Dysuria

Aka: Dysuria, Urethritis

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II. Definitions

  1. Dysuria
    1. Burning or stinging of the Urethra with voiding
  2. Urethritis
    1. Urethral inflammation with Dysuria, Pruritus or burning or visible discharge from meatus
  3. Transitional Epithelium (Urothelium)
    1. Lines the lower urinary tract (Bladder and proximal Urethra) as well as the upper tract (ureters and Kidneys)
      1. Distal Urethra is instead lined by stratified squamous epithelium
    2. Barrier to urinary tract toxins
    3. Multilayer cuboid Cell Structure allows the epithelium to expand and contract
    4. Disrupted by Trauma, infection, inflammation or obstruction
  4. Lamina propria (submucosa)
    1. Lies deep to the epithelium of the Urethra and Bladder
    2. Contains neurovacular structures, including Urethra and Bladder innervation
  5. Muscularis Propria (Detrusor Muscle)
    1. Bladder Smooth Muscle comprises the outer layer

III. Physiology

  1. Dysuria may originate from the Urethra's lamina propria or may be referred from the Bladder

IV. Causes: By Cohort

  1. See Dysuria in Women
  2. See Dysuria in Men
  3. See Dysuria in Children

V. Causes: Infectious

  1. Urinary Tract Infection
    1. Cystitis
    2. Pyelonephritis
    3. Urethritis
  2. Sexually Transmitted Infections
    1. White discharge
      1. NeisseriaGonorrhea
    2. Watery or no discharge
      1. Chlamydia Trachomatis (15-40% of cases)
      2. Gut Flora (following anal intercourse)
      3. Genital Herpes Simplex Virus (HSV II)
      4. Mycoplasma Genitalium (15-20% of Non-Gonococcal Urethritis causes in women)
      5. Ureaplasma Urealyticum
      6. Trichomonas vaginalis
  3. Other genitourinary infections by gender
    1. Women
      1. See Dysuria in Women
      2. Vulvovaginitis (e.g. Bacterial Vaginosis, Yeast Vaginitis)
      3. Cervicitis
    2. Men
      1. See Dysuria in Men
      2. Prostatitis
      3. Epididymitis or Orchitis
      4. Balanitis
    3. Uncommon infections in either gender
      1. Adenovirus
      2. Mumps
      3. Schistosoma Haematobium

VI. Causes: Dermatologic

  1. Contact Dermatitis or chemical irritation
    1. See Periuretheral Contact Dermatitis in Women
    2. Spermacidal gel
    3. Topical deodorants
  2. Lichen Sclerosus
  3. Lichen Planus
  4. Psoriasis
  5. Behcet Syndrome
  6. Stevens-Johnson Syndrome
    1. May cause vulvovaginal erosions and ulcerations

VII. Causes: Medication and food causes of Dysuria

  1. See Dysuria due to Genitourinary Contact Dermatitis
  2. Medications
    1. Dopamine
    2. Cantharidin
    3. Ticarcillin
    4. Penicillin G
    5. Cyclophosphamide
    6. Opioids
    7. Ketamine
    8. Nifedipine
    9. SGLT2 Inhibitors
  3. Food and herbal supplement adverse effects
    1. Saw Palmetto
    2. Pumpkin seeds
    3. Acidic Foods
    4. Alcohol
    5. Artificial Sweeteners
    6. Carbonated beverages
    7. Caffeine

VIII. Causes: Miscellaneous - General (Either gender)

  1. Urethral
    1. Urethral Stricture
    2. Urethral Diverticulum
    3. Urethral foreign body
    4. Reiter's Syndrome
    5. Local Urethral Trauma (e.g. Bicycling, horse back riding)
    6. Genitourinary instrumentation or surgery
  2. Bladder
    1. Bladder Cancer
  3. Kidney
    1. Renal Cancer
    2. Nephrolithiasis
  4. Abdomen and Pelvis
    1. Lymphoma
    2. Pelvic Irradiation
    3. Genitourinary foreign body (e.g. stent)

IX. Causes: Miscellaneous - Men

  1. See Dysuria in Men
  2. Phimosis
  3. Balanitis
  4. Penis
    1. Penile Cancer involving Urethra
  5. Prostate
    1. Prostatitis
    2. Benign Prostatic Hyperplasia
    3. Prostate Cancer (advanced with urinary obstruction)

X. Causes: Miscellaneous - Women

  1. See Dysuria in Women
  2. Vulva and Vagina
    1. Atrophic Vaginitis (Menopause)
    2. Vaginal cancer
    3. Vulvar Cancer
  3. Uterus
    1. Endometriosis
    2. Uterine Fibroids (paraurethral)

XI. Causes: Psychogenic and social

  1. Somatization
  2. Chronic Pain Syndrome (e.g. Chronic Pelvic Pain)
  3. Major Depression
  4. Chemical Dependency
  5. Sexual abuse

XII. History: Characteristics of Dysuria

  1. Timing
    1. Start of void: Urethral source
    2. End of void: Bladder source
  2. Pain location
    1. Cystitis
      1. Bladder and Urethral pain
    2. Bladder Distention
      1. Suprapubic or retropubic pressure
    3. Vaginitis
      1. External pain distribution
    4. Prostatitis (or other deeper pelvic source)
      1. Deep perineal pain
    5. Epididymitis
      1. Testicular Pain

