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Home , Cystocele, Dysuria, Urination

DYSURIA A CLINICAL APPROACH TO IN WOMEN

Dysuria is a common presenting symptom among women and is not always associated with a .

Dysuria is defined as , burning or discomfort on , which is common- ly accompanied by frequency or urgency. Although many doctors equate dysuria with urinary tract infections (UTIs) and treat empirically without adequate evalua- tion, it is a symptom that is associated with many different clinical entities. Dysuria is more frequent in young women. A comprehensive history and a step- wise diagnostic approach, accompanied by inexpensive office laboratory testing, are usually sufficient to determine the cause of dysuria. Table I lists disorders associated with symptoms of dysuria and their characteristic symptoms, laborato- ry and physical findings.

DIFFERENTIATION BY HISTORY Pain occurring at the start of urination may indicate urethral pathology, whereas SR RAMPHAL pain occurring at the end of micturition (strangury) is usually of bladder origin. MB ChB, Dip Med COG, FCOG Dysuria with frequency and urgency with internal discomfort located in the ure- Principal Specialist/Lecturer thra and bladder usually suggests cystitis, while dysuria with external discomfort Department of Obstetrics and suggests labial irritation or associated . Sexual intercourse is associated with many causes of dysuria, but women with postcoital cystitis typically develop Nelson R Mandela School of Medicine symptoms within a few days of intercourse. University of KwaZulu-Natal

Durban Women are at risk of developing UTIs because of their short , and certain behavioural factors which include delay in micturition, sexual activity and the use Dr Ramphal currently heads the of diaphragms and spermicides which promote colonisation of the periurethral Gynaecology Endoscopy Unit and the area with coliform bacteria. Haematuria is common with UTI, and is unlikely to occur with other potential causes. About 15 - 20% of women with acute cystitis Urogynaecology Reconstruction have suprapubic pain.1 Postmenopausal women not receiving hormone replace- Unit in the department. ment therapy are prone to vaginitis and urinary tract infection.

Dysuria associated with a suggests some type of vaginitis. with the sensation of external dysuria is highly suggestive of vagini- tis. Dysuria at the start of micturition with symptoms of pelvic inflammatory dis- ease (PID) is suggestive of .2

Associated fever, myalgia and headaches suggest acute or as a cause of dysuria. The former usually has renal angle tenderness while the latter has tender vesicles in the and vaginal area. Dysuria with post-micturition dribble, frequency, urgency and dyspareunia is highly suspicious of a and needs to be investigated. Questions should be asked about the use of medications and topical products since dysuria can be caused by penicillin G, cyclophosphamide, vaginal sprays, vaginal and bubble baths. Bladder irritation from compression by - es and radiation or chemical exposure also produces dysuria.

DIFFERENTIATION ON EXAMINATION The physical examination is usually not remarkable and special focus should be placed on the genito-. In patients with cystitis, only 15 - 20% have

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Table I. of dysuria in females

Laboratory and other test Diagnosis Associated symptoms Physical examination results

Acute cystitis Frequency, urgency 15 - 20% suprapubic Usually positive for pyuria with occasional tenderness and occasionally positive haematuria for bacteriuria and nitrite Subclinical Frequency, urgency May have suprapubic Positive for pyuria, pyelonephritis with infrequent tenderness. No sometimes positive for haematuria costovertebral angle bacteriuria and nitrite, tenderness culture >105 colony- forming units/ml Acute pyelonephritis Nausea, fever, Costovertebral Pyuria with casts of WBC, emesis, back/flank angle tenderness. urine culture >105 colony- pain. History of Deep right or left upper forming units/ml urine preceding cystitis quadrant tenderness Urethritis Usually No suprapubic pain, Urethral swab: positive for asymptomatic. unless associated with WBC, Gram stain for Gram- If symptoms develop PID, rarely visible urethral negative diplococci. Molecular they are usually discharge techniques for delayed (> 1 week) and gonorrhoea Vaginitis External irritation, Vaginal discharge, Positive KOH or vaginal vaginal discharge or inflamed vaginal mucosa saline preparation, elevated pruritus, dyspareunia (absent in bacterial pH (, or premenstrual vaginosis), inflamed CX ) exaggeration of (trichomoniases), vaginal symptoms atrophy (postmenopausal) Genital herpes Dysuria, fever, Grouped vesicles Viral culture (optional) headaches, myalgia, usually on or pubic vulval pain area, tender inguinal lymphadenopathy Frequency, urgency, Long-standing Urinalysis negative for haematuria (20%) symptoms with negative WBC or bacteria, positive for with associated cultures, may have glomerulations on dysuria suprapubic tenderness Urethral diverticulum Postmicturition Suburethral swelling, Opening at dribble, dyspareunia occasional pus expressed cystourethroscopy, and dysuria from urethra contrast in diverticulum at voiding Burning vulvar Dysuria is external, Exquisite tenderness by syndrome burning sensation on cotton swab palpation on vulva vestibule, reddish spots at introitus

