Dysuria (painful urination)
Dysuria (painful urination) 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.
The key objective in evaluating women with dysuria is to exclude serious upper urinary tract disease, such as acute pyelonephritis, and sexually transmitted diseases. In elderly men, dysuria may be a symptom of prostatitis. In contrast, in younger men, urethritis accounts for the vast majority of cases of dysuria.
Urinalysis: Urinalysis is probably over utilized in the evaluation of dysuria. The probability of culture-confirmed UTI among women with a history and physical examination compatible with uncomplicated cystitis is about 70–90%. Urinalysis is most helpful in atypical presentations of cystitis. Dipstick detection (greater than trace) of leukocytes, nitrites, or blood supports a diagnosis of cystitis.
Urine culture: Urine culture should be considered for all women with upper tract symptoms (prior to initiating antibiotic therapy), as well as those with dysuria and a negative urine dipstick test. In symptomatic women, a clean catch urine culture is considered positive when 102–103 colony forming units/mL of a uropathogenic organism is detected.
Renal imaging: When severe flank or back pain is present, the possibility of complicated kidney infection (perinephric abscess, nephrolithiasis) or of hydronephrosis should be considered. Renal ultrasound or CT scanning should be done to rule out abscess and hydronephrosis. To exclude nephrolithiasis, non-contrast helical CT scanning is more accurate than intravenous urography and is the diagnostic test of choice.
The differential diagnosis of dysuria in women includes acute cystitis, acute pyelonephritis, vaginitis (Candida, bacterial vaginosis, Trichomonas, herpes simplex), urethritis/cervicitis (Chlamydia, gonorrhea), and interstitial cystitis/painful bladder syndrome. Nucleic acid amplification tests from first-void urine or vaginal swab specimens are highly sensitive for detecting chlamydial infection. Other infectious pathogens associated with dysuria and urethritis in men include Mycoplasma genitalium and Enterobacteriaceae.
Inflammatory disorders of the bladder and urethra are the most common causes of dysuria. Among these, infections of the bladder, urethra, kidneys, and genital organs are the most prevalent, including uncomplicated cystitis, pyelonephritis, and urethritis. Distinguishing a complicated urinary tract infection (UTI) from cystitis is important, because misdiagnosis increases the risk of treatment failure. In women, dysuria is also a common presentation of vaginitis. In men, prostatitis can present with dysuria. Sexually transmitted infections (STIs) can also cause dysuria.
Inflammatory, noninfectious conditions that can lead to dysuria include the presence of a foreign body (e.g., stent, bladder stone), noninfectious urethritis (e.g., reactive arthritis, formerly Reiter syndrome), and dermatologic conditions.
Non-inflammatory conditions can be divided into the following categories: anatomic; endocrine; neoplastic; medication, food, or recreational drug related; iatrogenic; and idiopathic. Any condition that causes hematuria with clots can cause dysuria, including renal neoplasms and nephrolithiasis. Interstitial cystitis (also known as bladder pain syndrome) refers to chronic bladder pain, often with voiding symptoms, lasting six weeks or more without an identifiable cause.