II. Definitions
- Dysuria
- Burning or stinging of the Urethra with voiding
- Urethritis
- Transitional Epithelium (Urothelium)
- Lines the lower urinary tract (Bladder and proximal Urethra) as well as the upper tract (ureters and Kidneys)
- Distal Urethra is instead lined by stratified squamous epithelium
- Barrier to urinary tract toxins
- Multilayer cuboid Cell Structure allows the epithelium to expand and contract
- Disrupted by Trauma, infection, inflammation or obstruction
- Lines the lower urinary tract (Bladder and proximal Urethra) as well as the upper tract (ureters and Kidneys)
- Lamina propria (submucosa)
- Muscularis Propria (Detrusor Muscle)
- Bladder Smooth Muscle comprises the outer layer
III. Physiology
IV. Causes: By Cohort
- See Dysuria in Women
- See Dysuria in Men
- See Dysuria in Children
V. Causes: Infectious
-
Urinary Tract Infection
- Cystitis
- Pyelonephritis
- Urethritis
-
Sexually Transmitted Infections
- White discharge
- Watery or no discharge
- Chlamydia Trachomatis (15-40% of cases)
- Gut Flora (following anal intercourse)
- Genital Herpes Simplex Virus (HSV II)
- Mycoplasma Genitalium (15-20% of Non-Gonococcal Urethritis causes in women)
- Ureaplasma Urealyticum
- Trichomonas vaginalis
- Other genitourinary infections by gender
- Women
- Men
- Uncommon infections in either gender
- Adenovirus
- Mumps
- Schistosoma Haematobium
VI. Causes: Dermatologic
-
Contact Dermatitis or chemical irritation
- See Periuretheral Contact Dermatitis in Women
- Spermacidal gel
- Topical deodorants
- Lichen Sclerosus
- Lichen Planus
- Psoriasis
- Behcet Syndrome
-
Stevens-Johnson Syndrome
- May cause vulvovaginal erosions and ulcerations
VII. Causes: Medication and food causes of Dysuria
- See Dysuria due to Genitourinary Contact Dermatitis
- Medications
- Food and herbal supplement adverse effects
- Saw Palmetto
- Pumpkin seeds
- Acidic Foods
- Alcohol
- Artificial Sweeteners
- Carbonated beverages
- Caffeine
VIII. Causes: Miscellaneous - General (Either gender)
-
Urethral
- Urethral Stricture
- Urethral Diverticulum
- Urethral foreign body
- Reiter's Syndrome
- Local Urethral Trauma (e.g. Bicycling, horse back riding)
- Genitourinary instrumentation or surgery
- Bladder
- Kidney
-
Abdomen and Pelvis
- Lymphoma
- Pelvic Irradiation
- Genitourinary foreign body (e.g. stent)
IX. Causes: Miscellaneous - Men
- See Dysuria in Men
- Phimosis
- Balanitis
-
Penis
- Penile Cancer involving Urethra
-
Prostate
- Prostatitis
- Benign Prostatic Hyperplasia
- Prostate Cancer (advanced with urinary obstruction)
X. Causes: Miscellaneous - Women
- See Dysuria in Women
-
Vulva and Vagina
- Atrophic Vaginitis (Menopause)
- Vaginal cancer
- Vulvar Cancer
-
Uterus
- Endometriosis
- Uterine Fibroids (paraurethral)
XI. Causes: Psychogenic and social
- Somatization
- Chronic Pain Syndrome (e.g. Chronic Pelvic Pain)
- Major Depression
- Chemical Dependency
- Sexual abuse
XII. History: Characteristics of Dysuria
- Timing
- Pain location
- Cystitis
- Bladder Distention
- Suprapubic or retropubic pressure
- Vaginitis
- External pain distribution
- Prostatitis (or other deeper pelvic source)
- Deep perineal pain
- Epididymitis
XIII. History: Associated symptoms and contributing factors
-
Bladder and lower urinary tract symptoms
- Urinary Frequency or urinary urgency
- Hematuria
- Abnormal Urine Odor
- Urinary Incontinence
- Nocturia
- Kidney and upper urinary tract symptoms
- Past medical history
- Pyelonephritis
- Nephrolithiasis
- Sexually Transmitted Infection
- Genitourinary procedures
- Genitourinary malignancy
- Medications and topical agents