KOH = potassium hydroxide. suprapubic tenderness. Pyrexia, renal A tender, reddish introitus may suggest DIFFERENTIATION WITH angle tenderness, or deep right or left and the presence of a ten- LABORATORY upper quadrant tenderness to deep der suburethral swelling with a ure- INVESTIGATIONS palpation, suggest acute pyelonephri- thral discharge will be suspicious of a Urine analysis tis. Vaginal atrophy, especially in the urethral diverticulum. elderly, will reflect the hypo-oestro- Pyuria is the most sensitive laboratory genic state. indicator for UTI. A positive leucocyte esterase dipstick test is 75 - 95% sen-

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sitive in detecting pyuria secondary to experience at least one episode of cys- Uncomplicated cystitis can be treated infection.3 Bacteruria and urine nitrite titis in their lifetime, and 20% will empirically with a single-dose antibiot- are frequently present but are less sen- have recurrent cystitis. ic or a 3-day course (Table III). The sitive as markers of UTI. Positive nitrite use of single-dose antibiotic therapy is over 90% specific for UTI, but the Pathogenesis has recently fallen into disfavour as sensitivity is only 30%.4 The sensitivity The shorter urethra in women predis- there is a high risk of recurrence with- is increased to 60% if the first voided poses them to ascending infection of in 6 weeks of initial treatment.7 This morning urine sample is tested. bacteria, especially during sexual was attributed to failure to eradicate Therefore a dipstick test that is positive intercourse. Naturally occurring Gram-negative bacteria from the rec- for nitrite suggests UTI. However a defence mechanisms that tend to be tum which is a source or reservoir for negative test does not rule out the protective are indicated below. When ascending infections. It is now accept- diagnosis. these defence mechanism are disrupt- ed that a 3-day regimen offers the ed, patients are prone to developing optimal combination of convenience, Microscopic examination UTIs. low cost and efficacy comparable with Urine microscopic examination of a that of a 7-day regimen with fewer clean-catch, spun midstream urine sed- Naturally occurring defence side-effects.8 iment is regarded as the gold stan- mechanisms dard for evaluating dysuria. Pyuria is • Normal urine has a low pH, a high Recurrent infections are usually re- diagnosed by the presence of 3 - 5 osmolality, and a content that infections (infections with different white blood cells per high-power field makes it a natural bactericide. organisms) separated by an asympto- and haematuria is diagnosed by the • Normal urine flow and voiding matic interval of at least 1 month. presence of 3 - 5 red blood cells per expels bacteria. Fortunately, most of these are uncom- high-power field.5 •A protective mucous coating of the plicated and are generally not associ- uroepithelial cells inhibits adher- ated with underlying anatomical Urine culture ence of bacteria. abnormalities. They are usually caused Non-pregnant women with uncompli- •Vaginal secretions have a low pH by vaginal and rectal colonisation cated cystitis do not usually require a that inhibits growth of coliform bac- with uropathogens. urine culture. However, if it is per- teria. formed, then more than 103 colony- Patients who have more than 3 UTI Conditions that cause an forming units/ml is significant. Urine recurrences documented by urine cul- increased incidence of cultures are also deferred if dysuria is ture within 1 year should be managed urinary tract infection described as external and a probable using one of the three preventive urethral or vaginal cause is identified. • Obstruction or alteration in urine strategies: flow secondary to tumours, stones, • acute self-treatment with a 3-day Vaginal or urethral cystocele, pregnancy, and post- course of standard therapy when smears/pH incontinence . symptoms of UTI develop Increased vaginal pH is characteristic • Disruption of the mucin layer fol- • postcoital prophylaxis with trimetho- of trichomoniasis, bacterial vaginosis, lowing catherterisation with a prim-sulfamethoxazole if UTI has and in conditions where Lactobacillus Foley’s catheter, or urinary tract been clearly related to intercourse is replaced with coliform bacteria. instrumentation. • continuous daily prophylaxis for a Urethral smears with more than 5 • Alteration in the normal vaginal period of 6 months with nitrofuran- white blood cells per high-power field lactobacillus colonisation, especial- toin 100 mg per day, or trimetho- are highly suggestive of a urethritis. ly with usage of spermicides prim 100 mg per day. (nonoxynol-9), antibiotics, and post- The above regimens have been shown Vaginal/urethral cultures menopausal women with oestrogen to decrease the morbidity of recurrent Although cultures for Chlamydia tra- deficiency. UTIs without concomitant increase in chomatis and Neisseria gonorrhoeae Table II lists the likely bacterial antibiotic resistance.9 are the gold standard for identification pathogens in uncomplicated and com- of these organisms, they are not rou- plicated UTIs. Complicated UTIs tinely done. Complicated UTIs are defined as those Treatment CONDITIONS PRESENTING occurring in women with an anatomi- Many episodes of bacterial cystitis WITH DYSURIA cally or functionally abnormal urinary resolve without treatment. Antibiotics tract, or in women who are immuno- Acute cystitis hasten the reduction of symptoms and compromised, which predisposes them prevent the spread of infection into the Acute cystitis is the most common bac- to persistent infections, recurrent infec- upper urinary tract.6 terial infection in young women. tions or treatment failure. Approximately 40% of women will

