PROBLEM-ORIENTED DIAGNOSIS Evaluation of Dysuria in Adults JUDY D. BREMNOR, M.D., and RICHARD SADOVSKY, M.D. State University of New York Health Science Center at Brooklyn College of Medicine, Brooklyn, New York Dysuria, defined as pain, burning, or discomfort on urination, is more common in women than in men. Although urinary tract infection is the most frequent cause of dysuria, O A patient infor- empiric treatment with antibiotics is not always appropriate. Dysuria occurs more often mation handout on dysuria, written by in younger women, probably because of their greater frequency of sexual activity. Older the authors of this men are more likely to have dysuria because of an increased incidence of prostatic hyper- article, is provided plasia with accompanying inflammation and infection. A comprehensive history and on page 1597. physical examination can often reveal the cause of dysuria. Urinalysis may not be needed in healthier patients who have uncomplicated medical histories and symptoms. In most patients, however, urinalysis can help to determine the presence of infection and confirm a suspected diagnosis. Urine cultures and both urethral and vaginal smears and cultures can help to identify sites of infection and causative agents. Coliform organisms, notably Escherichia coli, are the most common pathogens in urinary tract infection. Dysuria can also be caused by noninfectious inflammation or trauma, neoplasm, calculi, hypoestro- genism, interstitial cystitis, or psychogenic disorders. Although radiography and other forms of imaging are rarely needed, these studies may identify abnormalities in the upper urinary tract when symptoms are more complex. (Am Fam Physician 2002;65:1589-96, 1597. Copyright© 2002 American Academy of Family Physicians.) Members of various ysuria is the sensation of pain, percent of American women report acute family practice depart- burning, or discomfort on dysuria every year.10 The symptom is most ments develop articles urination.1,2 Although many prevalent in women 25 to 54 years of age and for “Problem-Oriented 11 Diagnosis.” This article physicians equate dysuria in those who are sexually active. In men, is one in a series from with urinary tract infection dysuria and its associated symptoms become the Department of D(UTI), it is actually a symptom that has many more prevalent with increasing age.6 Family Practice at potential causes. Empiric treatment with SUNY Health Science antibiotics may be inappropriate, except in Causes of Dysuria Center at Brooklyn 3-5 INFECTION AND INFLAMMATION College of Medicine. carefully selected patients. Guest coordinator of Dysuria most often indicates infection or Infection is the most common cause of the series is Miriam inflammation of the bladder and/or urethra. dysuria and presents as cystitis, prostatitis, Vincent, M.D. Other common causes of dysuria include pro- pyelonephritis, or urethritis, depending on the statitis and mechanical irritation of the ure- area of the urogenital tract that is most thra in men, and urethrotrigonitis and vagini- affected. The hollow or tubular structures of tis in women. Dysuria can also result from the urinary system are vulnerable to infection malformations of the genitourinary tract, by coliform bacteria. These bacteria are neoplasms, neurogenic conditions, trauma, believed to gain access to the urethral meatus hormonal conditions, interstitial cystitis, and through sexual intercourse or local contami- psychogenic disorders6-8 (Table 1). nation and then ascend to the affected region.1 Dysuria accounts for 5 to 15 percent of vis- A community-based study10 found that its to family physicians.9 Approximately 25 about two thirds of culture-proven UTIs are caused by Escherichia coli. Other less frequent pathogens include Staphylococcus saprophyticus Infection is the most common cause of dysuria and presents (15 percent), Proteus mirabilis (10 percent), Staphylococcus aureus (5 percent), Enterococ- as cystitis, prostatitis, pyelonephritis, or urethritis, depending cus species (3 percent), and Klebsiella species on the area of the urogenital tract that is most affected. (3 percent). Abnormalities in urinary anatomy or func- APRIL 15, 2002 / VOLUME 65, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1589 TABLE 1 Selected Causes of Dysuria Infections: pyelonephritis, cystitis, prostatitis, urethritis, cervicitis, epididymo-orchitis, vulvovaginitis Hormonal conditions: hypoestrogenism, endometriosis Malformations: bladder neck obstruction (e.g., benign prostatic hyperplasia), urethral strictures or diverticula Neoplasms: renal cell tumor; bladder, prostate, vaginal/vulvar, and penile cancers urgency.14 Other noninfectious causes of Inflammatory conditions: spondyloarthropathies, drug side