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Dysuria

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Dysuria, Urethritis

  • 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
  • Causes
  • By Cohort
  • Causes
  • Infectious
  • Causes
  • Dermatologic
  • Causes
  • Medication and food causes of Dysuria
  1. Medications
    1. Dopamine
    2. Cantharidin
    3. Ticarcillin
    4. Penicillin G
    5. Cyclophosphamide
    6. Opioids
    7. Ketamine
    8. Nifedipine
  2. Food and herbal supplement adverse effects
    1. Saw Palmetto
    2. Pumpkin seeds
  • Causes
  • Miscellaneous
  • Causes
  • Miscellaneous - Women
  • 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
  • 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
  • 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. 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)
  • 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
  • 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
  • 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
  • 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
  • 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. Discontinue offending agents
  • ' Consider regional pain sources
    1. Endometriosis
    2. Interstitial Cystitis
  1. Consider empiric treatment for Mycoplasma Genitalium if testing is unavailable
    1. See Mycoplasma Genitalium