- Dysuria
- Burning or stinging of the Urethra with voiding
- Urethritis
- Urethral inflammation with Dysuria, Pruritus or burning or visible discharge from meatus
- 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
- Lamina propria (submucosa)
- Lies deep to the epithelium of the Urethra and Bladder
- Contains neurovacular structures, including Urethra and Bladder innervation
- Muscularis Propria (Detrusor Muscle)
- Bladder Smooth Muscle comprises the outer layer
- Dysuria may originate from the Urethra's lamina propria or may be referred from the Bladder
- Causes
-
Medication and food causes of Dysuria
- Causes
-
Miscellaneous - General (Either gender)
- Causes
-
Miscellaneous - Men
- Causes
-
Miscellaneous - Women
- Causes
-
Psychogenic and social
- History
-
Characteristics of Dysuria
- Timing
- Start of void: Urethral source
- End of void: Bladder source
- Pain location
- Cystitis
- Bladder and Urethral pain
- Bladder Distention
- Suprapubic or retropubic pressure
- Vaginitis
- External pain distribution
- Prostatitis (or other deeper pelvic source)
- Deep perineal pain
- Epididymitis
- Testicular Pain
- 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
- Flank Pain
- Fever
- Nausea or Vomiting
- 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
- Benign Prostatic Hyperplasia
- Testicular Pain
- 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)
-
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
-
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
- Nephrolithiasis
-
CT Abdomen and Pelvis with and without contrast (CT Urogram)
- Hematuria evaluation for malignancy
-
Cystoscopy
- Hematuria evaluation for malignancy
- Interstitial Cystitis
- 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
- 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
- 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
- See Expedited Partner Treatment
- Management
-
Persistent Dysuria with unremarkable evaluation
- ' Consider regional pain sources (primarily women)
-
Vulvar symptoms
- Vulvodynia
- Vulvar Vestibulitis
- Vulvovaginal Atrophy (Menopause)
-
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)
- Pelvic Pain with Urinary Incontinence
- Consider empiric treatment for Mycoplasma Genitalium if testing is unavailable
- See Mycoplasma Genitalium
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