- Exposures to possible urinary tract irritants or external Contact Dermatitis causes
- Additional history in women
- Pregnancy, current Contraception and Last Menstrual Period
- Vaginal Discharge or vaginal irritation
- Additional history in men
XIV. Exam
- Abdominal exam
- Abdominal tenderness (e.g. suprapubic tenderness)
- Flank tenderness (Costovertebral Angle Tenderness)
- Suprapubic fullness (Bladder Distention)
- Female genitourinary exam
- Vulvar lesions (e.g. vessicles or ulcerations as in HSV)
- Inguinal Lymphadenopathy
- Vaginal Discharge
- Vaginal Atrophy
- Cervical discharge
- Cervical motion tenderness
- Male genitourinary exam
- Penile discharge
- Penile Lesions, esp. at meatus (e.g. Vesicles, ulcers)
- Inguinal Lymphadenopathy
- Epididymal or testicular tenderness
- Swollen, tender Prostate
- Skin exam
- Localized genitourinary dermatitis (e.g. HSV, Contact Dermatitis, chronic inflammatory condition)
-
Polyarthritis
- Gonococcus (associated with scattered Pustules)
- Reiter's Syndrome (associated with Conjunctivitis)
XV. Labs
- Urinalysis
- Urine Culture
- STD Testing for Urethritis
- Gonorrhea PCR
- Chlamydia PCR testing
- Wet Prep
- Trichomonas PCR (NAAT)
- Mycoplasma Genitalium (CDC approved testing available as of 2019)
- Consider in persistent or recurrent Urethritis
- Also offer HIV Test, Hepatitis B and Syphilis Test
XVI. Imaging
-
Bladder and renal Ultrasound (or Bedside Ultrasound)
- Bladder Distention (may also be detected with Bladder scan or post-void residual catheterization)
- Hydronephrosis
- CT Abdomen and Pelvis without contrast
-
CT Abdomen and Pelvis with and without contrast (CT Urogram)
- Hematuria evaluation for malignancy
-
Cystoscopy
- Hematuria evaluation for malignancy
- Interstitial Cystitis
XVII. Management: General
- Symptomatic Management
- Phenazopyridine (Pyridium)
-
Antibiotic indications
- Urinary Tract Infection or Pyelonephritis
- Sexually Transmitted Infection or Pelvic Inflammatory Disease (see Urethritis below)
- Suspected Acute Prostatitis
- May be associated with Pelvic Pain, worse on Defecation and with ejaculation
XVIII. Management: Urethritis
- Treat as Sexually Transmitted Infection
- Despite risk of overtreatment, treat for suspected Chlamydia and Gonorrhea (prevents spread, complications)
- Gonorrhea management
- Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
- Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
- Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
- Chlamydia management
- Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
- Azithromycin 1 g orally for 1 dose
- References
- Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6
- Gonorrhea management
- Other management
- Consider Genital Herpes
- Treat Trichomonas vaginalis if present
- Metronidazole 2 grams orally or 500 mg orally twice daily for 7 days OR
- Tinidazole 2 grams orally
- As noted above, offer other STD testing (e.g. HIV Test, Syphilis Test)
- Treat sexual partners
XIX. Management: Persistent Dysuria with unremarkable evaluation
- Urge Incontinence or Overactive Bladder
- Topical or systemic irritants
- See Dysuria due to Genitourinary Contact Dermatitis
- Discontinue offending agents
XX. ' Consider regional pain sources (primarily women)
- Vulvar symptoms
-
Endometriosis (affecting female urinary tract)
- Cyclical urinary symptoms (cyclical Gross Hematuria may occur)
-
Interstitial Cystitis
- Persistent >6 weeks of Pelvic Pain/pressure and Urinary Frequency, urgency (+/- Dysuria)
- Urethral Diverticulum (women)
- Consider empiric treatment for Mycoplasma Genitalium if testing is unavailable