Dysuria: A Merck Manual of Patient Symptoms podcast

Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom in women, but it can affect men and can occur at any age.

Pathophysiology

Dysuria results from irritation of the bladder trigone or urethra. Inflammation or stricture of the urethra causes difficulty in starting urination and burning on urination. Irritation of the trigone causes bladder contraction, leading to frequent and painful urination. Dysuria most frequently results from an infection in the lower urinary tract, but it could also be associated with an upper UTI. Impaired renal concentrating ability is the main reason for frequent urination in upper UTIs.

Etiology

Dysuria is typically caused by urethral or bladder inflammation, although perineal lesions in women (eg, from vulvovaginitis or herpes simplex virus infection) can be painful when exposed to urine. Most cases are caused by infection, but sometimes noninfectious inflammatory disorders are responsible (see Table 1: Symptoms of Genitourinary Disorders: Some Causes of Dysuria).

Overall, the most common causes of dysuria are

• Cystitis
• Urethritis from a sexually transmitted disease (STD)

Table 1
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Some Causes of Dysuria Cause Suggestive Findings Diagnostic Approach Infectious disorders* Cervicitis Often cervical discharge History of unprotected intercourse STD testing Cystitis Typically frequency and urgency Sometimes bloody or malodorous urine Bladder tenderness Clinical evaluation with or without urinalysis unless red flags† are present Epididymo-orchitis Tender, swollen epididymis Clinical evaluation Prostatitis Enlarged, tender prostate Often history of obstructive symptoms Clinical evaluation Urethritis Usually visible discharge History of unprotected intercourse STD testing Vulvovaginitis Vaginal discharge Erythema of labia and introitus Clinical evaluation, urinalysis, and culture to rule out UTI Consideration of catheterization to minimize contamination of specimen Inflammatory disorders Contact irritant or allergen (eg, spermicide, lubricant, latex condom), foreign bodies in the bladder, parasites, calculi External inflammation Clinical history Family history Clinical evaluation Urinalysis Imaging of the urinary tract and pelvis Interstitial cystitis Chronic symptoms No other, more common causes found Cystoscopy Spondyloarthropathies (eg, reactive arthritis, Behçet's syndrome) Preceding GI or joint symptoms or both Sometimes skin and mucosal lesions Clinical evaluation STD testing Other disorders Atrophic vaginitis Postmenopausal (including estrogen deficiencies from drugs, surgery, or radiation) Often dyspareunia Atrophy or erythema of vaginal folds Vaginal discharge Clinical evaluation Tumors (usually bladder or prostate cancer) Long-standing symptoms Usually hematuria without pyuria or infection Cystoscopy Prostate biopsy *Common pathogens include nonsexually transmitted bacteria (mostly Escherichia coli) and sexually transmitted pathogens (eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex virus). †Red flags are fever, flank pain or tenderness, recent instrumentation of the GU tract, immunocompromised patient, recurrent episodes, and known urologic abnormalities. STD = sexually transmitted disease. Some Causes of Dysuria Cause Suggestive Findings Diagnostic Approach Infectious disorders* Cervicitis Often cervical discharge History of unprotected intercourse STD testing Cystitis Typically frequency and urgency Sometimes bloody or malodorous urine Bladder tenderness Clinical evaluation with or without urinalysis unless red flags† are present Epididymo-orchitis Tender, swollen epididymis Clinical evaluation Prostatitis Enlarged, tender prostate Often history of obstructive symptoms Clinical evaluation Urethritis Usually visible discharge History of unprotected intercourse STD testing Vulvovaginitis Vaginal discharge Erythema of labia and introitus Clinical evaluation, urinalysis, and culture to rule out UTI Consideration of catheterization to minimize contamination of specimen Inflammatory disorders Contact irritant or allergen (eg, spermicide, lubricant, latex condom), foreign bodies in the bladder, parasites, calculi External inflammation Clinical history Family history Clinical evaluation Urinalysis Imaging of the urinary tract and pelvis Interstitial cystitis Chronic symptoms No other, more common causes found Cystoscopy Spondyloarthropathies (eg, reactive arthritis, Behçet's syndrome) Preceding GI or joint symptoms or both Sometimes skin and mucosal lesions Clinical evaluation STD testing Other disorders Atrophic vaginitis Postmenopausal (including estrogen deficiencies from drugs, surgery, or radiation) Often dyspareunia Atrophy or erythema of vaginal folds Vaginal discharge Clinical evaluation Tumors (usually bladder or prostate cancer) Long-standing symptoms Usually hematuria without pyuria or infection Cystoscopy Prostate biopsy *Common pathogens include nonsexually transmitted bacteria (mostly Escherichia coli) and sexually transmitted pathogens (eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex virus). †Red flags are fever, flank pain or tenderness, recent instrumentation of the GU tract, immunocompromised patient, recurrent episodes, and known urologic abnormalities. STD = sexually transmitted disease.

Evaluation

History: History of present illness should cover duration of symptoms and whether they have occurred in the past. Important accompanying symptoms include fever, flank pain, urethral or vaginal discharge, and symptoms of bladder irritation (frequency, urgency) or obstruction (hesitancy, dribbling). Patients should be asked whether the urine is bloody, cloudy, or malodorous and the nature of any discharge (eg, thin and watery or thick and purulent). Clinicians should also ask whether patients have recently engaged in unprotected intercourse, have applied potential irritants to the perineum, have had recent urinary instrumentation (eg, cystoscopy, catheterization, surgery), or might be pregnant.

