Dysuria

Question 1

Features

Answer 1

Dysuria, or painful micturition, which is characterised mainly by urethral and suprapubic discomfort,

• indicates mucosal inflammation of the lower genitourinary tract (i.e. the urethra, bladder or prostate).

It is most common in women aged 15–44 yrs.

Although UTIs account for the majority of cases of dysuria in women, vaginitis and post-menopausal atrophic vaginitis can cause dysuria.

Question 2

Probability diagnosis

Answer 2

UTI (esp. cystitis)

Urethritis

Urethral syndrome—abacterial cystitis (female)

Vaginitis

Question 3

Serious disorders not to be missed

Answer 3

Neoplasia:

• bladder
• prostate
• urethra

Infection:

• gonorrhoea
• chlamydia/others
• genital herpes
• prostatitis

Reactive arthritis

Calculi (e.g. bladder)

Question 4

Pitfalls (often missed)

Answer 4

1. Menopause syndrome
2. Adenovirus urethritis
3. Prostatitis
4. Foreign bodies in lower urinary tract
5. Acidic urine
6. Acute fever
7. Interstitial cystitis
8. Urethral caruncle/diverticuli
9. Vaginal prolapse
10. Obstruction:

• benign prostatic hyperplasia
• urethral stricture
• phimosis
• meatal stenosis

Question 5

Masquerades checklist

Answer 5

Depression

Diabetes

Drugs

UTI

Question 6

Is the patient trying to tell me something?

Answer 6

Consider psychosexual problems, anxiety and hypochondriasis.

Question 7

Key history

Answer 7

It is important to determine whether dysuria is really genitourinary in origin and not attributable to functional disorders, such as psychosexual problems.

Disturbances of micturition are uncommon in the young male and if present suggest STIs.

Question 8

Key questions:

Answer 8

Could you describe the discomfort?

What colour is your urine?

Does it have a particular odour?

Have you noticed a discharge?

If so, could it be sexually acquired?

Do you find intercourse painful or uncomfortable (women)?

Have you any fever, sweats or chills?

Question 9

Key examination

Answer 9

General inspection looking for evidence of kidney disease and vital signs

Abdominal palpation to focus on the loins and suprapubic areas

The possibility of STIs should be considered;

• vaginal examination in females
• rectal and genital exam in males

In the menopausal female the cause may be evident from;

• a dry atrophic urethral opening
• a urethral caruncle
• urethral prolapse

Question 10

Key investigations

Answer 10

Dipstick testing of the urine

Microscopy or culture;

• midstream specimen of urine or
• suprapubic puncture in children
• first pass PCR urine testing for STIs esp. chlamydia

Urethral swabs for STIs

Further investigations depend on findings and referral for detailed investigation will be necessary if the primary cause cannot be found.

Question 11

Diagnostic tips

Answer 11

Urethritis causes pain at the onset of micturition and cystitis at the end.

Suprapubic discomfort is a feature of bladder infection (cystitis).

Unexplained dysuria could be a pointer to chlamydia urethritis.

Question 12

Relative causes of dysuria in women

Answer 12