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Dysuria: Evaluation and Differential Diagnosis in Adults

Ariel Hoffman, MD, MPH
Katelyn A. Dolezal, MD
Rob Powell, DO

American Family Physician. 2025;111(1):37-46.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Dysuria, a feeling of pain or discomfort during urination, is often caused by urinary tract infection but can also be due to sexually transmitted infection, bladder irritants, skin lesions, and some chronic pain conditions. History is most often useful for finding signs of sexually transmitted infection, complicated infections, lower urinary symptoms in males, and noninfectious causes. Most patients presenting with dysuria should have a urinalysis performed. Urine culture should be performed for infection to guide appropriate antibiotic use, especially for recurrent or suspected complicated urinary tract infection. Vaginal discharge decreases the likelihood of urinary tract infection, and other causes of dysuria, including cervicitis, should be investigated. If a patient has persistent urethritis or cervicitis with negative initial testing, Mycoplasma genitalium testing is recommended. Clinical decision rules may increase the accuracy of diagnosis with and without laboratory analysis. Evaluation and treatment of dysuria through a virtual encounter without laboratory testing may increase recurrent symptoms and antibiotic courses. Persistent symptoms after initial evaluation and treatment require further workup for infectious and noninfectious causes.

Dysuria is painful or uncomfortable urination, sometimes described as a burning sensation, that is caused by inflammation of internal or external structures that are irritated during voiding. Although the most common cause of dysuria is urinary tract infection (UTI), any infectious or inflammatory condition affecting the genitourinary tract in adults, as well as irritation from external skin defects or substances in the urine, can occur with dysuria.1 According to the National Center for Health Statistics survey, 1.8% of emergency department visits were for cystitis or assumed UTI, whereas 0.7% of ambulatory visits were attributed to cystitis or UTI.2,3 This article describes an evidence-based approach to evaluating adult outpatients with a concern of dysuria, focusing on history, physical examination, and specific tests. Although much of the cited literature uses the term women or men, this article uses females and males to refer to the sex assigned at birth.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations Evidence rating Comments
Ask females with dysuria about vaginal symptoms because the presence of vaginal discharge decreases the likelihood of UTI.12,37 C Expert review of literature
Perform urine culture with susceptibility testing in patients with a suspected infectious etiology to guide appropriate antibiotic use and reduce antibiotic resistance in patients with recurrent UTI or at risk for complicated infection.38,49 C Expert opinion, society guideline on recurrent UTI
Test patients with persistent or recurrent urethritis or cervicitis for Mycoplasma genitalium.41,43 C Expert review of literature
Perform urinalysis in most patients with dysuria to determine cause, especially in patients with recurrent UTIs, when there is suspicion for complicated UTI, and to prevent repeat encounters and repeat courses of antibiotics.48,49 C Expert opinion, society guidelines on recurrent UTI, and retrospective study demonstrating increased recurrence after empiric treatment

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 https://www.aafp.org/afpsort.

ARIEL HOFFMAN, MD, MPH, is residency faculty at Martin Army Community Hospital, Fort Moore, Georgia, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland.

KATELYN A. DOLEZAL, MD, is the associate program director at Madigan Army Medical Center Family Medicine Residency Program, Tacoma, Washington.

ROB POWELL, DO, is residency faculty at Martin Army Community Hospital, Fort Moore, Georgia.

Address correspondence to Ariel Hoffman, MD, MPH, at arielhoffman716@gmail.com.

Author disclosure: No relevant financial relationships.

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