Dysuria is the sensation of pain or burning on urination. In males, this sensation is usually felt in the distal urethra during voiding and resolves shortly after micturition. The timing of the discomfort can often predict its location in the urinary tract.¹ Pain at the start of urination usually indicates a urethral source of inflammation. More severe pain occurring over the suprapubic area on completion of urination suggests inflammation of the bladder.²

Urinary symptoms are far more common in women than in men and in older men than in younger men.³ Population-based surveys suggest that urinary tract symptoms significant enough to cause persons to seek medical attention occur in about 0.6 percent of women per year and about 0.1 percent of men each year.⁴ Voiding symptoms in men increase significantly between the ages of 40 and 60 years, reflecting the rising prevalence of benign prostatic hyperplasia (BPH) in aging men.⁵ Nearly one half of men over 55 years of age report some urinary symptoms, and about 25 percent of these men see a physician about their symptoms.⁶ Among men of all ages who complain of urinary symptoms occurring more than rarely, dysuria is mentioned as one of the symptoms about 5 percent of the time.⁷

Common Causes of Dysuria In Men

Any source of irritation or inflammation of the urinary tract, especially the bladder, prostate or urethra, can cause dysuria (Table 1). Dysuria is often associated with other irritative voiding symptoms, such as urgency, frequency and nocturia, but its most common cause is urinary tract infection. Urinary stasis resulting from urethral obstruction makes BPH a very common predisposing factor for urinary tract infection. The most common cause of recurring urinary tract infection in men is chronic bacterial prostatitis.⁸ Furthermore, as men age, urinary obstruction can induce changes in bladder compliance that result in both obstructive symptoms and increased irritative symptoms, including dysuria.^9,10

Dysuria also has other causes, such as malignancies of the urinary system, especially the bladder. Urinary calculi can damage urothelium, causing inflammation and urinary discomfort. Inflammation of mucosal surfaces, including the urethra, may occur with spondyloarthropathies and other autoimmune disorders. Certain toxins and numerous pharmaceutical agents, such as cantharidin¹¹ and dopamine,¹² can be uncommon sources of dysuria. (Of note, dysuria is mentioned as a side effect of approximately 200 medications in the Physicians' Desk Reference.¹³)

INFECTION

Dysuria is due to infection about 60 percent of the time. All portions of the urinary tract are susceptible to infection, although the causative organisms vary by site. Hollow, or tubular, structures in the urinary system, such as the kidney, renal pelvis, bladder, prostate and epididymis, are most vulnerable to infection by coliform bacteria. These bacteria are believed to gain access at the urethral meatus (through intercourse or local contamination) and then ascend to the affected organ.

A study of community-based practices found that about two thirds of culture-proven infections were caused by Escherichia coli.³ About 15 percent were due to Staphylococcus epidermidis, 10 percent to Proteus mirabilis, 5 percent to Staphylococcus aureus, 3 percent to Enterococcus species and 3 percent to Klebsiella species.³ Most community-acquired urinary tract infections can be managed with amoxicillin (Amoxil), trimethoprim-sulfamethoxazole (Bactrim) or nitrofurantoin (Furadantin).^14,15

Men with abnormalities in urinary anatomy or function are likely to have more unusual, recurrent or persistent infections with organisms such as Proteus, Klebsiella or Enterobacter species. Examples of urinary tract abnormalities include bladder diverticula, renal cysts, urethral stricture, BPH and neurogenic bladder resulting from multiple sclerosis, diabetes, stroke or spinal cord injury. Rarely, hematogenous spread of bacteria to the kidneys may cause pyelonephritis and subsequent dysuria.

Organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis preferentially infect the urethra.¹⁶ Urethral discharge is the most frequent manifestation of infection with these organisms. Discharge that is thick and discolored (yellow to gray) typifies gonococcal urethritis, whereas watery, scant or mucoid discharge is most common with nonspecific (nongonococcal) urethritis caused by infection with C. trachomatis or Ureaplasma urealyticum.^17,18 However, up to 18 percent of men with gonococcal infection do not have discharge, and up to 47 percent do not have dysuria.¹⁹ Note that a bloody discharge, as distinct from hematuria or hematospermia, raises concern about urethral carcinoma, an uncommon condition. Bacterial venereal infections are commonly treated with doxycycline (Vibramycin), erythromycin, quinolones or ceftriaxone (Rocephin).