effects, autoimmune disorders dysuria in women include the urethral syn- Trauma: catheter placement, “honeymoon” cystitis drome (defined as symptoms consistent with Psychogenic conditions: somatization disorder, major depression, stress disorders or a lower UTI but without the presence of sig- anxiety, hysteria nificant bacteriuria and conventional patho- gens),15 urethral trauma during sexual inter- course, and sensitivity to scented creams, tion allow more unusual, recurrent, and per- sprays, soaps, or toilet paper. sistent infections with organisms such as Pro- More than 50 percent of men over 70 years teus, Klebsiella, or Enterobacter species. Such of age have clinical symptoms of BPH, and abnormalities include bladder diverticula, nearly 90 percent have microscopic evidence renal cysts, urethral strictures, benign prosta- of prostatic hyperplasia.16 In older men, a UTI tic hyperplasia (BPH), and neurogenic blad- may result from obstruction and increased der. Rarely, bacteria may spread hematog- postresidual volume.17 However, dysuria may enously, causing pyelonephritis. be caused by inflammation of the distended The urethra is infected preferentially by urethral mucosa without superimposed infec- organisms such as Neisseria gonorrhoeae or tion. Obstruction and dysuria can also occur Chlamydia trachomatis. Other pathogens because of strictures caused by gonococcal include Ureaplasma urealyticum, Mycoplasma urethritis or because of urethral instrumenta- genitalium, Trichomonas vaginalis, and herpes tion or surgery. simplex virus.12,13 In both sexes, dysuria may be part of the Rare infectious causes of dysuria include clinical presentation of renal calculi and neo- adenovirus, herpesvirus, mumps virus, and the plasms of the bladder and renal tract. Spondy- tropical parasite Schistosoma haematobium. loarthropathies (e.g., Behçet’s syndrome, Reiter’s syndrome) can cause a general inflam- NONINFECTIOUS CAUSES matory state, including inflammation of the In postmenopausal women, the marked urothelium, that results in dysuria. reduction in endogenous estrogen can lead to Physical activities such as horseback riding lower urinary tract dysfunction. Atrophy, or bicycling can lead to dysuria with minimal dryness, and, occasionally, inflammation of urethral discharge. Dysuria may also be a fea- the vaginal epithelium contribute to urinary ture of psychogenic conditions such as soma- symptoms such as dysuria, frequency, and tization disorder, chronic pain syndromes, major depression, and chemical dependency.18 Sexually abused and other emotionally dis- tressed persons can have psychogenic urinary The Authors retention and dysuria. JUDY D. BREMNOR, M.D., is clinical assistant instructor at the State University of New York (SUNY) Health Science Center at Brooklyn College of Medicine. Dr. Bremnor Evaluation of Dysuria received her medical degree from the University of the West Indies Faculty of Medical Sciences, Mona, Jamaica. An algorithm for the evaluation of patients with acute dysuria is provided in Figure 1. RICHARD SADOVSKY, M.D., is associate professor of family practice at the SUNY Health Science Center at Brooklyn College of Medicine, where he earned his medical degree, completed a family practice residency, and served as residency director for 10 years. Dr. HISTORY Sadovsky has served as president of the New York chapter of the American Academy The timing, frequency, severity, and location of Family Physicians. He is presently an associate editor for American Family Physician. of dysuria are important. In adult women, a Address correspondence to Richard Sadovsky, M.D., Department of Family Practice, history of external dysuria (pain as the urine State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 67, Brooklyn, NY 11203 (e-mail: [email protected]). Reprints are passes over the inflamed vaginal labia) sug- not available from the authors. gests vaginal infection or inflammation, 1590 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 65, NUMBER 8 / APRIL 15, 2002 Dysuria whereas a history of internal dysuria (pain felt Longer duration and more gradual onset of inside the body) suggests bacterial cystitis or symptoms may suggest C. trachomatis infec- urethritis.1 Pain at the onset of urination is tion, whereas sudden onset of symptoms and usually caused by urethral inflammation, but hematuria suggests bacterial infection. suprapubic pain after voiding is more sugges- It is important to inquire about the presence tive of bladder inflammation or infection. of other genitourinary symptoms. Dysuria is Evaluation of Acute Dysuria* Male patient with dysuria Penile discharge, Penile lesion Scrotal pain Perineal pain, sexually active prostatic tenderness Epididymitis or orchitis Urethral smear and culture