Dysuria resident survival guide

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Dysuria
Resident Survival Guide
Overview
Causes
Diagnosis
Women
Men
Treatment
Women
Men
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] Rinky Agnes Botleroo, M.B.B.S.

Overview

Dysuria is typically described to be a burning, tingling, or stinging sensation of the urethra and meatus associated with voiding.Dysuria refers to painful urination. It is most often a result of an infection of the urinary tract.Noninfectious inflammatory causes include a foreign body in the urinary tract and dermatologic conditions such as Herpes,Irritant dermatitis,Erosive, Lichen planus,Contact Dermatitis.It may also be due to an STD, bladder stones, bladder tumors and any condition of the prostate. It can also occur as a side effect of medications. It is one of the constellations of irritative bladder symptoms, which includes the frequency of urination and haematuria.

Causes

Life Threatening Causes

Life-threatening causes of dysuria include

These conditions may result in death or permanent disability within 24 hours if left untreated

Common Causes

Common causes include: [1]

Diagnosis

  • Shown below are two algorithms summarizing the diagnosis of Dysuria

Diagnostic Approach in Women

Abbreviations: ER:Emergency room,KUB USS :Kidney and Bladder Ultrasound study,PVR: Post-void residual urine,USG : Ultrasonography

 
 
 
 
 
 
Woman with dysuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of:

❑ Comcomitant fever
Flank pain
❑ Abnormal vital signs:

Tachycardia
Tachypnea
Hypotension

Nausea

Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer the patient to ER
 
 
 
 
 
Urine Dipstick for Nitrites and Leukocytes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nitrite Postitive
 
 
 
Leukocytes positive,Nitrite negative
 
 
 
 
 
 
 
 
 
 
Both Nitrite and Leukocyte negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Empirical Antibiotic Therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with Specific Antibiotic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Postive
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of any Urethral discharge/Itching
 
 
 
 
 
 
Acid urine pH/history of Tuberculosis
 
 
Treat with Specific antibiotic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do Swab test
 
 
 
 
 
 
Urine speicific test for tuberculosis
 
 
 
 
 
 
 
Think of any other non-infectious urogenital disease or vulvo-vaginal disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer the patient to urologist/gynaecologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If the female patient presents with slow urine stream without any pain or burning sensation, then the algorithm below can be used to treat the patient

 
 
 
 
 
Female patient with only voiding symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
Ask about voidal habits: ❑Urinary frequency, ❑Interval between two consecutive micturation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Physical examination
Suprapubic palpation and Vaginal examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Urine culture
❑ Kidney and Bladder Ultrasound study (KUB USS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increased Detrusor wall thickness
 
Bladder diverticula
 
Increased post void residual(>100)
 
 
 
Hydronephrosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer to urologist
 
 
 
 

Diagnostic Approach in Men

Algorithm showing the diagnosis of dysuria in Male patients

 
 
 
 
 
 
 
Male patient with dysuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of urethral discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about the discharge
 
 
 
 
 
 
Presence Of Genital Lesion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
NO
 
Profuse,purulent discharge
Yellowish green colour
 
Thin,mucoid/mucopurulent discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Swab test
 
Swab test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gram negative Diplococci
 
NAAT/PCR test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gonorrhoea
 
Chlamydia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflammation of the glans penis
 
 
 
 
Ulcer
 
 
 
 
 
Painful Vesicles
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Balanitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Herpes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of:

❑ Firm, painless, non-itchy skin ulceration
❑ Multiple sores
❑ A diffuse rash involving the palms of the hands and soles of the feet
❑ Presence of gummas
 
 
Presence of:

❑ Painless genital ulcer
Anorectal pain
Tenesmus
Rectal discharge
❑ Rectal discharge,Inguinal lymphadenopathy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syphilis
 
 
Lymphogranuloma venereum (LGV)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of any Localized Pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suprapubic pain
 
 
 
 
Flank pain
❑[[Costovertebral angle tenderness]]
Fever
 
 
 
Joint pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Analysis
 
 
 
 
USG
 
 
 
X-ray
ESR/CRP
HLA-B27
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cystitis
 
 
 
 
Pyelonephritis
 
 
 
Spondyloarthropathy
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Treatment in Women

Shown below is an algorithm summarizing the treatment of Dysuria in female patients

