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Urination, Pain or Burning With

(Dysuria)

by Anuja P. Shah, MD

Burning or pain during urination may be felt at the opening of the urethra or, less often, over the bladder (in the pelvis, the lower part of the abdomen just above the pubic bone). Burning or pain during urination is an extremely common symptom in women, but it can affect men and can occur at any age.

Causes

Burning or pain during urination is typically caused by inflammation of the urethra or bladder. In women, inflammation in the vagina or in the region around the vaginal opening (called vulvovaginitis) can be painful when exposed to urine. Inflammation that results in burning or pain is usually caused by infection but sometimes by noninfectious conditions.

Common causes

Overall, the most common causes of burning or pain during urination are

  • Bladder infection (cystitis)

  • Infection of the urethra (urethritis) due to a sexually transmitted disease (STD)

Evaluation

Not every person who has pain or burning during urination needs to see a doctor right away. The following information can help people decide how quickly a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people who have pain or burning during urination, certain symptoms and characteristics are cause for concern. They include

  • Fever

  • Pain in the back or side (flank pain)

  • A recent history of insertion of a bladder catheter or other instrument

  • Immune system disorders

  • Repeat episodes (including frequent childhood infections)

  • A known urinary tract abnormality

When to see a doctor

People with immune system disorders and pregnant women with warning signs should see a doctor that day (or in the morning if symptoms develop overnight) because complications of a urinary tract infection can be serious in such people. Other people with warning signs should see a doctor in a day or two, as should those whose symptoms are particularly bothersome. For people without warning signs who have mild symptoms, a delay of 2 or 3 days is not harmful.

Women with frequent bladder infections may recognize characteristic symptoms that suggest another episode.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of the burning or pain during urination and the tests that may need to be done (see Table: Some Causes and Features of Painful Urination).

Doctors may ask whether similar symptoms have occurred in the past. Doctors ask about symptoms that may accompany the pain and provide clues to the cause. For example, doctors may ask whether

  • The urine is bloody, cloudy, or foul smelling

  • Any discharge is noticed

  • There has been any recent unprotected intercourse

  • Potential irritants have been applied to the genitals

  • A bladder catheter has recently been inserted or another urinary tract procedure has been done

Women are asked whether they might be pregnant.

In women, the physical examination usually includes a pelvic examination and the taking of samples of cervical and vaginal fluid to check for STDs. In men, the penis is examined for presence of a discharge, and doctors do a digital rectal examination to examine the prostate.

Doctors can sometimes get clues to the cause based on where symptoms are most severe. For example, if symptoms are most severe just above the pubic bone, a bladder infection may be the cause. If symptoms are most severe at the opening of the urethra, urethritis may be the cause. In men with a penile discharge, urethritis is often the cause. If burning affects mainly the vagina and the woman has a discharge, vaginitis may be the cause.

Some Causes and Features of Painful Urination

Cause

Common Features*

Tests

Infections

Cystitis (bladder infection)

Usually in women and girls

A frequent and urgent need to urinate

Getting up at night to urinate

Sometimes blood in the urine or foul-smelling urine

A doctor's examination

Usually urinalysis and urine culture

Epididymo-orchitis (infection of an epididymis and a testis)

Tenderness and swelling in a testis

Possibly frequent urination or a discharge from the urethra

Sometimes fever or nausea

A doctor's examination

Sometimes urinalysis

Sometimes STD testing

Prostatitis (infection of the prostate)

A tender prostate detected during a digital rectal examination

Often fever, difficulty starting urination, frequent urination, the need to urinate during the night, and burning or pain during urination

Sometimes blood in the urine

Often symptoms of a long-standing blockage in the urinary tract (including a weak urine stream, difficulty passing urine, or dribbling at the end of urination)

Urinalysis and urine culture

Urethritis (infection of the urethra), typically due to an STD

Usually a visible discharge from the urethra in men

Sometimes a discharge from the vagina in women

In people who have recently had unprotected intercourse

STD testing

Vulvovaginitis (infection of the vulva and vagina)

A discharge from the vagina

Often redness in the genital area

A doctor's examination, including examination of a sample of the discharge under a microscope

Disorders that cause inflammation

Connective tissue disorders that cause inflammation (such as reactive arthritis or Behçet syndrome)

General or bodywide symptoms (including body pain and joint pain) that develop before urination becomes painful

Sometimes sores on the skin, mouth, eyes, or genital area, including inside the vagina

STD testing

Sometimes blood tests to check for these connective tissue disorders

Contact with a substance that irritates the area or causes an allergic reaction (such as a spermicide, lubricant, or latex condom)

Sometimes redness in the genital area

In people who have been exposed to a substance that could cause irritation or an allergic reaction

Only a doctor's examination

Interstitial cystitis (inflammation of the bladder without infection)

More common among women

A frequent and urgent need to urinate

Long-standing symptoms

Urinalysis and urine culture

Examination of the interior of the bladder using a flexible viewing tube inserted through the urethra (cystoscopy), usually including removal of a sample of tissue for examination (biopsy of the bladder)

Other disorders

Atrophic vaginitis or urethritis (thinning of tissues in the vagina or urethra)

In postmenopausal women

Vaginal dryness

Often pain during intercourse

A discharge from the vagina

Changes in the interior of the vagina (it becomes smooth and pale)

Only a doctor's examination

Tumors (usually bladder or prostate cancer)

Long-standing symptoms, such as a weak urine stream or difficulty starting urination

Usually blood in the urine

If bladder cancer is suspected, cystoscopy

If prostate cancer is suspected, a blood test to measure PSA levels

If the PSA level is elevated, biopsy of the prostate

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Infectious organisms that commonly cause painful urination include sexually transmitted organisms (such as those that cause gonorrhea, chlamydial infection, and trichomoniasis) and bacteria that are not sexually transmitted, mostly Escherichia (E.) coli.

This cause is rare.

PSA = prostate-specific antigen; STD = sexually transmitted disease.

Testing

Doctors do not always agree on the need for tests for certain adult women who have symptoms that suggest a bladder infection. Some doctors do urine tests, whereas others treat without doing any testing. All doctors do tests when the diagnosis is unclear. The first test is usually urinalysis. In many cases, doctors also do a urine culture to identify organisms causing infection and determine which antibiotics would be effective. For women of childbearing age who are not known to be pregnant, a pregnancy test is done. Testing for STDs is often done, for example, for men who have a discharge from the penis and for many women who have a vaginal discharge.

Cystoscopy and imaging of the urinary tract may be needed to check for anatomic abnormalities or other problems, especially if antibiotics have not been effective.

Treatment

The cause is treated. Often the cause is an infection, and antibiotics provide relief in a day or two. If pain is severe, doctors may give phenazopyridine for a day or two to relieve discomfort until antibiotics start to work. Phenazopyridine turns the urine a red-orange color.

Key Points

  • Although bladder infections are a common cause, many other disorders may cause painful urination.

  • Burning or pain during urination may be a sign of an STD.

  • Doctors may decide to treat women with an antibiotic and see whether symptoms resolve rather than do testing.

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