Mohamed S. Ismail, MBChB, MRCS, PhD
Francis Xavier Keeley, Jr., MD, FRCS
BASICS
DESCRIPTION
• Dysuria is the symptom of discomfort, burning, or pain during micturition.
• It is often associated with other lower urinary tract symptoms.
EPIDEMIOLOGY
Incidence
• Dysuria accounts for up to 15% of visits to family doctors
• In men the incidence increases with age and 5% of men seeks medical help for dysuria
Prevalence
In the United States the reported prevalence of dysuria is 25%
RISK FACTORS
See associated conditions
Genetics
N/A
PATHOPHYSIOLOGY
• Dysuria results from the irritation of the urethra or bladder by inflammation or irritants
• The transient receptor potential subfamily vanilloid type 1 receptor (TRPV1) exists in the urethra
• Inflammatory mediators such as leukotrienes activate TRPV1 and result in pain and burning during voiding
ASSOCIATED CONDITIONS
• Bladder or urethral cancer
• BPH
• Connective tissue diseases
– Behçet disease
– Reiter (reactive arthritis) syndrome
• Pregnancy
• STD
• Urethral stricture disease
• Urinary tract infection
• Urolithiasis
GENERAL PREVENTION
• Hydration to flush out the urinary tract
• Women should wipe from front to back after bowel movements
• Women should empty the bladder immediately after intercourse
• Keep the genital area clean and dry
• Avoid irritating soap and vaginal products
• Treat infection with antibiotics
DIAGNOSIS
ALERT
Unexplained dysuria may indicate carcinoma in situ of the bladder.
HISTORY
• The cause of dysuria can be challenging to diagnose
• Dysuria is frequently associated with other lower urinary tract symptoms such as urinary frequency, hesitancy, urgency, and nocturia (1)
• Age and sex (2)
– Dysuria is more common in women
– The most common cause in young women is urethritis, in middle age women gynecologic causes, and in elderly women urinary tract infection
– The most common cause in young men is urolithiasis and in elderly are benign prostatic hyperplasia (BPH) and urinary tract infection
– Dysuria in children may suggest sexual abuse
• Onset
– Sudden onset symptoms suggest acute bacterial infection
– Gradual onset symptoms may suggest Chlamydia trachomatis infection
• Timing of pain
– At the onset of voiding indicates inflammation such as urethritis
– At the middle of voiding indicates obstruction such as urethral stricture or BPH
– At the end of voiding usually indicates bladder pathology such as cystitis
• Location of pain
– External discomfort associated with vaginal infection or inflammation
– Internal discomfort indicates bladder or urethral origin
• Associated symptoms
– Frequency, urgency, and suprapubic pain suggest diagnosis of interstitial cystitis
– Frequency, nocturia, and reduced flow suggest bladder outlet obstruction or urethral stricture
– Fever, rigor, and flank pain suggest pyelonephritis or urolithiasis
– Urethral discharge in young age indicates sexually transmitted diseases
– Vaginal irritation, discharge, and dyspareunia indicate genital tract infection such as:
– Vulvo-vaginitis, atrophic vaginitis, or sexually transmitted diseases
– Dyspareunia + dribbling + dysuria (“3 Ds”) suggests a urethral diverticulum in females
– The presence of joint or back pain may indicate connective tissue diseases
– Significant urgency occurs as a result of irritation of the bladder trigone and posterior urethras due to inflammation, bladder stone, or tumor.
– Oral and genital ulcers, uveitis, vasculitis with dysuria suggest Behçet disease
• History of recent surgery such as urethral instrumentation or continence surgery and history of recent catheterization should be obtained to rule out infection, inflammation, and urethral erosion.
• Sexual history
– Sexual behavior
– The use of contraceptives, diaphragms, condoms, etc.
– Previous history of sexually transmitted diseases and history of urethral scarring
• Drug history: Drugs associated with dysuria are ticarcillin, penicillin G, cyclophosphamide, saw palmetto, dopamine
PHYSICAL EXAM
• General exam and observation should be recorded
• Abdominal exam
– Inspection: Look for skin rash and abdominal distension which indicate full bladder
– Palpation: Feel for loin tenderness, palpable bladder, suprapubic tenderness, abdominal masses, and midline pulsation
– Percussion: To detect full bladder or any other abdominal mass
– Auscultation: To rule out other causes of abdominal distension
• Male genital exam
– Look for any penile lesions, urethral discharge, meatal stenosis, balanitis, perineal bruising, and abnormalities in the foreskin
– Examine the scrotum for swelling, tenderness, and testicular masses
– Digital rectal exam to rule out prostatitis, benign prostatic enlargement, and prostate cancer
• Female genital exam (3)
– Look for vaginal and urethral discharge
– Vulval lesions such as ulcers, vesicles, and rash
– Identify urethral lumps that indicate urethral caruncle, diverticulum, or stones. Look for signs of atrophic vaginitis
– Pelvic exam: Adnexal and cervical tenderness which indicates pelvic inflammatory disease, urethral tenderness, and urethral masses
– Bimanual exam to look for pelvic masses
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine dipstick is a useful and easy test to screen for urinary tract infection
– A positive test for nitrites is suggestive of urinary tract infection. A negative test does not rule out infection
– A positive leukocyte esterase suggests the presence of white blood cells in the urine which is associated with inflammation. It has 75% sensitivity to detect infection
• Urine microscopy
– Pyuria is defined by the presence of 3–5 white blood cells per high-power field
– Hematuria is defined by the presence of 3–5 red blood cells per high-power field
– Sterile pyuria is present in urolithiasis, transitional cell carcinoma, and atypical microorganisms such as tuberculosis
• Gram staining demonstrate the urinary pathogens
• Urine culture and sensitivity identify the causative microorganism of urinary tract infection and its antimicrobial sensitivities. Bacterial count of more than 1,000 colony forming units is diagnostic
• Vaginal and urethral smears: Important for the diagnosis of sexually transmitted diseases
• Vaginal PH measurement, potassium hydroxide microscopy, and yeast culture are indicated in patients with unexplained or recurrent dysuria
• Chlamydia: Nucleic amplification testing (NAAT) of vaginal swabs for women or 1st-catch urine for men
Imaging
• Renal ultrasound scan in suspected cases of upper tract pathology, urolithiasis, and bladder abnormalities
• Plain abdominal x-ray in suspected cases of urolithiasis and emphysematous pyelonephritis and cystitis
• Other imaging modalities can be arranged according to the suspected diagnosis such as voiding cystourethrography, retrograde urethrogram, computerized tomogram with intravenous contrast, magnetic resonance imaging
Diagnostic Procedures/Surgery
Cystoscopy: Allows careful assessment of the urethra and bladder.