 
 
 
 
 
 
 
Symptoms of lower urinary tract
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non recurrent
 
 
 
 
 
 
Recurrent
❑ At least 3 episodes of uncomplicated UTI in 12 months
❑ With at least one positive by urine culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncomplicated
Without any risk factors
 
Complicated :Presence of any of the following risk factors:

❑ Presence of indwelling catheter
Vesico-ureteric reflux
❑ Increased post void residual urine
❑ Increased post void residual urine
❑ Presence of diseases:

Renal insufficiency
Diabetes mellitus
Immunodeficiency
Obstructive Uropathy
 
 
 
 
Modify Lifestyle to intervene modifiable riskfactors and take prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment with short term antibiotic therapy
First line includes
❑ 3g oral dose of Fosfomycin trometamol
Pivmecillinam 400 mg twice a day for 3 days
Nitrofurantoin 100mg twice a day for 5-7days
In case of <20% resistance rates for E.coli
Cotrimoxazole 160/800 mg twice a day for 3 days
Trimethoprim 200 mg twice a day for 5 days
 
❑ Specific antibiotic depending on urine culture
❑ Long Empeirical long term antibiotic(Fluoroquinolones,Third generation Cephalosporins,Aminoglycosides) for 10-14 days
 
 
 
 
Measurements to prevent recurrent UTI
❑ Low dose Antimicrobial prophylaxis continuously or after sexual intercourse
❑ Interventions on modifiable risk factors:
1.Avoid using spermicide
2.Maintain blood glucose level
3.Improving the treatment of urinary incontinence
4.Unspecific prophylaxis with cranberry extracts
5.Local hormonal therapy in case of post menopausal women
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat urine culture in nonresponsive cases and pregnant women
 
Repeat urine culture after treatment,KUB ultrasound with PVR measurement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer the patient to urologist
 
 
 
 
If all of the above fails
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer to urologist

Treatment in Men

Treatment of dysuria in male patient

 
 
 
Male patient with dysuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of infection
 
 
 
No infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treatment with specific antibiotic for 7 days
❑ If sensitivity tests are not available empirical treatment with Quinolone
 
 
 
 
Further investigate to exclude Bladder cancinoma if
❑ Patient is smoker
or
❑ H/o exposure to carcinogen
or
❑ Presence of Storage symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent UTI or prostatitis
 
 
 
 
Look for other non infective causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refer to Urologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat according to the specific cause
 
No specific cause found, Suspect chronic pelvic pain syndrome (CPPS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Quinolone-naive treatment
 
 
Previously had treatment with Quinolones
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No response for 4 weeks
 
Response
 
Apply UPOINT classification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply UPOINT classification
 
 
 
 
 
Response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Response
 
 
 
 
No response
 
Refer to specialized pain clinic in Hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No response
 
Refer to specialized pain clinic in Hospital
 
 
 
 



UPOINT CLASSIFICATION


Phenotype Domains Clinical Features
Urinary Lower urinary tract symptoms that creates discomfort or High post-micturation residual volume
Psychological Patient with depression or severe anxiety thinking the worst will happen to them
Organ-specific Tenderness in Prostate,Presence of blood in ejaculation,Leukocytes in prostatic fluid or post-massage urine
Infectious Infection with gram negative bacilli or Enterococci localized to prostate or presence of Ureaplasma in urine
Systemic Pain anywhere else in the body except abdomen or pelvis or having a diagnosis of fibromyalgia,chronic fatigue or irritable bowel syndrome
Tenderness Presence of palpable muscle spams in abodomen or pelvic floor

Do's

Instruct the female patients to:

Don'ts

Instruct the female patients not to:

  • Delays in urinating[3]
  • Drink the following items a lot:
    • Caffeinated sodas
    • Alcohol
    • Spicy foods
    • Acidic fruits

References

  1. 1.0 1.1 1.2 1.3 1.4 Michels TC, Sands JE (November 2015). "Dysuria: Evaluation and Differential Diagnosis in Adults". Am Fam Physician. 92 (9): 778–86. PMID 26554471.
  2. "Dysuria, Frequency, and Urgency - Clinical Methods - NCBI Bookshelf".
  3. 3.0 3.1 3.2 3.3 3.4 3.5 "www.visitcompletecare.com".


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