Viruses such as adenovirus, herpesvirus or mumps virus can also cause dysuria. Hemorrhagic cystitis may result from adenovirus infection of the bladder. Herpesvirus infection may disrupt meatal integrity, causing dysuria.²⁰ Acyclovir (Zovirax) or valacyclovir (Valtrex) can decrease symptom duration and viral shedding with herpesvirus infections. Mumps infection of the epididymis and testicles can produce urethral inflammation and dysuria, although these complications have become infrequent since the introduction of the mumps vaccine. In developing countries, a common cause of bladder infection and dysuria is the parasite Schistosoma haematobium.²¹

OBSTRUCTION

In aging men, BPH is the most common cause of urinary complaints, including dysuria and obstruction. More than 50 percent of men over 70 years of age have the clinical syndrome of BPH, and nearly 90 percent have microscopic evidence of prostatic hyperplasia.²²

BPH-induced dysuria may be caused by urinary infection resulting from obstruction and stasis. It may also be caused by inflammation of the distended urethral mucosa. Over time, chronic obstruction of urinary outflow as a result of BPH can cause bladder hyperplasia, trabeculation and, eventually, decompensation.²³

The syndrome of BPH is thought to be the manifestation of a static component, a dynamic component, or both. The static component results from hyperplastic enlargement of the gland, which occludes the prostatic urethra. Blocking the conversion of testosterone to dihydrotestosterone using a 5-alpha reductase inhibitor such as finasteride (Proscar) can shrink the gland. The dynamic component is due to increased tone of the fibromuscular stroma of the prostate, resulting in compression of the urethra. This increased tone is modulated primarily by α₁-adrenoreceptors and can be reduced by alpha-blocker medications.

Alpha blockers have been shown to improve BPH-related dysuria.²⁴ Nearly one half of men with mild BPH symptoms, however, stay the same or improve with expectant management.⁹ Surgery, most often transurethral resection of the prostate, continues to represent the most definitive and enduring treatment for BPH.²⁵ Seminal vesicle congestion following prostatectomy has been described as a cause of dysuria.²⁶ Decreased symptoms and improved urine flow have also been demonstrated with microwave hyperthermia therapy.²⁷

Urethral obstruction may be the result of a stricture. Strictures usually occur because of prior instrumentation or surgery affecting the urethra.

MALIGNANCY

Dysuria may be the earliest symptom of the irritative changes caused by carcinoma in situ of the bladder. In particular, bladder cancer should be considered when a male smoker presents with dysuria and culture-negative microhematuria. Urethral carcinoma is rare and is an uncommon cause of dysuria. Other malignancies, such as renal cell cancer (hypernephroma), may provoke sufficient urothelial inflammation to induce dysuria.

Surgical excision is usually used to treat urothelial cancers (i.e., cancers arising from the lining of the ureters, bladder or urethra), either by fulguration via a transurethral approach or by more extensive surgery such as cystectomy. Radiation is often used as augmentative therapy.

STONE DISEASE

As renal calculi descend from the kidney or develop in the bladder, they can injure the urothelium, resulting in inflammation and dysuria. Relative dehydration superimposed on various metabolic states (e.g., hyperoxaluria, hyperuricemia and hypercalciuria) is the most common precipitant of a stone attack. Depending on the frequency of attacks, treatment may range from adequate hydration to more definitive therapy such as diuretics or allopurinol (Zyloprim).

SPONDYLOARTHROPATHIES

The constellation of dysuria, oligoarthralgia, low back or heel pain, and ocular symptoms (e.g., uveitis) are typical in spondyloarthropathies such as Reiter's syndrome.²⁸ The additional finding of oral ulcers is consistent with Behçet's syndrome. Treatment has included anti-inflammatory agents such as prednisone, immunosuppressants such as azathioprine (Imuran) and antibiotics such as doxycycline. Other autoimmune processes, such as systemic vasculitis or necrotizing glomerulonephritis, have also been associated with dysuria.²⁹

Diagnosis of Dysuria In Men

In most men, the diagnostic evaluation of dysuria will require only three steps: a history, a focused physical examination and urinalysis (Table 2). Other tests are occasionally needed to better define and manage dysuria.

HISTORY

The physician should ask the patient about the timing, frequency, severity and location of the dysuria, as well as the presence of other irritative symptoms such as urgency, frequency or nocturia. It is also important to inquire about obstructive symptoms such as weak stream, hesitancy, intermittency and dribbling.