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Although many doctors Accessory tests, such as antibody-coat- The median age of diagnosis is 40 equate dysuria with urinary ed bacteria assay, erythrocyte sedi- years. The diagnosis is difficult to tract infections (UTIs) and mentation rate (ESR) and renal cortical make and a study showed that scintigraphy, have been used to identi- patients on an average have had their treat empirically without fy patients with subclinical symptoms for 4.5 years before they adequate evaluation, it is a pyelonephritis but the specificity of were correctly diagnosed.10 Of signifi- symptom that is associated these tests is too poor to make them cance, patients with interstitial cystitis with many different clinical useful. are more likely to have had UTIs both entities. as children and adults. Risk factors for subclinical pyelonephri- tis in women are: The exact aetiology of interstitial cysti- Dysuria with frequency and • immunosuppression tis remains unclear and the proposed urgency with internal dis- • mellitus theory is that there is an alteration in comfort located in the ure- •pregnancy the glycosaminoglycan mucous layer, •anatomic anomaly of the urinary possibly in response to a previous bac- thra and bladder usually tract terial urinary tract infection, allowing suggests cystitis, while • solutes in the urine to provide an dysuria with external dis- • relapse of symptoms within 3 days inflammatory response. comfort suggests labial irri- of treatment for cystitis tation or associated vagini- • history of acute pyelonephritis within Characteristic features of interstitial tis. 1 year. cystitis are: • symptoms of suprapubic pain with Interstitial cystitis frequency, urgency, dysuria, noc- Aggressive clinical investigation is Interstitial cystitis is a clinical syn- turia and dyspareunia for at least important since only 35% are drome of urinary frequency and pelvic 9 months Escherichia coli related and they are pain in a patient in whom no other • bladder capacity less than 350 ml more likely to harbour resistant organ- pathology can be established. It is sig- and low first sensation and urge to isms.2 Accurate urine culture and sus- nificantly more common than was orig- void (usually less than 150 ml) ceptibility tests are necessary to best inally believed, affecting an estimated • no recent diagnosis of bacterial target and eradicate the pathogens. 450 000 people in the USA, 90% of cystitis (within last 3 months) Therapy consists of broad-spectrum whom are women. agents such as quinalone derivatives for at least 10 - 14 days. Follow-up urine cultures should be performed after treatment to ensure complete Table II. Incidence of bacterial pathogens in lower urinary tract cure. infections

