Dysuria

Article Author:
Parth Mehta
Article Editor:
Anil Kumar Reddy Reddivari
Updated:
11/12/2019 9:07:13 PM
PubMed Link:
Dysuria

Introduction

Dysuria is a symptom of pain and/or burning, stinging, or itching of the urethra or urethral meatus with urination. It is among the most common symptoms experienced by most people at least once over their lifetime. Dysuria usually happens due to bladder muscle contraction and peristalsis of the urethra, which ends up causing the urine to come in contact with the inflamed mucosal lining, which in turn stimulates pain receptors and causes one to feel pain and/or burning. Other conditions can cause dysuria from different mechanisms. Also, dysuria requires differentiation from other symptoms, which can also occur due to bladder discomfort due to increased bladder volume, such as suprapubic or retropubic pain.[1]

Etiology

Primarily, causes of dysuria can be divided broadly into two categories, infectious and non-infectious. Infectious causes include urinary tract infection or urethritis, kidney or prostate infections, vaginal infections, and sexually transmitted diseases. Non-infectious causes include skin conditions, foreign body or stone in the urinary tract, trauma, benign prostatic hypertrophy, and tumors. Also, interstitial cystitis, certain medications, specific anatomic abnormalities, menopause, atrophic vaginitis can cause dysuria.[2]

Epidemiology

Dysuria can happen in both males and females. One of the most common causes of dysuria is urinary tract infection. Urinary tract infections are more common in females than males due to female anatomy, having a shorter and straight urethra compared to males who have longer and curved urethra due to male anatomy. In females, bacteria can reach the bladder more easily due to shorter and straight urethra as they have less distance to travel. Also, females who use the wrong wiping technique from back to front instead of front to back can predispose themselves to more frequent urinary tract infections due to the opening of the urethra being closer to the rectum. Because of these reasons, females tend to experience dysuria more frequently compared to males. Also, most urinary tract infections are uncomplicated. However, complicated urinary tract infections are also common in cases of urinary tract infection happening in men, pregnancy, immunocompromised status, anatomical or functional abnormalities of the urinary tract, and systemic spread.[3]

Pathophysiology

Dysuria from inflammatory causes like urinary tract infection results from bladder muscle contraction and urethral peristalsis, causing urine to come in contact with inflamed mucosa. This contact causes stimulation of sensory nerves and pain receptors and causes pain along with burning, stinging, or itching. The sensitivity of these receptors can become enhanced during the inflammatory or neuropathic processes. Occasionally inflammation from the surrounding organs such as colon can also sometimes result in dysuria. Dysuria from non-inflammatory causes like stone, tumor, trauma, or foreign body can result not only from the irritation of the urethral or bladder mucosa but also can also result from decreased capacity and elasticity of the bladder which can cause urinary urgency or incontinence along with dysuria.[4]

History and Physical

Detailed history taking is essential when someone presents with dysuria. The clinician must try to determine the timing, severity, duration, and persistence of the symptoms. Initial history should include features of a possible local cause, which may be causing dysuria, like vaginal or urethral irritation. Also, history regarding risk factors like pregnancy, the possibility of stone, trauma, tumor, recent urologic procedure, and the possibility of urologic obstruction merit consideration. Patient history should include information regarding associated symptoms like fever, chills, flank pain, low back pain, nausea, vomiting, joint pains, hematuria, nocturia, urgency, frequency, and incontinence. In elderly patients, history regarding changes in mental status is necessary as many times the most common symptom of urinary tract infection in older adults is confusion. History regarding recurrence of symptoms is also necessary, and thorough physical examination should be carried out.

