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Dysuria
Aka: Dysuria, Urethritis
- See Also
- Urinary Tract Infection
- Urinary Tract Infection in Children
- Dysuria in Women
- Periuretheral Contact Dermatitis in Women
- Dysuria in Men
- Dysuria in Children
- Definitions
- Dysuria
- Burning or stinging of the Urethra with voiding
- Urethritis
- Urethral inflammation
- Causes: By Cohort
- See Dysuria in Women
- See Dysuria in Men
- See Dysuria in Children
- Causes: Infectious
- Urinary Tract Infection
- Cystitis
- Pyelonephritis
- Urethritis
- Sexually Transmitted Infections
- White discharge
- NeisseriaGonorrhea
- Watery or no discharge
- Chlamydia trachomatis (15-40% of cases)
- Gut Flora (following anal intercourse)
- Genital Herpes Simplex Virus (HSV II)
- Mycoplasma genitalium (15-20% of Non-Gonococcal Urethritis causes in women)
- Ureaplasma urealyticum
- Trichomonas vaginalis
- Other genitourinary infections
- Women
- See Dysuria in Women
- Vulvovaginitis (e.g. Bacterial Vaginosis, Yeast Vaginitis)
- Cervicitis
- Men
- See Dysuria in Men
- Prostatitis
- Epididymitis or Orchitis
- Causes: Dermatologic
- Contact Dermatitis or chemical irritation
- See Periuretheral Contact Dermatitis in Women
- Spermacidal gel
- Topical deodorants
- Lichen Sclerosus
- Lichen Planus
- Psoriasis
- Behcet Syndrome
- Causes: Medication and food causes of Dysuria
- Medications
- Dopamine
- Cantharidin
- Ticarcillin
- Penicillin G
- Cyclophosphamide
- Opioids
- Ketamine
- Nifedipine
- Food and herbal supplement adverse effects
- Saw Palmetto
- Pumpkin seeds
- Causes: Miscellaneous
- Urethral
- Urethral Stricture
- Urethral diverticulum
- Reiter's Syndrome
- Local Urethral Trauma (e.g. Bicycling, horse back riding)
- Bladder
- Bladder Cancer
- Kidney
- Renal Cancer
- Nephrolithiasis
- Abdomen and Pelvis
- Lymphoma
- Pelvic Irradiation
- Genitourinary foreign body (e.g. stent)
- Causes: Miscellaneous - Men
- See Dysuria in Men
- Phimosis
- Prostate
- Prostatitis
- Benign Prostatic Hyperplasia
- Prostate Cancer
- Causes: Miscellaneous - Women
- See Dysuria in Women
- Vulva and Vagina
- Atrophic Vaginitis
- Vaginal cancer
- Vulvar Cancer
- Uterus
- Endometriosis
- Uterine Fibroids (paraurethral)
- Causes: Psychogenic and social
- Somatization
- Chronic Pain Syndrome (e.g. Chronic Pelvic Pain)
- Major Depression
- Chemical Dependency
- Sexual abuse
- History: Characteristics of Dysuria
- Timing
- Start of void: Urethral source
- End of void: Bladder source
- Pain location
- Cystitis
- Bladder and Urethral pain
- Bladder Distention
- Suprapubic or retropubic pressure
- Vaginitis
- External pain distribution
- Prostatitis (or other deeper pelvic source)
- Deep perineal pain
- Epididymitis
- Testicular Pain
- History: Associated symptoms and contributing factors
- Bladder and lower urinary tract symptoms
- Urinary Frequency or urinary urgency
- Hematuria
- Abnormal Urine Odor
- Urinary Incontinence
- Nocturia
- Kidney and upper urinary tract symptoms
- Flank Pain
- Fever
- Nausea or Vomiting
- Past medical history
- Pyelonephritis
- Nephrolithiasis
- Sexually Transmitted Infection
- Genitourinary procedures
- Genitourinary malignancy
- Medications and topical agents
- Exposures to possible urinary tract irritants or external Contact Dermatitis causes
- Additional history in women
- Pregnancy, current Contraception and Last Menstrual Period
- Vaginal Discharge or vaginal irritation
- Additional history in men
