Approach to dysuria: Clinical sciences

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Introduction0:00–0:43

This urea 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 noninfectious.
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 noninfectious causes like benign prostatic hyperplasia, nephrolithiasis, urologic malignancy and interstitial cystitis.

Unstable0:43–1:04

When approaching a patient with dysuria first, you should perform an ABCD E 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 BP, heart rate and pulse oximetry.

Stable1:04–1:37

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 get back to the ABCD E assessment and take a look at stable patients. If your patient is stable, you should perform a focused history and physical examination.

Vulvovaginitis1:37–2:10

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 a vulvovaginal edema or erythema, you can diagnose vulvovaginitis.

Cervicitis2:10–2:59

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.

Urethritis2:59–3:26

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 P ID.
For short patients with P ID usually have a history of lower abdominal or pelvic pain. The physical exam typically reveals cervical motion, tenderness, and uterine or adnexal tenderness.

Epididymitis3:26–4:25

If left untreated pid can lead to long term complications such as tubo ovarian abscess, ectopic pregnancy, chronic pain, and even infertility.
All right 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 1 to 2 days, and the physical examination shows unilateral swelling and tenderness of the testis or epididymis, then you can diagnose epididymitis.

No symptoms of genital tract infection4:25–4:53

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.

Lower urinary tract infection4:53–5:07

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.

Pyelonephritis5:07–5:28

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.
In this case, order, labs including a urinalysis and urine culture. If the urinalysis reveals pyuria bacteriuria and leukocyte esterase with or without nitrites or hematuria.

Acute bacterial prostatitis5:28–5:45

Diagnose urinary tract infection. A positive urine culture confirms the diagnosis.
Next, assess the location of the infection if history reveals findings such as urinary frequency, urgency and blood tinged or cloudy urine and physical exam reveals suprapubic tenderness, diagnose a lower urinary tract infection.

Non-infectious causes of dysuria5:45–6:04

BPH6:04–6:49

Sometimes your patient can present with systemic symptoms like fever, chills, malaise as well as nausea and vomiting and physical exam.
Findings that include flank or costovertebral angle tenderness. Additionally, urinalysis can reveal white blood cell casts.
In this case, you can diagnose pyelonephritis. Finally, your patient may report urinary frequency or urgency as well as fevers, chills, malaise and perineal pain.
While a physical exam can reveal prostate tenderness. In this case, you should diagnose acute bacterial prostatitis.
Ok. Now, let's go back to our urinalysis and urine culture results if urinalysis is either positive or negative for pyuria.

Nephrolithiasis6:49–7:18

But with negative urine cultures consider noninfectious causes of dysuria such as benign prostatic hyperplasia, nephrolithiasis, urologic malignancy and interstitial cystitis.
So, your patient may report urinary frequency or urgency as well as nocturia, incomplete bladder emptying and urinary hesitancy.
While on physical exam, digital rectal examination can reveal an enlarged prostate. In this case, the diagnosis is benign prostatic hyperplasia or B PH for short.

Urologic malignancy/Interstitial cystitis7:18–8:09

Now, here's a clinical pearl. To keep in mind.
If you suspect BPH, you should also check their urine for hematuria to distinguish it from bladder cancer. Bladder cancer typically presents with painless hematuria, but sometimes patients also have lower urinary tract symptoms.
So, consider bladder cancer in patients with hematuria and dysuria and especially if they have risk factors like older age, smoking or occupational exposures.
Next, let's say your patient reports unilateral flank pain, frank blood in the urine with or without systemic symptoms such as nausea and vomiting and physical exam reveals costovertebral angle tenderness.
In this case, consider nephrolithiasis also known as renal calculi or kidney stones and order imaging with a noncontrast CT scan.

Review8:09–10:45

If the CT scan shows renal calculi, then you can diagnose nephrolithiasis. Finally, let's take a look at a patient that has a history of urinary frequency or urgency, pelvic pain and dyspareunia for at least six weeks.
Additionally, the patient may have been treated with antibiotics but the symptoms did not resolve indicating inadequate response on a physical exam.
You find suprapubic tenderness with no evidence of a genital tract infection. In this case, you should perform a cystoscopy for further evaluation.
If cystoscopy reveals malignant lesions, the patient can be diagnosed with a urologic malignancy on the flip side, if cystoscopy reveals normal findings or the presence of hunter lesions, which are inflammatory bleeding lesions on the bladder wall.
Then the patient has interstitial cystitis. But keep in mind, although hunter lesions are specific to interstitial cystitis, they do not need to be present to make the diagnosis.
All right, as a quick recap when approaching a patient with dysuria, first perform an ABCD E assessment to determine if they're unstable or stable.
If unstable, stabilize their airway breathing and circulation. Obtain IV access and monitor their vital signs.
If signs of sepsis are present, obtain cultures and start IV fluids and broad spectrum antibiotics right away on the flip side if stable, start by assessing for symptoms of genital tract infection.
If present, consider genital tract infections such as vulvovaginitis, cervicitis, urethritis, and epididymitis. Use laboratory tests to confirm the cause if no symptoms of genital tract infection are present.
Order labs including urinalysis and urine culture. If urinalysis reveals pyuria bacteriuria and leukocyte esterase with or without nitrites or hematuria, diagnose urinary tract infection and consider a urine culture.
Next. Assess the infection location to determine if your patient has a lower urinary tract infection, pyelonephritis or acute bacterial prostatitis.
However, if lab findings are inconsistent with infection, consider noninfectious conditions such as benign prostatic hyperplasia, nephrolithiasis, urologic malignancy and interstitial cystitis.