Dysuria

Dysuria is the symptom of painful micturition. It is a common reason for medical consultations. Treatment depends on identifying the underlying cause.

There are related articles on Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women.

• Abdominal causes: note that dysuria can occur with abdominal pain emergencies such as appendicitis and ectopic pregnancy (due to irritation of nearby urinary structures).
• Urinary tract causes:
  • Urinary tract infection (UTI):
    • Bacterial UTI
    • Urethritis, e.g. chlamydia, gonococcus or non-gonococcal urethritis; in men aged <35, this is a common cause of dysuria²
    • Urinary schistosomiasis
  • Interstitial cystitis
  • Obstruction: prostatic enlargement, urethral stricture
  • Kidney stones in bladder or urethra
  • Malignancy, e.g. carcinoma of the bladder or urethral tumours
• Genital causes:
  • Urethral or vaginal trauma, including sexual abuse or a foreign body
  • Genital herpes simplex
  • Women: vaginitis, e.g. vaginal candidiasis, atrophic vaginitis, bacterial vaginosis
  • Men: prostatitis, epididymo-orchitis, epididymitis
• Other disease:
  • Spondyloarthropathy, e.g. Reiter's syndrome or Behcet's disease.
  • Compression from a pelvic mass
• Irritants:
  • Drugs, e.g. cyclophosphamide, allopurinol, danazol, tiaprofenic acid, and possibly other nonsteroidal anti-inflammatory drugs³
  • Chemical irritants: allergic or irritant reaction to soaps, vaginal lubricants, spermicides, contraceptive foams and sponges, tampons and toilet paper
  • Mechanical irritation, e.g. from a poorly fitting contraceptive diaphragm or vaginal ring pessary
  • Radiation or chemical exposure

History

Depending on the situation, possible questions are:

• Pain symptoms:
  • Onset and duration of dysuria
  • Is there abdominal pain? - if present, consider abdominal pain causes, e.g. appendicitis and ectopic pregnancy
  • Radiation of pain (e.g. to loin or back, suggesting upper urinary tract pathology)
• Other symptoms:
  • Fever, rigors or malaise - suggest pyelonephritis
  • Haematuria - occurs with infection, stones, neoplasms and renal disease
  • Urethral or vaginal discharge - consider genital tract infection
  • Odour - suggests bacterial infection
  • Pruritus - common with genital candidiasis
  • Frequency and urgency - indicate bladder irritation
  • Urine volume and flow - is there obstruction?
• Medical history:
  • Possible pregnancy
  • Past history: previous UTI, other genitourinary disease, pelvic surgery or irradiation, other general illness, medication
  • Recent sexual history; method of contraception; bear in mind the possibility of child sexual abuse
  • Occupation: exposure to dyes and solvents is a risk factor for bladder cancer

Examination

May not be required for simple situations, e.g. if the history suggests uncomplicated lower UTI. If relevant, examine for:

• Fever, tachycardia and loin tenderness (pyelonephritis).
• Abdominal/pelvic tenderness, guarding, masses or adnexal tenderness; enlarged bladder.
• Vaginal discharge, candidiasis, genital herpes simplex or vaginitis.
• An enlarged prostate may be felt on rectal examination.
• If child sexual abuse is suspected, specialist assessment is required.

Consider the appropriate level of investigation for the clinical picture, or whether to treat empirically. Investigations are generally required for children and men with dysuria, but not always for women (see below).

Possible investigations for dysuria

Depending on the clinical picture, these include:

• Urine dipstick, microscopy and culture (see below).
• Consider whether pregnancy test needed.
• Investigation for sexually transmitted infection (or refer to STI clinic).
• Ultrasound of urinary tract, pelvis or abdomen if obstruction or masses suspected.
• Plain "KUB" X-ray if renal tract stones suspected.
• Urodynamic studies.
• Urine cytology.
• Further tests, e.g. cystoscopy, require a specialist setting.

Which initial investigations for suspected UTI?

Children

This section only covers initial testing; for more information see Childhood Urinary Tract Infection.

NICE guidance suggests the following strategy when testing for suspected UTI in children^4,5 (although the guidelines have been disputed).⁶ The NICE guidance on urine testing is:

• Infants age under 3 months: all need urgent paediatric referral.
• Children age 3 months-3 years with urinary symptoms:
  • If well, send urine for microscopy and culture, and start antibiotic treatment.
  • If unwell or risk of serious illness, need urgent paediatric referral (and will need urgent urine microscopy and culture)
  • If upper UTI symptoms, need urine microscopy and culture; start antibiotics; consider urgent paediatric referral.
• Children age >3 years:
  • Urine culture is needed if:
    • Child unwell or upper UTI features (may also need urgent paediatric referral)
    • Recurrent UTI history
    • Positive dipstick for leucocyte esterase or nitrite
    • Not responding treatment within 24-48 hours
    • Clinical symptoms and dipstick tests do not correlate
  • Otherwise, urine dipstick can be used as initial assessment:
    • If leucocyte esterase and nitrite are both positive, start antibiotic; also send urine culture if risk of serious illness, upper UTI features or previous UTI.
    • If leucocyte esterase is negative and nitrite is positive, start antibiotic if the sample was fresh; send urine for culture.
    • If leucocyte esterase is positive and nitrite is negative, consider infection elsewhere; start antibiotic if clinical evidence of UTI; send urine for microscopy and culture.
    • If both leucocyte esterase and nitrite are negative, consider other causes; consider whether urine culture needed.

Adults

This section only deals with initial urine tests for suspected UTI. For information on treatment and further investigations, see Urinary Tract Infection in Adults.

• Women with suspected lower UTI:⁷
  • Non-pregnant: no tests are needed for an otherwise healthy woman with multiple, typical symptoms and signs of lower UTI (the diagnosis can be made clinically).
  • Pregnant women with dysuria (who are otherwise well):
    • Test with dipstick and send for culture.
    • Dipstick positive for leucocyte esterase OR nitrite - start antibiotic.
    • Dipstick negative: await culture results.
  • N.B: Fever, loin or back pain suggest upper UTI and merit urine culture.
• Men with suspected UTI:³
  • Urine should always be sent for culture.
  • Be aware of atypical presentations in frail, elderly men or those with catheters.
  • Further investigations are often appropriate.