Dysuria: Evaluation and Differential Diagnosis in Adults

 


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Am Fam Physician. 2015 Nov 1;92(9):778-788.

  Patient information: See related handout on dysuria, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The most common cause of acute dysuria is infection, especially cystitis. Other infectious causes include urethritis, sexually transmitted infections, and vaginitis. Noninfectious inflammatory causes include a foreign body in the urinary tract and dermatologic conditions. Noninflammatory causes of dysuria include medication use, urethral anatomic abnormalities, local trauma, and interstitial cystitis/bladder pain syndrome. An initial targeted history includes features of a local cause (e.g., vaginal or urethral irritation), risk factors for a complicated urinary tract infection (e.g., male sex, pregnancy, presence of urologic obstruction, recent procedure), and symptoms of pyelonephritis. Women with dysuria who have no complicating features can be treated for cystitis without further diagnostic evaluation. Women with vulvovaginal symptoms should be evaluated for vaginitis. Any complicating features or recurrent symptoms warrant a history, physical examination, urinalysis, and urine culture. Findings from the secondary evaluation, selected laboratory tests, and directed imaging studies enable physicians to progress through a logical evaluation and determine the cause of dysuria or make an appropriate referral.

Dysuria is burning, tingling, or stinging of the urethra and meatus associated with voiding. It should be distinguished from other forms of bladder discomfort, such as suprapubic or retropubic pain, pressure, or discomfort that usually increases with bladder volume.13 Dysuria is present at least occasionally in approximately 3% of adults older than 40 years, according to a survey of roughly 30,000 men and women.4 Acute cystitis is the most common cause in women, accounting for 8.6 million outpatient visits in 2007 and 2.3 million emergency department visits in 2011.5,6 This article describes an evidence-based approach to the evaluation of adult outpatients with dysuria, focusing on the history, physical examination, and selected tests.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

In low-risk women with dysuria and no vaginal symptoms or other typical UTI symptoms, physicians should obtain a dipstick urinalysis for nitrites and leukocyte esterase.

C

24, 25

Nitrites have higher predictive value for UTI but also higher false-negative rates than leukocyte esterase.

Patients with dysuria who are at risk of complications or whose symptoms do not respond to initial treatment should undergo a detailed history, directed physical examination, and urinalysis and culture.

C

8, 10

Clinical evaluation is useful to direct additional workup.

Further investigation and urology referral should be considered in patients with recurrent UTI, urolithiasis, known or suspected urinary tract abnormality or cancer, history of urologic surgery, hematuria, persistent symptoms, or in men with abnormal postvoid residual urine level (greater than 100 mL).

C

8, 10, 11, 29, 33

Some evaluations, such as postvoid residual urine, computed tomography urography, and symptom questionnaires, can be initiated by the family physician.

Women with an uncomplicated history who present with acute dysuria, urinary urgency or frequency, and no vaginal discharge can be treated for acute cystitis without other evaluation.

B

9, 2325, 31, 35

Uncomplicated history includes 16 to 55 years of age, not pregnant, no history of recurrent or childhood UTI, not immunocompromised, no diabetes mellitus, and no anatomic urologic abnormality or recent urologic instrumentation.


UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

In low-risk women with dysuria and no vaginal symptoms or other typical UTI symptoms, physicians should obtain a dipstick urinalysis for nitrites and leukocyte esterase.

C

24, 25

Nitrites have higher predictive value for UTI but also higher false-negative rates than leukocyte esterase.

Patients with dysuria who are at risk of complications or whose symptoms do not respond to initial treatment should undergo a detailed history, directed physical examination, and urinalysis and culture.

C

8, 10

Clinical evaluation is useful to direct additional workup.

Further investigation and urology referral should be considered in patients with recurrent UTI, urolithiasis, known or suspected urinary tract abnormality or cancer, history of urologic surgery, hematuria, persistent symptoms, or in men with abnormal postvoid residual urine level (greater than 100 mL).

C

8, 10, 11, 29, 33

Some evaluations, such as postvoid residual urine, computed tomography urography, and symptom questionnaires, can be initiated by the family physician.

Women with an uncomplicated

The Authors

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THOMAS C. MICHELS, MD, MPH, is a faculty physician in the Family Medicine Residency at Madigan Army Medical Center, Tacoma, Wash. He is also a clinical instructor at the University of Washington School of Medicine in Seattle....

JARRET E. SANDS, DO, is a family physician and serves as the medical director at the South Sound Family Medicine Clinic of the Madigan Healthcare System, Olympia, Wash. He is also a clinical instructor at the University of Washington School of Medicine and the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to Thomas C. Michels, MD, MPH, Department of Family Medicine, Madigan Army Medical Center, 9040 Reid St., Tacoma, WA 98431 (e-mail: thomas.c.michels.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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