Subclinical pyelonephritis Pathogens Incidence (%) This condition represents a diagnostic challenge since these patients have Uncomplicated infections renal parenchymal involvement, but • Escherichia coli 80 they experience only symptoms of cys- • Staphylococcus saprophyticus 10 titis. This clinical condition has impor- • Proteus mirabilis 5 tant therapeutic sequelae, since infec- • Klebsiella pneumoniae 4 tions are more difficult to eradicate • Enterobacter species 1 and it requires a 2-week course of • β-haemolytic streptococcus < 1 antibiotic therapy compared with the usual 3-day course for cystitis. Complicated infections • Escherichia coli 35 Identifiable factors that increase a • Entrerococcus faecalis 16 patient's risk for subclinical • Proteus mirabilis 24 pyelonephritis are listed below. Most • Staphylococcus epidermidis 23 patients with this condition tend to • Klebsiella pneumoniae 7 5 have bacterial counts greater than 10 • Pseudomonas aeruginosa 5 units/ml on quantitative culture, but • Staphylococcus aureus 4 the specificity of this culture is not high • Enterobacter species 3 enough to be clinically useful. • Others 5

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Table III. Empirical oral antibiotic therapy for uncomplicated cystitis in women

Drug Dose Active

Single dose • Fosfomycin 3 g sachet — stat Citrobacter, Enterobacter, • Amoxicillin 3 g Klebsiella, Serrata species • Ciprofloxacin 500 mg

3-day cover • Trimethoprim sulfa- methoxazole (Bactrim) 2 tabs bd/3 days • Nitrofurantoin 100 mg 4x/3 days • Ciprofloxacin 250 mg bd/3 days

• no alternative explanation for the trolled studies evaluating their efficacy • amitryptyline (Tryptanol) — start symptoms, e.g. tuberculous cystitis, are lacking. Intravesical therapy at 25 mg nocte, increasing by radiation cystitis, chemical cystitis including hydrodistension of the blad- 25 mg every 2 - 4 weeks up to • characteristic cystoscopic appear- der during cystoscopic evaluation, 100 mg ance. dimethyl sulfoxide (DMSO), intravesi- • imipramine (Tofranil) — 25 mg cal capsaicin and resinferatoxin is usu- nocte Definitive diagnosis is made with the ally used as second-line approach.11 • hydroxyzine (Aterax) — 25 - 50 identification of Hunner’s ulcers Surgery should be reserved as last mg/day nocte (mucosal ulceration on the bladder choice for patients in whom other • nifedipine (Adalat) — 30 mg wall) or glomerulations (petechial-like forms of management have failed.12 (extended release) daily haemorrhages on the bladder Surgical procedures include supratrig- • cimetidine (Tagamet) — 200 mg mucosa). onal cystectomy with formation of an 3 times/day enterovesical anastomosis. Treatment CONCLUSION There is no known curative therapy for Management of interstitial Dysuria is a common symptom that interstitial cystitis. Hence management cystitis family care practitioners are faced is directed towards alleviating symp- • Dietary — avoid acidic, alcoholic with on a daily basis. Although many toms and improving function. In gener- or carbonated beverages, spicy equate dysuria with UTIs it is a symp- al, treatment begins with dietary foods, coffee, tea and chocolates. tom with many causes. A detailed his- changes and oral medication. A com- •Bladder retraining — increasing tory and simple examination will iden- bination of Taven-sp, Aterax and an time interval between voids. tify most causes so that appropriate antidepressant is usually first-line thera- • Medical therapy therapy can be instituted. py. While these agents have been • pentosan polysulfate (Elmiron) shown to improve symptoms relative to — 300 mg/day References available on request. placebos, large double-blind, con- • Taven-SP — 50 - 100 mg bd

IN A NUTSHELL

Dysuria is defined as pain, burning or discomfort on urination.

It is commonly accompanied by frequency or urgency.

Pain at the start of urination suggests urethral pathology, while pain at the end of urination suggests bladder origin.

Haematuria is common with UTI. and is unlikely to occur with other potential causes.

Pyuria is the most sensitive laboratory indicator for UTI.

A positive nitrite test is suggestive of UTI, but a negative test does not rule out the diagnosis.

Other conditions which present with dysuria are cystitis, acute and subclinical pyelonephritis, urethritis, vaginitis, genital herpes, interstitial cystitis, urethral diverticulum and burning vulvar syndrome.

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