococcal Nongonococcal
urethritis urethritis
*—Because UTI is the most common cause of dysuria in men and women, urinalysis may be useful at any stage of the evaluation to confirm or
rule out an infectious process.
FIGURE 1. Suggested algorithm for the evaluation of acute dysuria in patients of either gender or both genders. (LGV =
lymphogranuloma venereum; STD = sexually transmitted disease; UTI = urinary tract infection)
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Evaluation of Acute Dysuria (continued)
Yes No
Yes No
Positive Negative
Neoplasm, ureteral Mechanical cause of dysuria
stone, or bladder (e.g., bladder dysfunction),
Neoplasm, stone ureteral stricture, diverticuli,
nephrolithiasis, BPH, prostatodynia,
≥ 103 CFU per mL, < 103 CFU per mL, two tuberculosis, epididymitis, orchitis,
single organism or more organisms or BPH perineal inflammation,
interstitial cystitis,† or
psychogenic factors
FIGURE 1. Suggested algorithm for the evaluation of acute dysuria in patients of either gender. (UTI = urinary tract infec-
tion; CFU = colony-forming unit; BPH = benign prostatic hyperplasia)
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TABLE 2
Possible Diagnoses Based on the History
in Patients with Dysuria
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TABLE 3
Possible Diagnoses Based on the Physical Findings
in Patients with Dysuria
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Dysuria
TABLE 4
Diagnostic Testing in Patients with Dysuria
Urinalysis History of internal dysuria Used for screening; inexpensive, easy to perform
Urine culture Patients in whom covert bacteriuria can cause Accurate diagnosis of infection; helpful for determining
complications, such as pregnant women and antimicrobial susceptibility of infecting bacteria21
patients with disorders that affect immune
status (e.g., diabetes mellitus)21
All male patients with suspected UTI4
Urine cytology Gold standard for bladder cancer screening22 Poor sensitivity but excellent specificity; can detect
high-grade malignant cells before cystoscopically
distinguishable gross lesion is present
Vaginal and urethral Vaginal and urethral discharge Easy to perform; wet-mount preparation can detect
smears Trichomonas vaginalis and Candida species; Gram
staining can detect Neisseria gonorrhoeae
Vaginal cultures Must be used in cases of rape or child abuse Gold standard (specificity close to 100 percent for
N. gonorrhoeae and Chlamydia trachomatis )
Ligase chain reaction Suspected STD Detects N. gonorrhoeae and C. trachomatis; results
and polymerase available sooner than with cultures
chain reaction tests
Ultrasonography Suspected upper urinary tract pathology Noninvasive, relatively inexpensive, and rapid in
(e.g., abscess, hydroureter, hydronephrosis) emergencies; no exposure to radiation or contrast medium
Suspected stones or diverticula in the bladder, Limitations: user dependent; poor visualization in obese
suspected stones in the urethra patients and patients with open wounds, and dressings or
other devices overlying pertinent area
Plain-film radiography Unusual gas patterns (e.g., emphysematous Inexpensive
of kidneys, ureters, pyelonephritis) Limitations: lack of visualization if urinary tract is obscured
and bladder Suspected stones (if radiopaque) by gas, feces, contrast medium, or foreign bodies in
intestine; clear visualization prevented by uterine fibroids,
ovarian lesions, obesity, and ascites
Intravenous pyelography Recurrent UTI Visualization of renal parenchyma, calyces pelvis, ureters,
bladder, and, occasionally, urethra; therefore, can identify
extent of urinary obstruction
Voiding Assessment for causes of chronic dysuria, such as Highly accurate in determining extent of vesicoureteric reflux
cystourethrography congenital abnormalities of lower urinary tract
and abnormal bladder (e.g., vesicoureteric reflux,
neurogenic bladder, BPH, urethral strictures,
diverticula)
CT with and without Discrimination of different types of solid tissue Contrast-enhanced CT is radiologic test of choice; easy to
contrast medium, (noncontrast study) perform and easily accessible; improved visualization in
helical CT23,24 Detection of calcifications in renal parenchyma obese patients
or ureter No misregistration artifacts with helical CT (unlike regular
Improved visualization of avascular structures CT with or without contrast medium); therefore, reliable
such as cysts, abscesses, necrotic tumors, and demonstration of small lesions
infarcts (contrast study)
Measurement of concentrating ability of kidneys
MRI23 Identification of urinary tract obstruction or mass Useful in patients with renal insufficiency or allergy to
Evaluation of renal function iodinated contrast media, because gadolinium contrast
Evaluation of renal vasculature (MRA) agents are non-nephrotoxic and hypoallergenic
Without contrast medium, MRI is not the screening
method for renal masses; when contrast medium and
fat suppression are used, sensitivity of MRI is comparable
to that of CT with contrast medium.
Cystoscopy Detection of bladder or urethral pathology Direct visualization, allowing for biopsy and histologic
Confirmation of diagnosis of interstitial cystitis diagnosis
UTI = urinary tract infection; STD = sexually transmitted disease; BPH = benign prostatic hyperplasia; CT = computed tomographic scanning;
MRI = magnetic resonance imagine; MRA = magnetic resonance angiography.
Information from references 4 and 21 through 24.
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Dysuria
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