Dysuria

Definition and Character of the Pain

• Distal urethra in men - present only during voiding and resolves soon after.
• Urethra in women - often described as "internal" dysuria.
• Bladder (suprapubic, at the end of voiding) - suggests bladder inflammation as the primary site.

• Smith and Tanagho's General Urology, 19th Edition
• Harrison's Principles of Internal Medicine, 22nd Ed.

Differential Diagnosis

• Calculi (urinary stones)
• Meatal stenosis
• Neoplasm - bladder, prostate, vulvovaginal, penile
• Interstitial cystitis / urethral syndrome
• Atrophic vaginitis/urethritis (postmenopausal women)
• Trauma - foreign body, postcoital, mechanical
• Chemical/irritant urethritis - soaps, spermicides, hygiene products
• Medications
• Somatization
• Spondyloarthropathy-associated urethritis
• Textbook of Family Medicine, 9th Ed. (Table 40-3)

Key History Points

1. Onset and character - acute vs. gradual; internal ("bladder") vs. external ("skin contact with urine")
2. Associated symptoms - frequency, urgency, hematuria, flank pain, fever (point toward UTI/pyelonephritis)
3. Vaginal/urethral discharge - strongly suggests STI or vaginitis rather than simple cystitis
4. Sexual history - new or multiple partners, condom use, partner symptoms
5. Vaginal symptoms - pruritus, odor, discharge (suggest vaginitis as a cause of external dysuria)
6. Medications and hygiene products - irritant causes
7. Systemic symptoms - fever, chills, rigors suggest upper tract or systemic infection

Approach by Patient Group

Women

• Acute dysuria + frequency/urgency, no discharge, no vaginal symptoms - most likely uncomplicated cystitis. Urine culture may not be necessary in healthy, non-pregnant, low-risk women.
• Dysuria + vaginal discharge, new partner, or STI risk factors - consider urethritis (chlamydia, gonorrhea), cervicitis, or vaginitis. Send urinalysis, urine culture, and STI screen (NAAT for C. trachomatis and N. gonorrhoeae); perform pelvic exam.
• Dysuria + external burning + pruritus + discharge, no pyuria - suggest vaginitis (Candida, Trichomonas). No urgency/frequency in these cases.
• Dysuria caused by urethritis - more gradual onset, associated with cervicitis or vulvovaginal herpetic lesions; pyuria present but hematuria rare.
• Postmenopausal women - atrophic urethritis/vaginitis is common; physical exam shows thinning of vaginal mucosa.
• Berek & Novak's Gynecology; Harrison's Principles of Internal Medicine 22E

Men

• Dysuria is less common in young men and more frequent with advancing age (e.g., BPH-related).
• Young sexually active man + urethral discharge - urethritis (gonococcal vs. non-gonococcal) is the leading diagnosis.
  • Gram stain: >2 neutrophils/HPF confirms urethritis; gram-negative intracellular diplococci = gonorrhea.
  • No diplococci = NGU (most likely C. trachomatis or M. genitalium).
• Dysuria without evidence of urethritis - evaluate for prostatitis (digital prostate exam, urine culture) or cystitis.
• Harrison's Principles of Internal Medicine, 22nd Ed.

Special populations

• Indwelling catheter - consider catheter-associated UTI (CAUTI); exchange/remove catheter, send urinalysis and culture.
• Elderly patients / immunocompromised / spinal cord injury - complicated UTI with atypical presentations; obtain urine and blood cultures.
• Pregnant women - negative dipstick does NOT rule out bacteriuria; urine culture required for screening.

Investigations

• Harrison's Principles of Internal Medicine, 22nd Ed.

Management Principles

Uncomplicated cystitis (women)

• Nitrofurantoin 100 mg modified-release twice daily x 5 days, or trimethoprim-sulfamethoxazole 160/800 mg twice daily x 3 days (where resistance rates allow), or fosfomycin 3 g single dose.

Urethritis - Gonococcal

• Ceftriaxone IM single dose (per current CDC guidelines; dose has changed to 500 mg or 1 g over time - confirm local guidelines).

Urethritis - Non-gonococcal (NGU)

• Doxycycline 100 mg orally twice daily x 7 days (first-line).
• Azithromycin 1 g single dose (alternative, but rising M. genitalium resistance is a concern).
• Treat current sexual partner(s).
• No test of cure needed if symptoms resolve.

Vaginitis

• Candida - fluconazole 150 mg single oral dose or topical antifungals.
• Trichomonas - metronidazole 500 mg twice daily x 7 days (or 2 g single dose).
• Bacterial vaginosis - metronidazole 500 mg twice daily x 7 days.

Pyelonephritis

• Outpatient: levofloxacin 750 mg daily x 7 days, or TMP-SMX x 14 days.
• Inpatient: parenteral ceftriaxone, levofloxacin, or gentamicin.
• Berek & Novak's Gynecology; Harrison's Principles of Internal Medicine 22E; Textbook of Family Medicine 9E

Important Clinical Pearls

• Dysuria alone does NOT confirm UTI - empiric antibiotics based on this symptom alone leads to unnecessary antibiotic use. Combining it with frequency, urgency, hematuria, and absence of vaginal discharge significantly increases the likelihood of UTI. - Textbook of Family Medicine, 9th Ed.
• A negative dipstick (nitrite AND leukocyte esterase both negative) should prompt alternative diagnoses.
• Vaginal discharge + dysuria - do not treat as simple UTI; evaluate for STI/vaginitis.
• In men with suspected urethritis who lack objective evidence of urethritis, repeated antibiotic courses are not beneficial - consider other etiologies.
• Asymptomatic bacteriuria (ASB) should NOT be treated in most patients; treatment is only warranted in pregnancy and before invasive urologic procedures.