III. History: Associated symptoms and contributing factors

IV. Exam

  1. Abdominal exam
    1. Abdominal tenderness (e.g. suprapubic tenderness)
    2. Flank tenderness (costovertebral angle tenderness)
    3. Suprapubic fullness (Bladder distention)
  2. Female genitourinary exam
    1. Vulvar lesions (e.g. vessicles or ulcerations)
    2. Inguinal Lymphadenopathy
    3. Vaginal Discharge
    4. Vaginal Atrophy
    5. Cervical discharge
    6. Cervical motion tenderness
  3. Skin exam
    1. Localized genitourinary dermatitis (e.g. HSV, Contact Dermatitis, chronic inflammatory condition)

V. Symptoms and Signs

VI. Evaluation

  1. Urine Sample
    1. Urinalysis
    2. Urine Culture
  2. Vaginitis suspected: Vaginal Discharge examination
    1. KOH Preparation
    2. Saline Preparation (Wet Prep)
  3. Sexually active patient
    1. Urine Pregnancy Test
    2. Gonorrhea PCR and Chlamydia PCR
    3. Consider Gram Stain of cervical discharg

VII. Management: Persistent Dysuria with unremarkable evaluation

  1. Consider Topical or systemic irritants
    1. Discontinue offending agents
  2. Consider treating for Ureaplasma in sexually active women
    1. Doxycycline for 7 days or Azithromycin for 5 days
    2. Consider adding Metronidazole 2 g orally once (covers Trichomonas)
  3. Consider empiric trimethoprim
    1. 75% Respond to trimethoprim (25% for Placebo) who had Dysuria with negative UA/UC
    2. Richards (2005) BMJ 331:143-6 [PubMed]
  4. Consider Urge Incontinence or Overactive Bladder
    1. Pelvic Floor Exercises and Bladder TrainingExercises

VIII. ' Consider regional pain sources

    1. Endometriosis
    2. Interstitial Cystitis
  1. Consider imaging or Consultation with urology
    1. Persistent Microscopic Hematuria not due to Menses
    2. Sterile pyuria (not due to Vaginitis, STI, dermatitis or other gynecologic cause)

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