Pathologic Findings
Based on specific diagnosis
DIFFERENTIAL DIAGNOSIS
• Disease of the urinary tract
– Urinary tract infection
– Urolithiasis, bladder calculus, crystalluria
– Interstitial cystitis
– Prostatitis (acute, chronic bacterial and chronic pelvic pain syndrome)
– Malignancy (carcinoma in situ, prostate cancer, urethral cancer)
• Diseases of the genital tract
– Sexually transmitted disease: Gonorrhea, Chlamydia, and herpes simplex infection
– Vulvo-vaginitis, cervicitis, pelvic inflammatory disease
– Epididymitis
– Urethral diverticulum
• Systemic diseases
– Connective tissue diseases: Reiter (reactive arthritis) syndrome and Behçet disease
• Local irritants
– Chemicals irritants: Cyclophosphamide, laundry detergents, bubble baths, intravaginal lubricants
– Mechanical irritation: Radiation cystitis
• Infants and adolescents
– Labial adhesions
– Exploratory sexual activity, masturbation
• Diverticulosis
TREATMENT
GENERAL MEASURES
• Encourage good hydration
• Personal hygiene
• Protective measures against STD
• Treat the primary cause
MEDICATION
First Line
• Mainly directed to relief symptoms and treat the underlying cause
• Symptomatic relief can be achieved by using phenazopyridine hydrochloride 200 mg PO TID
• Urinary tract infections are treated with oral antibiotics according to the causative microorganism. In men presumptive organisms are gram negative. Chronic bacterial prostatitis may require a prolonged course
• Urethritis in males is typically due to Chlamydia or gonorrhea
Second Line
• Associated symptoms of urgency can be treated with antimuscarinic drugs such as solifenacin 5 mg PO OD
• Associated symptoms of bladder outlet obstruction can be treated with α-blockers such as tamsulosin 0.4 mg PO OD
SURGERY/OTHER PROCEDURES
Surgical management is reserved for specific causes such as stones, bladder tumors, urethral diverticulum, and bladder outlet obstruction
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Interstitial cystitis is treated by replacing the glycosaminoglycan layer in the bladder using sodium hyaluronate
Complementary & Alternative Therapies
Acupuncture, nutritional therapy, pelvic floor exercises, and biofeedback can be useful complementary treatments for dysuria
ONGOING CARE
PROGNOSIS
• Prognosis depend on the causative factor
• Urinary tract infection has a good prognosis
COMPLICATIONS
Based on the primary diagnosis
FOLLOW-UP
Patient Monitoring
Based on the primary diagnosis
Patient Resources
http://www.aafp.org
REFERENCES
1. Bremnor J, Sadovsky R. Evaluation of dysuria in adults. Am Fam Physician. 2002;65:1589–1597.
2. Roberts RG, Hartlaub PP. Evaluation of dysuria in men. Am Fam Physician. 1999;60:865–872.
3. Kurowski K. The women with dysuria. Am Fam Physician. 1998;57:2155–2164.
ADDITIONAL READING
• Ismail M, Mackenzie K, Hashim H. Contemporary treatment options for chronic prostatitis/chronic pelvic pain syndrome. Drugs Today (Barc). 2013;49(7):457–462.
• Saini S, Secord E. Dysuria in a young man. Contemp Pediatrics. 2014;14. (http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/dysuria-young-man?page=full accessed August 8, 2014)
See Also (Topic, Algorithm, Media)
• Bacteruria and Pyuria
• Cystitis, General Considerations
• Dysuria Algorithm 
• Prostatitis, Chronic Nonbacterial, Inflammatory and Noninflammatory (NIH CP/CPPS III A and B)
• Prostatitis, General
• Sexually Transmitted Infections (STI) (Sexually Transmitted Diseases [STDs]), General
• Urethra, Stricture, Male
• Urethritis, Gonococcal and Nongonococcal
• Urgency, Urinary (Frequency and Urgency)
CODES
ICD9
• 592.9 Urinary calculus, unspecified
• 597.80 Urethritis, unspecified
• 788.1 Dysuria
ICD10
• N20.9 Urinary calculus, unspecified
• N34.2 Other urethritis
• R30.0 Dysuria
CLINICAL/SURGICAL PEARLS
• Unexplained persistent dysuria should NEVER be ignored; must rule out occult malignancy, such as carcinoma in situ of the bladder.
• Persistent hematuria after adequate treatment of dysuria related to UTI must have formal hematuria workup.