Approach to dysuria: Clinical sciences

Dysuria is the sensation of painful or uncomfortable urination. Patients typically describe their discomfort as a burning, tingling, or stinging sensation that occurs when urine passes through an inflamed or irritated urethra. Bladder contractions can also worsen this pain.

The main causes of dysuria are categorized as infectious and non-infectious. A good approach is to first assess for genital tract infections like cervicitis and epididymitis; next, look for lower urinary tract infections or pyelonephritis; and finally look for non-infectious causes like benign prostatic hyperplasia, nephrolithiasis, urologic malignancy, and interstitial cystitis.

When approaching a patient with dysuria, first you should perform an ABCDE assessment to determine if they are unstable or stable.

If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access, and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry.

Here’s a clinical pearl! If a patient with dysuria is exhibiting signs of instability, there’s a concern that they may have developed sepsis. It's crucial to quickly obtain blood and urine cultures, begin IV fluids and broad-spectrum antibiotics, and closely monitor their condition.

Now, let’s go back to the ABCDE assessment and take a look at stable patients.

If your patient is stable, you should perform a focused history and physical examination. Next, assess the history for symptoms of a genital tract infection, like vaginal irritation or discharge, urethral discharge, and scrotal pain.

Additionally, the patient might report risk factors for sexually transmitted infections, such as unprotected sexual intercourse or having multiple sexual partners. In this case, you should consider a genital tract infection.

Your next step is to proceed with a genital exam to diagnose.

If your patient has a history of vulvar itching and vaginal discharge, and the physical exam reveals abnormal vaginal discharge and vulvovaginal edema or erythema, you can diagnose vulvovaginitis.

Vulvovaginitis can be caused by sexually transmitted infections like trichomoniasis as well as non-sexually transmitted infections caused by an imbalance of the vaginal flora, such as candida vulvovaginitis. Laboratory testing should be done to identify the causative organism.

Vulvovaginitis can also be associated with a decline in estrogen, like in atrophic vaginitis.

On the other hand, if history reveals dyspareunia or vaginal bleeding, and the physical exam reveals purulent discharge from the endocervical canal and a friable cervix, diagnose cervicitis, which is most commonly caused by gonorrhea or chlamydia. Collect a sample for testing to confirm the cause.

Now, here’s a high-yield fact to keep in mind! Untreated cervicitis can lead to a serious ascending infection of the genital tract, called pelvic inflammatory disease, or PID for short. Patients with PID usually have a history of lower abdominal or pelvic pain, and the physical exam typically reveals cervical motion tenderness and uterine or adnexal tenderness. If left untreated, PID can lead to long-term complications, such as tubo-ovarian abscess, ectopic pregnancy, chronic pain and even infertility.

Alright, now moving on to a patient that reports urethral discomfort, itching, tingling or urethral discharge. Physical exam might reveal erythema around the urethral opening as well as urethral discharge, which could be mucopurulent, white or even clear. With these history or exam findings, diagnose urethritis.

Keep in mind that in urethritis, the physical exam can also be totally normal, so in either case make sure to collect a urethral swab, urinalysis, and urine cultures to confirm or rule out the diagnosis.

Finally, if history reveals scrotal pain developing over one to two days, and the physical examination shows unilateral swelling and tenderness of the testis or epididymis, then you can diagnose epididymitis.

Epididymitis is most often caused by gonorrhea or chlamydia in sexually active patients under age 35. Over age 35, without high-risk sexual behavior, sexually transmitted causes of epididymitis are less common, and it usually develops as a result of retrograde flow of infected urine.

Now, here’s a clinical pearl to keep in mind! Remember, an important differential diagnosis to consider in a patient with unilateral testicular pain is testicular torsion, which is a surgical emergency. Testicular torsion usually presents with sudden onset of severe scrotal pain, and physical exam shows a high-riding testis. If the diagnosis is unclear, patients should have immediate doppler ultrasound of the scrotum to rule out testicular torsion.

Ok, now that we’ve reviewed what to do if your patient has a genital tract infection, let’s discuss those with no symptoms of a genital tract infection.