The American Urological Association (AUA) has developed a survey to more precisely define the nature and severity of prostate-related symptoms (Figure 1).³⁰ The family physician can use this survey or the International Prostate Symptom Score³¹ to track the progress of prostate symptoms.

Prostatitis can cause a sensation of rectal pain or perineal aching (prostalgia or prostadynia). A urethral discharge may indicate a sexually transmitted disease (STD), and the color, type and amount of discharge should be determined. Bladder cancer can cause dysuria and hematuria. Prostate cancer rarely results in dysuria or other urinary symptoms.

Various systemic symptoms can help identify the cause of the dysuria. Fever, chills, nausea and emesis suggest infection. Associated arthralgias, oral mucosal symptoms or ocular symptoms may indicate a spondyloarthropathy such as Reiter's syndrome or other autoimmune condition.

It is also important to ask about toxins and medications that might cause dysuria (e.g., dopamine and cantharidin) as well as herbal remedies that may have been taken for genitourinary problems (e.g., saw palmetto for BPH or pumpkin seeds for prostatitis).

PHYSICAL EXAMINATION

Palpation and percussion of the abdomen can provide information about possible enlargement of the kidneys (suggesting renal cell tumor) or bladder (suggesting distention and possible retention). Tenderness to palpation or percussion over the costovertebral angle can be consistent with pyelonephritis.

Examination of the penis may reveal a urethral discharge indicative of an STD or meatal lesions consistent with a viral infection or other dermatologic condition. Testicular swelling and tenderness (arthritis) are most often caused by a viral infection. Pain along the epididymis is usually due to inflammation resulting from a bacterial infection. However, it may be difficult to clinically distinguish isolated swelling of the epididymis from orchitis.

A digital rectal examination should also be performed. A tender, boggy prostate is consistent with prostatitis, whereas an enlarged prostate suggests BPH. A hard, nodular prostate is typical of prostate cancer. When prostatitis is suspected, gentle digital rectal examination is advised, because an overly vigorous examination may precipitate bacteremia with subsequent sepsis. It is important to remember that a man can have significant symptoms of BPH without the finding of obvious enlargement of the prostate on rectal examination. Most of the prostate is anterior to the examining finger, and significant symptoms can result from increased muscular tone without much enlargement of the gland.

URINALYSIS

The sensitivity of the urine dipstick test makes it a useful tool for identifying blood or infection. However, certain bacteria (e.g., Enterococcus species³²) may be nitrate negative. Thus, the gold standard remains clean-catch, midstream urine that is spun and examined under a microscope.

The presence of any white or red blood cells in the urine specimen of a circumcised man is not normal, but the finding of more than 3 to 5 cells per high-power field is typically used for the diagnosis of pyuria or hematuria. Some clinicians and investigators also advocate routine Gram staining of unspun urine to identify potential organisms. Although colony counts greater than 10⁵ per mL are frequently used to diagnose asymptomatic infection, a pure colony count of 10² per mL in the presence of symptoms is considered sufficient to conclude that an infection is present. Hematuria without pyuria should raise the question of stone disease or a urinary tract malignancy such as bladder cancer.

OTHER TESTS

Urethral discharge should be Gram stained and tested for N. gonorrhoeae and C. trachomatis.³³ More commonly, however, DNA probe testing or rapid antigen testing is being used.

In men with chronic prostalgia, the precise diagnosis of dysuria can be elusive. Determining whether a patient has nonbacterial prostadynia or true infection may require microscopic evaluation or culture of expressed prostatic secretions.

Concerns about upper urinary tract pathology (e.g., abscess, hydroureter or hydronephrosis) may warrant ultrasound examination of the kidneys and ureters. Ultrasound examination can also be helpful in evaluating the prostate for biopsy needle placement and assessing the bladder for stones (a sign of urinary stasis) or diverticula (a sign of bladder compensation).

Excretion urography (intravenous pyelography) is often used to localize ureteral calculi. Cystoscopy must be considered in the evaluation of noninfectious hematuria to rule out bladder or urethral cancer.

Men with more complicated BPH findings, such as incomplete emptying, may require urodynamic studies to determine bladder decompensation.

Final Comment

The family physician who conducts a focused history and physical examination and who analyzes the urine should be able to diagnose and manage most male patients with dysuria.³⁴ When the findings are not consistent with the more common and readily managed causes of dysuria, some patients may need to be referred to a urologist for further evaluation and treatment.³⁵