Review of systems should seek symptoms of a possible cause, including back or joint pain and eye irritation (connective tissue disorder) and GI symptoms, such as diarrhea (reactive arthritis).

Past medical history should note prior urinary infections (including those during childhood) and any known abnormality of the urinary tract. As with any potentially infectious illness, a history of immune compromise or recent hospitalization is important.

Physical examination: Examination begins with review of vital signs, particularly to note the presence of fever.

Skin, mucosa, and joints are examined for lesions suggesting reactive arthritis (eg, conjunctivitis, oral ulcers, vesicular or crusting lesions of palms, soles, and around nails, joint tenderness). The flank is percussed for tenderness over the kidneys. The abdomen is palpated for tenderness over the bladder.

Women should have a pelvic examination to detect perineal inflammation or lesions and vaginal or cervical discharge. Swabs for STD testing and wet mount should be obtained at this time rather than doing a 2nd examination.

Men should undergo external inspection to detect penile lesions and discharge; the area under the foreskin should be examined. Testes and epididymis are palpated to detect tenderness or swelling. Rectal examination is done to palpate the prostate for size, consistency, and tenderness.

Red flags: The following findings are of particular concern:

• Fever
• Flank pain or tenderness
• Recent instrumentation
• Immunocompromised patient
• Recurrent episodes (including frequent childhood infections)
• Known urinary tract abnormality

Interpretation of findings: Some findings are highly suggestive (see Table 1: Symptoms of Genitourinary Disorders: Some Causes of Dysuria). In young, healthy women with dysuria and significant symptoms of bladder irritation, cystitis is the most likely cause. Visible urethral or cervical discharge suggests an STD. Thick purulent material is usually gonococcal; thin or watery discharge is nongonococcal. Vaginitis and the ulcerative lesions of herpes simplex virus infection are typically apparent on inspection. In men, a very tender prostate suggests prostatitis, and a tender, swollen epididymis suggests epididymitis. Other findings also are helpful but may not be diagnostic; eg, women with findings of vulvovaginitis may also have a UTI or another cause of dysuria.

Findings suggestive of infection are more concerning in patients with red flag findings. Fever, flank pain, or both suggest an accompanying pyelonephritis. History of frequent UTIs should raise concern for an underlying anatomic abnormality or compromised immune status. Infections following hospitalization or instrumentation may indicate an atypical or resistant pathogen.

Testing: No single approach is uniformly accepted. Many clinicians presumptively give antibiotics for cystitis without any testing (sometimes not even urinalysis) in young, otherwise healthy women presenting with classic dysuria, frequency, and urgency and without red flag findings. Others evaluate everyone with a clean-catch midstream urine sample for urinalysis and culture. Some clinicians defer culture unless dipstick testing detects WBCs. In women of childbearing age, a pregnancy test is done (UTI during pregnancy is of concern because it may increase the risk of preterm labor or premature rupture of the membranes). Vaginal discharge warrants a wet mount. Many clinicians routinely obtain samples of cervical (women) or urethral (men) exudate for STD testing (gonococcus and chlamydia culture or PCR) because many infected patients do not have a typical presentation.

A finding of > 10⁵ bacteria colony-forming (CFU) units/mL suggests infection. In symptomatic patients, sometimes counts as low as 10² or 10³ CFUs indicate UTI. WBCs detected with urinalysis in patients with sterile cultures are nonspecific and may occur with an STD, vulvovaginitis, prostatitis, TB, tumor, or other causes. RBCs detected with urinalysis in patients with no WBCs and sterile cultures may be due to cancer, calculus, foreign body, glomerular abnormalities, or recent instrumentation of the urinary tract.

Cystoscopy and imaging of the urinary tract may be indicated to check for obstruction, anatomic abnormalities, cancer, or other problems in patients who have no response to antibiotics, recurrent symptoms, or hematuria without infection. Pregnant patients, older patients, and patients with prolonged or recurrent dysuria need closer attention and a more thorough investigation.

Treatment

Treatment is directed at the cause. Many clinicians do not treat dysuria in women without red flag findings if no cause is apparent from examination and the results of a urinalysis. If treatment is decided upon, a 3-day course of trimethoprim/sulfamethoxazoleSome Trade Names
BACTRIM
SEPTRA
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, trimethoprimSome Trade Names
PROLOPRIM
TRIMPEX
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alone, or a fluoroquinolone is recommended. Some clinicians give presumptive treatment for an STD in men with similarly unremarkable findings; other clinicians await STD test results, particularly in reliable patients.

Acute, intolerable dysuria due to cystitis can be relieved somewhat by phenazopyridineSome Trade Names
PYRIDIUM
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100 to 200 mg po tid for the first 24 to 48 h. This drug turns urine red-orange; patients should be cautioned not to confuse this effect with progression of infection or hematuria. Upper UTI requires 10 to 14 days of treatment with an antibiotic that is effective against gram-negative organisms, particularly Escherichia coli.

Key Points

• Dysuria is not always caused by a bladder infection.
• STDs should be considered.

Last full review/revision September 2009 by Seyed-Ali Sadjadi, MD

Content last modified February 2012