- Benign Prostatic Hyperplasia
- Testicular Pain
- Exam
- Abdominal exam
- Abdominal tenderness (e.g. suprapubic tenderness)
- Flank tenderness (Costovertebral Angle Tenderness)
- Suprapubic fullness (Bladder Distention)
- Female genitourinary exam
- Vulvar lesions (e.g. vessicles or ulcerations)
- Inguinal Lymphadenopathy
- Vaginal Discharge
- Vaginal Atrophy
- Cervical discharge
- Cervical motion tenderness
- Male genitourinary exam
- Penile discharge
- Penile Lesions, esp. at meatus (e.g. Vesicles, ulcers)
- Inguinal Lymphadenopathy
- Epididymal or testicular tenderness
- Swollen, tender Prostate
- Skin exam
- Localized genitourinary dermatitis (e.g. HSV, Contact Dermatitis, chronic inflammatory condition)
- Polyarthritis
- Gonococcus (associated with scattered Pustules)
- Reiter's Syndrome (associated with Conjunctivitis)
- Labs
- Urinalysis
- Urine Culture
- STD Testing for Urethritis
- Gonorrhea PCR
- Chlamydia PCR testing
- Wet Prep
- Trichomonas PCR (NAAT)
- Mycoplasma genitalium (CDC approved testing available as of 2019)
- Consider in persistent or recurrent Urethritis
- Also offer HIV Test, Hepatitis B and Syphilis Test
- Imaging
- Bladder and renal Ultrasound (or Bedside Ultrasound)
- Bladder Distention (may also be detected with Bladder scan or post-void residual catheterization)
- Hydronephrosis
- CT Abdomen and Pelvis without contrast
- Nephrolithiasis
- CT Abdomen and Pelvis with and without contrast (CT Urogram)
- Hematuria evaluation for malignancy
- Cystoscopy
- Hematuria evaluation for malignancy
- Interstitial Cystitis
- Management: General
- Symptomatic Management
- Phenazopyridine (Pyridium)
- Antibiotic indications
- Urinary Tract Infection or Pyelonephritis
- Sexually Transmitted Infection or Pelvic Inflammatory Disease (see Urethritis below)
- Suspected Acute Prostatitis
- May be associated with Pelvic Pain, worse on Defecation and with ejaculation
- Management: Urethritis
- Treat as Sexually Transmitted Infection
- Despite risk of overtreatment, treat for suspected Chlamydia and Gonorrhea (prevents spread, complications)
- Gonorrhea management
- Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
- Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
- Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
- Chlamydia management
- Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
- Azithromycin 1 g orally for 1 dose
- References
- Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- Other management
- Consider Genital Herpes
- Treat Trichomonas vaginalis if present
- Metronidazole 2 grams orally or 500 mg orally twice daily for 7 days OR
- Tinidazole 2 grams orally
- As noted above, offer other STD testing (e.g. HIV Test, Syphilis Test)
- Treat sexual partners
- See Expedited Partner Treatment
- Management: Persistent Dysuria with unremarkable evaluation
- Urge Incontinence or Overactive Bladder
- Pelvic Floor Exercises and Bladder TrainingExercises
- Topical or systemic irritants
- Discontinue offending agents
- ' Consider regional pain sources
- Endometriosis
- Interstitial Cystitis
- Consider empiric treatment for Mycoplasma genitalium if testing is unavailable
- Moxifloxacin 400 mg orally daily for 7-14 days OR
- Azithromycin 1 gram orally OR
- Doxycycline 100 mg orally twice daily for 7 days
- References
- Bremnor (2002) Am Fam Physician 65(8):1589-97 [PubMed]
- Michels (2015) Am Fam Physician 92(9): 778-86 [PubMed]
- Sell (2021) Am Fam Physician 103(9): 553-8 [PubMed]