Approach to dysuria: Clinical sciences

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A 22-year-old man presents to the clinic with a 3-day history of dysuria and yellow penile discharge. He denies fever, back pain, and gastrointestinal symptoms. He states that he had unprotected sex with a new partner approximately three weeks ago. Vitals are within normal limits. Physical examination is unremarkable except for a mucopurulent discharge seen at the urethral meatus. Which of the following is the most appropriate next step to confirm the diagnosis?  

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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 into 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 closely monitor their condition for any additional symptoms of systemic infection, and seek medical attention promptly.

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.

Sources

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  2. "ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction" Journal of the American College of Radiology (2020)
  3. "Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America" Clinical Infectious Diseases (2010)
  4. "Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. 208(1):34-42." J Urol (2022)
  5. "Diagnosis of vaginitis. 62(5):1095-1104." Am Fam Physician (2000)
  6. "Genitourinary Tract Infections" Microbiology Spectrum (2016)
  7. "Dysuria: Evaluation and Differential Diagnosis in Adults. 92(9):778-786." Am Fam Physician (2015)
  8. "Evaluation of dysuria in men. 60(3):865-872." Am Fam Physician (1999)
  9. "A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting" International Journal of Clinical Practice (2007)
  10. "Urethral Discharge and Dysuria. In: Seller RH, Symons AB, eds. Differential Diagnosis of Common Complaints.:32, 379-390. " Elsevier Inc (2018)
  11. "Prostatitis: diagnosis and treatment. 82(4):397-406." Am Fam Physician (2010)
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