XIII. History: Associated symptoms and contributing factors

  1. Bladder and lower urinary tract symptoms
    1. Urinary Frequency or urinary urgency
    2. Hematuria
    3. Abnormal Urine Odor
    4. Urinary Incontinence
    5. Nocturia
  2. Kidney and upper urinary tract symptoms
    1. Flank Pain
    2. Fever
    3. Nausea or Vomiting
  3. Past medical history
    1. Pyelonephritis
    2. Nephrolithiasis
    3. Sexually Transmitted Infection
    4. Genitourinary procedures
    5. Genitourinary malignancy
  4. Medications and topical agents
    1. Exposures to possible urinary tract irritants or external Contact Dermatitis causes
  5. Additional history in women
    1. Pregnancy, current Contraception and Last Menstrual Period
    2. Vaginal Discharge or vaginal irritation
  6. Additional history in men
    1. Benign Prostatic Hyperplasia
    2. Testicular Pain

XIV. 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 as in HSV)
    2. Inguinal Lymphadenopathy
    3. Vaginal Discharge
    4. Vaginal Atrophy
    5. Cervical discharge
    6. Cervical motion tenderness
  3. Male genitourinary exam
    1. Penile discharge
    2. Penile Lesions, esp. at meatus (e.g. Vesicles, ulcers)
    3. Inguinal Lymphadenopathy
    4. Epididymal or testicular tenderness
    5. Swollen, tender Prostate
  4. Skin exam
    1. Localized genitourinary dermatitis (e.g. HSV, Contact Dermatitis, chronic inflammatory condition)
  5. Polyarthritis
    1. Gonococcus (associated with scattered Pustules)
    2. Reiter's Syndrome (associated with Conjunctivitis)

XV. Labs

  1. Urinalysis
  2. Urine Culture
  3. STD Testing for Urethritis
    1. Gonorrhea PCR
    2. Chlamydia PCR testing
    3. Wet Prep
    4. Trichomonas PCR (NAAT)
    5. Mycoplasma Genitalium (CDC approved testing available as of 2019)
      1. Consider in persistent or recurrent Urethritis
    6. Also offer HIV Test, Hepatitis B and Syphilis Test

XVI. Imaging

  1. Bladder and renal Ultrasound (or Bedside Ultrasound)
    1. Bladder Distention (may also be detected with Bladder scan or post-void residual catheterization)
    2. Hydronephrosis
  2. CT Abdomen and Pelvis without contrast
    1. Nephrolithiasis
  3. CT Abdomen and Pelvis with and without contrast (CT Urogram)
    1. Hematuria evaluation for malignancy
  4. Cystoscopy
    1. Hematuria evaluation for malignancy
    2. Interstitial Cystitis

XVII. Management: General

  1. Symptomatic Management
    1. Phenazopyridine (Pyridium)
  2. Antibiotic indications
    1. Urinary Tract Infection or Pyelonephritis
    2. Sexually Transmitted Infection or Pelvic Inflammatory Disease (see Urethritis below)
    3. Suspected Acute Prostatitis
      1. May be associated with Pelvic Pain, worse on Defecation and with ejaculation

XVIII. Management: Urethritis

  1. Treat as Sexually Transmitted Infection
  2. Despite risk of overtreatment, treat for suspected Chlamydia and Gonorrhea (prevents spread, complications)
    1. Gonorrhea management
      1. Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
      2. Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
      3. Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
    2. Chlamydia management
      1. Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
      2. Azithromycin 1 g orally for 1 dose
    3. References
      1. Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6

        1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  3. Other management
    1. Consider Genital Herpes
    2. Treat Trichomonas vaginalis if present
      1. Metronidazole 2 grams orally or 500 mg orally twice daily for 7 days OR
      2. Tinidazole 2 grams orally
  4. As noted above, offer other STD testing (e.g. HIV Test, Syphilis Test)
  5. Treat sexual partners
    1. See Expedited Partner Treatment

XIX. Management: Persistent Dysuria with unremarkable evaluation

  1. Urge Incontinence or Overactive Bladder
    1. Pelvic Floor Exercises and Bladder TrainingExercises
  2. Topical or systemic irritants
    1. See Dysuria due to Genitourinary Contact Dermatitis
    2. Discontinue offending agents

XX. ' Consider regional pain sources (primarily women)

    1. Vulvar symptoms
      1. Vulvodynia
      2. Vulvar Vestibulitis
      3. Vulvovaginal Atrophy (Menopause)
    2. Endometriosis (affecting female urinary tract)
      1. Cyclical urinary symptoms (cyclical Gross Hematuria may occur)
    3. Interstitial Cystitis
      1. Persistent >6 weeks of Pelvic Pain/pressure and Urinary Frequency, urgency (+/- Dysuria)
    4. Urethral Diverticulum (women)
      1. Pelvic Pain with Urinary Incontinence
  1. Consider empiric treatment for Mycoplasma Genitalium if testing is unavailable
    1. See Mycoplasma Genitalium

XXI. References

  1. Bremnor (2002) Am Fam Physician 65(8):1589-97 [PubMed]
  2. Hoffman (2025) Am Fam Physician 111(1): 37-46 [PubMed]
  3. Michels (2015) Am Fam Physician 92(9): 778-86 [PubMed]
  4. Sell (2021) Am Fam Physician 103(9): 553-8 [PubMed]

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