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Dysuria

Dysuria is painful micturition - a symptom and not a disease; and treatment depends on identifying cause.

Epidemiology
Incidence The commonest cause of dysuria, especially in sexually active women is lower urinary tract infection or cystitis. At least 30% of women will have such an episode in their lives and about 20% of this group will have recurrent infection.

Prevalence Population-based surveys suggest that urinary tract symptoms requiring medical attention occur in about 0.6% of women per year and about 0.1% of men. Symptoms in men increase significantly between the ages of 40 and 60 years as benign prostatic hyperplasia (BPH) becomes more common. Nearly half of men over 55 report some urinary symptoms, and about a quarter consult a doctor. 90% of interstitial cystitis occurs in women.

Risk Factors Being female, sexual activity and impaired immunity are all risk factors. Infection is more likely with anatomical abnormalities of the renal tract, foreign bodies like stones, stasis as in BPH or malignancies.

Presentation
Symptoms The causes of lower urinary tract symptoms in women tends to be different from lower urinary tract symptoms in men.

The following features need to be ascertained:

• When did the dysuria begin?
• Is it only during micturition?
• Does the pain stop after micturition?
• Is it just in the urethra or does it radiate elsewhere, perhaps to the back or loin?

Ask about other symptoms:

• Has there been pyrexia or more general illness?
• Is there urethral or vaginal discharge?
• Is there an abnormal smell?
• Is the volume or frequency normal?
• Is there urgency?
• Is there haematuria?
• Is there any genital pruritis?

General enquiries include:

• Any medication
• Possible pregnancy
• Previous UTI
• Allergies to anything
• Recent sexual history
• Surgery or irradiation to uro-genital area

Signs The history will give a good indication of the cause. Signs may confirm it.

• In cystitis 15 to 20% have supra-pubic tenderness. There may be some tenderness in interstitial cystitis too.
• Pyelonephritis can be subclinical and very similar to cystitis in presentation. A fulminant pyelonephritis presents with a high temperature, usually over 38.5º but even around 40°, perhaps vomiting and a very ill patient. There may be tender ness over either loin or the left upper quadrant.
• In vaginitis the vagina may be inflamed and tender. Urethral discharge may be apparent in either sex but is unusual. The vesicles of herpes simplex may be obvious but they might be on the cervix. There may be inguinal lymphadenopathy.
• An enlarged prostate may be felt on rectal examination.
• A palpable bladder suggests bladder outflow obstruction.

Differential Diagnosis

• Cystitis or lower urinary tract infection. Usually a sexually active woman with dysuria, frequency and urgency.
• Pyelonephritis or upper urinary tract infection.
• Interstitial cystitis
• Vulvo-vaginitis
• Urethritis, usually Chlamydia or Gonnococcus¹. Sexually transmitted diseases are the commonest cause in young men.
• In older men prostatic hypertrophy causes urinary stasis, predisposing to UTI. Prostatitis also causes dysuria.
• Genital herpes. 80% of patients with primary symptomatic genital herpes have dysuria but it is usually absent in recurrence. Seventy-five percent of patients with genital herpes will have vaginal discharge. 75% of women with genital herpes have vaginal discharge.
• Atrophic vaginitis. Dysuria occurs because of contact of urine with the inflamed atrophic tissues or because there is an increased incidence of UTI. Atrophic vaginitis is common, affecting from 20 to 30% of postmenopausal women. Decreased vaginal secretions, vaginal tenderness and dyspareunia are common. They may also have bloody vaginal spotting, especially after intercourse. Approximately 10 to 15% of women over 60 have frequent urinary tract infections.
• Spondyloarthropathy like Reiter's syndrome or Behçet's Disease
• Bladder irritation from a distal urethral stone
• Malignancy. Carcinoma-in-situ of the bladder can present as dysuria.
• Compression from an adnexal mass
• Radiation or chemical exposure can also produce dysuria
• Adenovirus or mumps can all cause dysuria.
• Drugs - over 200 drugs have dysuria listed as a possible side-effect but perhaps the most significant is cyclophosphamide. A high urine volume should be maintained.
• Schistosomiasis especially around the Nile
• Vaginal and urethral trauma, including sexual abuse² and the insertion of a foreign body, can cause dysuria
• Irritant or topical allergic responses to soaps, douches, vaginal lubricants, spermicidal jellies, contraceptive foams and sponges, tampons and sanitary towels, perfumed soaps and toilet paper also cause dysuria. Avoidance of the irritative agent generally leads to the resolution

Investigations Urine dipstick analysis and MSU for microscopy, C+S. Pyuria in a MSU is an essential feature of UTI. It should be possible to grow an organism but the commonest cause of "sterile pyuria" is antibiotic in the urine. Persistent sterile pyuria must be investigated with 3 early morning specimens to exclude tuberculosis. A leukocyte esterase dipstick test is 75 to 95 percent sensitive in detecting pyuria from infection. Vaginitis does not cause pyuria unless there is contamination. White blood cell casts suggest acute pyelonephritis. Nitrite is frequently present but less sensitive. Nitrite is over 90% specific for UTI, but sensitivity is usually only about 30%, increasing to 60% with an early morning urine sample. The investigation of vaginitis is described elsewhere. Dysuria must be investigated in children, both boys and girls.

Management
Non-Drug Encourage fluids++. Bacterial cystitis may resolve without treatment. Making the urine more alkaline improves dysuria in all causes and reduces infection.

Drugs Antibiotics improve symptoms and prevent infection from spreading to the kidneys. Adult women who are not pregnant, with simple cystitis may be treated empirically with a three-day course of antibiotics based on their clinical presentation³. Urine culture is not necessary in these women but should be performed if the cystitis does not resolve. Low dose long-term antibiotics may be of value in recurrent UTI. If atrophic vaginitis causes recurrent UTI then topical oestrogen therapy can be helpful⁴.

Surgical Anatomical problems may be treated surgically. This may include abnormalities of the renal tract, prostatic hypertrophy, stones or foreign bodies or malignancy.

Prevention Maintaining a high urine output is useful. Cranberry juice reduces the risk of infection and can be a useful prophylactic in recurrent UTI.

References Used

1. Clad A; ;Ther Umsch 2002 Sep;59(9):459-63.[abstract]
2. Chariot P, Rey C, Werson P; Pitfalls in the diagnosis of child sexual abuse.;J Clin Forensic Med 1999 Mar;6(1):35-8.[abstract]
3. Rothberg MB, Wong JB; All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms.;J Gen Intern Med 2004 May;19(5 Pt 1):433-43.[abstract]
4. Rozenberg S, Pastijn A, Gevers R, et al; Estrogen therapy in older patients with recurrent urinary tract infections: a review.;Int J Fertil Womens Med 2004 Mar-Apr;49(2):71-4.[abstract]

Internet and Further Reading

• Kurowski.K  Dysuria in women
• Roberts.G, Hartlaub.PP  Dysuria in men
• Medline plus  

Acknowledgements EMIS is grateful to the Mentor authoring team for writing this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2004.

Last issued 30 Aug 2006