The clinician should also look for physical findings of fever, rash, direct tenderness over the bladder area, and joint pain. Physical findings of increased temperature, increased pulse, low blood pressure in the presence of dysuria can indicate systemic infection. Urological obstruction due to stone or tumor can result in findings of hematuria, decreased urination, and bladder spasms. All these physical findings should be looked for carefully while obtaining history. History regarding recent sexual activity is crucial. In women, it is essential to take history regarding complaints of vaginal discharge, history of menstruation, and whether the patient is using contraception.[2][5] Males can present with different symptoms than females and may have perineal pain or obstructive symptoms along with dysuria, which could be caused by prostatitis.[6]

Evaluation

Evaluation of dysuria starts with detailed history taking and thorough physical examination. Associated signs and symptoms of hematuria, suprapubic tenderness, urinary frequency, urgency, fever, chills, nausea, vomiting, low back pain, joint pain, rash, etc. require close followup. Urinalysis is the most useful test to start the work up in a patient of dysuria. Urinalysis positive for nitrite carries a high predictive value of a positive urine culture. Also, urine dipstick showing leukocytes as equal predictive value as the presence of nitrites. When both are present, the predictive value goes even higher. If the patient only has leukocyte esterase or bacteria in the urine, then dysuria may suggest that the patient probably has urethritis.[7] 

If the patient has risk factors for a complicated urinary tract infection and those who do not respond to initial treatment, they should also have a urine culture and sensitivity performed. Also, it is important to check complete blood count and a metabolic panel, including serum creatinine if systemic infection is suspected, especially if the patient is having nausea, vomiting, fever, or chills. Blood cultures need to be done if there is a suspicion for systemic spread of infection. In severe cases, hospitalization requires consideration, as well.[8] 

Women who have vaginal symptoms, wet mount, or vaginal DNA probe is necessary. If sexually-transmitted infections are suspected, then a urethral or vaginal probe should be performed, and samples should be obtained to diagnose Neisseria gonorrhoeae and Chlamydia trachomatis.[9] In male patients where chronic prostatitis is suspected, gentle prostatic massage can be done to obtain a urine culture.[10] If the patient has hematuria and if bladder cancer is suspected, then urine cytology can be helpful.[11] Imaging tests like ultrasonography or CT scan may be in order in cases of dysuria where patients show signs of having complicated urinary tract infection, obstruction, abscess, stones, or tumors.[12] In certain cases, cystoscopy can be performed to evaluate for symptoms of chronic dysuria, which could be associated with bladder cancer or hematuria. Sometimes patients who have been having chronic dysuria may need a urology referral to rule out uncommon causes.[13][14]

Treatment / Management

Treatment of dysuria depends on the cause of dysuria. The most common cause of dysuria is urinary tract infection. Empiric antibiotic therapy based on a patient's history and symptoms is usually the most cost-effective therapy. No further evaluation is necessary in those cases where dysuria from uncomplicated urinary tract infection is suspected.[15] Where the clinician suspects complicated urinary tract infections, in the presence of associated symptoms like nausea, vomiting, fever, or chills, then along with starting antibiotics, additional testing like blood cultures, metabolic panel, or complete blood count are all viable options. In the case of suspected stones or obstruction, imaging with ultrasonography or CT scan can be diagnostic.

Depending on the risk factors, the clinician should be mindful of the possibility of anti-microbial resistance, and optimal antibiotics should start based on likely pathogens. The choice of antibiotics should be made based on local resistance patterns and costs associated with the treatment.[16] When dysuria is occurring due to chronic prostatitis in males, oral antibiotics merit consideration after obtaining urine culture.[17] If the cause of dysuria is renal stones, then various treatment options can be considered depending on the size and location of stones. Stones smaller than 5 mm typically pass on their own, and patients should be asked to hydrate themselves and strain the urine to document the evidence of a passed stone. The stones that are bigger than 5 mm are treatable through various modalities, including extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) or open surgery.[18] 

When the patient presents with dysuria and a perinephric abscess is suspected, then it should be first evaluated with an imaging study like an ultrasonography or CT scan. Once it is confirmed to be an abscess, the patient should be hospitalized, and intravenous antibiotics should be initiated, which can be followed by open surgical drainage or percutaneous catheter drainage or both. [19] If the cause of dysuria is benign prostatic hypertrophy, then medical treatment with alpha-blockers or 5-alpha reductase inhibitors should be considered. If the patient has no symptomatic improvement after trying the medical therapy, then the surgical option of transurethral resection of the prostate should be considered.[20]

Differential Diagnosis

Differential diagnoses broadly divide into two categories. Inflammatory and noninflammatory.[21][2]

