Dysuria- painful or difficult urinationâ€”is commonly accompanied by urinary frequency, urgency, or hesitancy. This symptom usually reflects lower urinary tract infection (UTI)â€”a common disorder, especially in women.
Dysuria results from lower urinary tract irritation or inflammation, which stimulates nerve endings in the bladder and urethra. The onset of pain provides clues to its cause. For example, pain just before voiding usually indicates bladder irritation or distention, whereas pain at the start of urination typically results from bladder outlet irritation. Pain at the end of voiding may signal bladder spasms; in women, it may indicate vaginal Candidiasis.
Causes of dysuria
¨ Appendicitis. Occasionally, appendicitis causes dysuria that persists throughout voiding and is accompanied by bladder tenderness.
¨ Bladder cancer. Bladder cancer, a predominantly male disorder, causes dysuria throughout voiding. It’s a late symptom associated with urinary frequency and urgency, nocturia, and haematuria and perineal, back, or flank pain.
¨ Cystitis. Dysuria throughout voiding is common in all types of cystitis, as are urinary frequency, nocturia, straining to void, and haematuria.
¨ Paraurethral gland inflammation. Dysuria throughout voiding occurs with urinary frequency and urgency, a diminished urine stream, mild perineal pain and occasionally, haematuria.
¨ Prostatitis. Acute prostatitis commonly causes dysuria throughout or toward the end of voiding as well as diminished urine stream, urinary frequency and urgency, haematuria, and suprapubic fullness. With chronic prostatitis, urethral narrowing causes dysuria throughout voiding.
¨ Pyelonephritis (acute). Pyelonephritis causes dysuria throughout voiding as well as haematuria, urinary urgency, and frequency. Other findings include a persistent high fever with chills, costovertebral angle tenderness, and unilateral or bilateral flank pain.
¨ Retier syndrome. Reiter syndrome is a predominantly male disorder in which dysuria occurs 1 to 2 weeks after sexual contact. Initially, the patient has a mucopurulent discharge, urinary urgency and frequency, meatal swelling and redness, suprapubic pain, anorexia, weight loss, and a low-grade fever.
¨ Urinary obstruction. Outflow obstruction by urethral strictures or calculi produces dysuria throughout voiding. Other findings include a diminished urine stream, frequency, urgency, and sensation of fullness or bloating in the lower abdomen or groin.
¨ Vaginitis. Characteristically, dysuria occurs throughout voiding with vaginitis, as urine touches inflamed or ulcerated labia. Other findings in vaginitis include urinary frequency and urgency, nocturia, haematuria, perineal pain, and vaginal discharge and odor.
Differential Diagnosis of dysuria
UTI is the most common cause of dysuria. Dysuria can also be from other focal inflammation in the vagina, perineal area, prostate, or urethra; however, common vaginal infections that cause dysuria include bacterial vaginosis, vaginal Candidiasis, and vaginal trichomoniasis.
Vaginal atrophy, from the loss of estrogen stimulation to the vaginal mucosa and vulvar skin, can also be associated with dysuria. As the epithelium thins, it becomes prone to injury, with resulting dysuria and pruritis.
Urethritis is caused by sexually transmitted infections such as gonorrhea, Chlamydia, herpes simplex, or trichomoniasis. Prostate infections can cause dysuria and are typically associated with decreased urine flow, urgency, and hesitancy. Both acute prostatitis and upper tract UTI may present as fever and dysuria.
Dysuria is sometimes attributed to the poorly understood “urethral syndrome”. This syndrome of pain on urination without clearly identifiable cause has been ascribed to trauma, chemical irritation, low levels of urinary pathogens, or infection of periurethral tissue by unknown microorganisms.
The diagnosis of urethral syndrome is made only after the symptomatic patient has had normal findings on physical examination, and normal urinalysis and culture.
Workup and Diagnosis for dysuria
-UTI, STD, sexual activity, recent antibiotic exposure
-Instrumentation/irritation (urinary catheters, bubble baths, creams, masturbation)
-Fever, abdominal pain, flank pain, vaginal discharge
-Enuresis (especially new-onset), macroscopic haematuria, frequency, urgency
-Family history of kidney stones (increased likelihood of hyper-calciuria)
¨ Physical exam
-Fever, CVA tenderness
-Exam of the urethra/periurethral area for irritation
-Pelvic exam (if done) for cervical motions tenderness, cervicitis, or vaginal discharge.
-Urinalysis, urine culture
-STD screening if sexually active
-Urine spot calcium and creatinine if evidence of microscopic haematuria
¨ Additional studies based on clinical suspected
-Pelvic ultrasound if PID suspected
-Renal ultrasound/voiding cystourethrogram if history of previous UTI (in girls <7 and boys of any age), or if macroscopic haematuria is present.
-High resolution CT without contrast (kidney stones)
-24-hour urine calcium (hypercalciuria, kidney stones)
Treatment of dysuria
- UTI: Empiric antibiotics (e.g., co-trimoxazole) pending culture; adjust antibiotics based on bacterial sensitivities
-Simple cervicitis: Treat with IM ceftriaxone and PO azithromycin, metronidazole if Trichomonas present
-For an ill patient with signs of PID, consider hospital admission; give IV cefoxitin and PO doxycycline
- Candidal vaginitis: Topical antifungal agents or oral fluconazole
- Hypercalciuria/kidney stones
-Increase fluid intake, decrease sodium intake (increase urinary calcium excretion), do not restrict calcium intake.
-Treat with thiazide diuretics (decrease urinary calcium excretion) if patient is persistently symptomatic and/or has urinary calculi.
- Avoid instrumentation/local irritations (e.g. bubble baths)
Homeopathic treatment of dysuria
Cantharis: Burning or scalding and painful emission of urine, It is passed drop by drop.
Ignatia: Suppression of urine in hysterical cases.
Apis Melilotus: Burning and soreness when urinating; frequent desire. Passes only a few drops, Urine scanty and highly coloured
Clematis: When flow is interrupted by sudden spasms of urethra. Flow by fits and starts, Mucus in urine but not pus. Beginning of inflammatory stricture.
Conium: Urine stops suddenly and does not begin go flow for some moments.
Camphor: in acute cases when due to poisoning or suppression from cold. Give in low potency.
Terebinth: Difficult urination with lumbago-like pain.
Magnesia Mur: Urine can only be passed by pressing the abdominal muscles.
Sarsaparilla: Great pain after passing urine. Can pass urine only when standing, it only dribbles down when sitting
Cannabis Ind.: Burning or scalding before, during and after urination. Urging and straining but cannot pass a drop.
Hepar Sulph: Urination impeded. Obliged to wait before the urine is passed and then it flows slowly, feels as if some urine always remains behind in bladder.
Natrum Mur.: Cannot pass urine in the presence or other persons, Cannot pass it in a public place.
Nux Vom.: For spasmodic suppression. He must strain to urinate. There is tenesmus, urging. The bladder is full and the urine dribbles away. Yet when he strains, it ceases to dribble.
Lippincott Williams & Wilkins- Interpreting signs and symptoms; 2007; 220
Lippincott Williams & Wilkins- Portable Signs & Symptoms; 2007; 231
Philip D. Sloane, Lisa M. Slatt, Mark H Ebell- Essential of family medicine; 2008; 425
Jonathan E. Teitelbaum, Kathleen O. DeAntonis, Scott Kahan- In a page: Pediatric signs & symptoms; 2004; 122