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Dysuria is painful or uncomfortable urination. It is an extremely common symptom in women (most commonly due to UTIs), but it can affect men, can occur at any age, and has many noninfectious causes (see Table 2: Approach to the Genitourinary Patient: Causes of Dysuria ).
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Table 2
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Causes of Dysuria
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Type
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Examples
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Infectious*
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Cervicitis
Cystitis
Epididymo-orchitis
Prostatitis
Urethritis
Vulvovaginitis
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Inflammatory
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Spondyloarthropathies (reactive arthritis or Behçet's syndrome)
Vestibulitis
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Physical
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Catheterization
Obstruction of bladder neck (benign prostatic hyperplasia) or urethra (strictures)
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Other
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Hypoestrogenism
Tumors
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*Common pathogens include nonsexually transmitted bacteria (mostly Escherichia coli) and sexually transmitted pathogens (eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex virus).
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Evaluation
History and physical
examination:
Localization of symptoms is often nonspecific but may help identify the site of infection or inflammation (eg, periurethral symptoms suggest urethritis or vaginitis; suprapubic symptoms suggest cystitis). History of frequent UTIs suggests recurrence. Vaginal discharge, dyspareunia, and use of douches or other topical agents suggests vaginosis, vulvovaginitis, or vestibulitis. Fever or flank pain suggests pyelonephritis. Back or joint pain or conjunctivitis suggests spondyloarthropathy.
Penile discharge suggests urethritis; scrotal tenderness or erythema suggests epididymitis; changes in prostate consistency and prostate tenderness suggest prostatitis. Atrophy or erythema of vaginal folds and vaginal discharge suggest vulvovaginitis.
Testing:
No single testing protocol is correct.Many clinicians use antibiotics without any testing to treat dysuria in young, otherwise healthy women. An evaluation always begins with urinalysis. If a dipstick test of a portion of a clean-catch specimen detects WBCs, routine urine culture is indicated, although doing both tests simultaneously is common practice. A finding of > 1000 bacteria colony-forming units/mL suggests infection. WBCs in a sterile culture suggest sexually transmitted infection, vulvovaginosis, vulvovaginitis, prostatitis, TB, tumor, calculi, or interstitial nephritis. Any vaginal discharge warrants a wet mount, and cervical (women) and urethral (men) smear should be sent for gonococcus and chlamydia culture or PCR. If there is no response to empiric antibiotics and test results are negative, imaging of the urinary tract may be indicated to check for obstruction, calculi, cancer, or other abnormalities.
Treatment
Phenazopyridine 200 mg po tid can be used to relieve acute, intolerable dysuria in the 1st 24 to 48 h. The drug turns urine red-orange; patients should be cautioned not to confuse this effect with progression of infection or hematuria. Definitive treatment is directed at the cause; a short course of antibiotics is effective in most patients (see Urinary Tract Infections (UTI): Treatment).
Last full review/revision November 2005
Content last modified November 2005
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