Inflammatory 

  1. Infectious causes - Cystitis, urethritis, pyelonephritis, sexually transmitted infections. In females, vulvovaginitis, and cervicitis can be the causes of dysuria while in males, prostatitis, and epididymo-orchitis.
  2. Dermatologic - Contact dermatitis, psoriasis, Behcet syndrome, lichen sclerosus, lichen planus, Stevens-Johnson syndrome
  3. Noninfectious causes - Stone, a urethral or ureteral stent

Noninflammatory 

  1. Trauma - Foreign body, surgery, urinary tract instrumentation, pelvic radiation.
  2. Endocrine - Atrophic vaginitis, endometriosis
  3. Drugs - Cyclophosphamide, Ketamine
  4. Anatomic - Benign prostatic hypertrophy, urethral stricture.
  5. Neoplastic - Renal cell cancer, bladder cancer, lymphoma, vaginal cancer, vulvar cancer, prostate cancer, penile cancer, metastatic cancer. 
  6. Idiopathic - Interstitial cystitis

Prognosis

The prognosis for dysuria depends upon the cause of dysuria. Most of the etiologies of dysuria, including inflammatory and noninflammatory, demonstrate a good long term prognosis, but early detection of causes of dysuria is essential. However, systemic infections occurring due to urinary tract infections can cause lead to higher morbidity or mortality compared to systemic infections of other organs or systems; sepsis from urinary tract infections still has a better prognosis.[22] Long term complications can occur due to stones, chronic infections, or benign prostatic hypertrophy, which can lead to renal failure and in severe cases, end-stage renal disease. During pregnancy, complications can arise in both mother and fetus if urinary tract infections do not receive treatment timely and adequately.[4] Prognosis of dysuria occurring from neoplastic causes like renal cancers or bladder cancers depends upon the stage and type of cancer when it gets diagnosed. Early diagnosis and quick follow-up with adequate treatment carries a good prognosis, while a delayed diagnosis is associated with higher recurrence and poor prognosis.[23]

Complications

Depending on the cause of dysuria, short term complications can include acute renal failure, development of systemic infection and sepsis, acute anemia from hematuria, emergent hospitalization while long term complications can consist of the development of end-stage renal disease, infertility, long term disability from recurrent infections or urinary tract cancers and even death from severe systemic infections or advanced urinary tract cancers. Patients who have complicated urinary tract infections can end up having recurrent infections and higher antibiotic resistance, which may lead to higher rates of hospitalizations, and higher morbidity and mortality.[24]

Deterrence and Patient Education

Patient education is crucial in preventing recurrent cases of dysuria. If women have dysuria due to recurrent urinary tract infections or vaginal infections, they should be educated about not using douches, maintain perineal hygiene, and use correct wiping techniques. For patients who are experiencing recurrent sexually transmitted infections, they should be educated about safe sex practices, using condoms, urinating right after sex. For patients who get recurrent urinary tract infections due to uncontrolled diabetes should be educated about the importance of controlling their blood sugars. Patients who have dysuria from atrophic vaginitis can benefit from the education of hormone replacement therapy. Male patients suspected of having dysuria from benign prostatic hypertrophy should be educated about routine prostate exams and taking medications to control the symptoms. Patients who are high risk or are suspected of having cancer of the urinary tract should receive education about early detection and intervention with specialty referral. All patients should understand the importance of early detection of infections, which can present as dysuria as the earliest sign and should be encouraged to seek proper follow-up and treatment.

Enhancing Healthcare Team Outcomes

Using these recommendations, the interprofessional health care team can modify their approach to diagnose and treat patients of dysuria. It will also benefit in terms of increasing efficiency and reducing unnecessary testing. It will improve patient outcomes by educating them about the importance of early detection, adequate follow-up, and timely treatment. 

Given the broad spectrum of possible etiologies for dysuria, all members of the healthcare team must collaborate and function as a unit. The clinician who first encounters the complaint must order appropriate testing, and this will often form the basis for referrals. Diagnosis and management can end up including specialists from several different disciplines, and prompt care is to discover the underlying cause and get the patient to the proper provider.


References

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