Dysuria

Aka: Dysuria, Urethritis

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