Dysuria


Continuing Education Activity

Dysuria is a symptom of pain and/or burning, stinging, or itching of the urethra or urethral meatus with urination. It is a very common urinary symptom experienced by most people at least once over their lifetimes. Causes of dysuria can be divided broadly into two categories, infectious and non-infectious. Treatment varies depending on the etiology. This activity describes the evaluation and treatment of dysuria and explains the role of the healthcare team in improving care for patients with this condition.

Objectives:

  • Identify the various pathophysiologies of dysuria.
  • Summarize the history and physical exam of a patient presenting with dysuria.
  • Review the management options available for dysuria.
  • Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with dysuria.

Introduction

Dysuria is defined as the sensation of pain and/or burning, stinging, or itching of the urethra or urethral meatus associated with urination. It is a very common urinary symptom experienced by most people at least once over their lifetime. Dysuria typically occurs when urine comes in contact with the inflamed or irritated urethral mucosal lining. This is exacerbated by and associated with detrusor muscle contraction and urethral peristalsis, which then stimulates the submucosal pain receptors resulting in pain or a burning sensation during urination. Several conditions can cause dysuria via different mechanisms. True dysuria requires differentiation from other symptoms, which can also occur due to pelvic discomfort from various bladder conditions such as interstitial cystitis, prostatitis, and suprapubic or retropubic pain.[1]

Etiology

The causes of dysuria can be divided broadly into two categories, infectious and non-infectious. Infectious causes include urinary tract infections or urethritis, pyelonephritis, prostatitis, vaginitis, and sexually transmitted diseases. Non-infectious causes include skin conditions, foreign body or stone in the urinary tract, trauma, benign prostatic hypertrophy, and tumors. Also, interstitial cystitis, certain medications, specific anatomic abnormalities, menopause, reactive arthritis (Reiter's syndrome), and atrophic vaginitis can all cause dysuria.[2]

One of the most common causes of dysuria is urinary tract infection (UTI) which occurs in both males and females. Urinary tract infections are much more common in females than males due to anatomical considerations. In females, bacteria can reach the bladder more easily due to a shorter and straighter urethra compared to males, as the bacterial organisms have far less distance to travel to reach the bladder from the urethral meatus. Females who use the wrong wiping technique, from back to front instead of the preferred front to back, take baths instead of showers, or do not use washcloths to clean their vaginal area first when bathing, can predispose themselves to more frequent urinary tract infections due to repeated contamination of the urethral meatus to peri-rectal and other bacteria. Because of their higher likelihood of recurrent urinary tract infections, females also tend to experience dysuria more frequently than males. Most urinary tract infections are uncomplicated and relatively simple to treat. However, persistent dysuria may be associated with complicated urinary tract infections which are found in men with UTIs, incompletely treated simple UTIs, prostatitis, pregnancy, immunocompromised status, catheters, nephrolithiasis, renal failure, dialysis, neurogenic bladder, anatomical or functional abnormalities of the urinary tract, pelvic floor dysfunction, and overactive bladder.[3]

The most common cause of male urethritis is infectious from sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium. Chlamydia is the most commonly identified cause of non-gonococcal urethritis (found in about 50%), followed by Mycoplasma genitalium.[4][5] Less commonly, other organisms will be found, such as Trichomonas vaginalis, Mycoplasma genitalium, Mycoplasma hominis, Gardnerella vaginalis, and Ureaplasma urealyticum.[5][6] Refractory cases should have testing for Trichomonas vaginalis. When testing patients suspected or at risk for sexually transmitted infections, consider screening for HIV and syphilis as well. 

Gonorrhea is found in about 22% of symptomatic men, with an overall incidence of 213 cases per 100,000 males in 2018, and the incidence is increasing. Rates are significantly higher in non-Hispanic African Americans compared with the general population. Rates are also higher in the geographic South compared to other regions in the US. Other parts of the world have even higher rates, such as a reported 62% incidence of gonorrhea in symptomatic men in South Africa.[7]

Urethritis associated with bacterial prostatitis is most often caused by gram-negative organisms such as E. coli.  Dysuria together with epididymitis is most often caused by Chlamydia trachomatis in men less than 35 years and by E. coli, Pseudomonas, and other gram-negative coliforms in older men. 

Dysuria associated with frequency and suprapubic pain without any objective evidence of infection, inflammation, or any other identifiable cause is sometimes called urethral pain syndrome (formerly urethral syndrome). This is very similar to a mild form of interstitial cystitis, which is possibly just a different variety of the same disorder. Both lack positive urine findings of infection. The main clinical differences are:

  • Urethral syndrome has more continuous but somewhat milder dysuria, usually described as a constant irritation. It is possibly related to urethral stenosis and/or hormonal imbalances, although the exact cause is still unknown. Painful spasms of the pelvic musculature are common. Suprapubic discomfort and urinary frequency may be present but are usually not the primary urinary symptoms and are generally not as severe as with interstitial cystitis. Urinary frequency is much more severe during the daytime when it can often require voiding every 30 to 60 minutes with little or no nocturia. Urethral syndrome patients are typically female from 13 to 70 years of age.
  • Interstitial cystitis typically has more bladder discomfort, frequency, urgency, and pain when the bladder is full and is relieved somewhat upon voiding. 

Various foods can increase bladder and urethral irritation, of which caffeine is the most prevalent. High potassium and hot, spicy foods are also considered irritating to the bladder and urethra.  A complete, detailed list is available at: http://my.clevelandclinic.org/disorders.overactive_bladder/hic_bladder_irritating_foods.aspx.[2]

Uncommon causes of dysuria would include endometriosis, atrophic vaginitis, urethral strictures, diverticula, inflammation or infection of the paraurethral/Skene's glands, syphilis, mycobacterium, herpes genitalis, and infected urachal cysts.[8] 

Other causes would include the presence of a double J urinary stent, recent urethral instrumentation or Foley catheterization, bladder calculi, prostatitis, traumatic sexual intercourse, pelvic floor dysfunction, herpes zoster, and lichen sclerosis.

Topically applied products, such as douches, bubble baths, and contraceptive gels, are also potentially irritating to the urethra. A clinical trial of avoiding any and all topical agents is reasonably warranted. 

Overactive bladder will present with urgency and frequency as the primary symptoms. There may also be intermittent suprapubic pain or discomfort.

Epidemiology

Dysuria typically affects about 3% of all adults over 40 years of age at any given time, making it one of the most common of all urinary symptoms.[2] Acute cystitis is the most common cause of dysuria. It accounts for about 7 million outpatient visits yearly in the United States, with one-fifth of these occurring in Emergency Departments.[2]

Pathophysiology

Dysuria typically occurs when urine comes in contact with the inflamed or irritated urethral mucosal lining. This is exacerbated by and associated with detrusor muscle contractions and urethral peristalsis, which then stimulates the submucosal pain and sensory receptors resulting in pain, itching, or a burning sensation during urination. Various inflammatory or neuropathic processes can increase the sensitivity of these receptors. Occasionally, inflammation from surrounding organs, such as the colon, can result in dysuria.

Non-infectious causes of dysuria, such as urinary calculi, tumors, trauma, strictures or foreign bodies, and atrophic vaginitis, can result from irritation of the urethral or bladder mucosa. Decreased capacity and elasticity of the detrusor can cause urinary urgency or incontinence along with dysuria.[9]

History and Physical

Detailed history taking is essential when someone presents with dysuria. The clinician must try to determine the timing, severity, duration, and persistence of the symptoms. For example, pain at the beginning of urination suggests a urethral problem such as urethritis.  Pain at the end of urination may be from the bladder or prostate. Initial history should include features of a possible local cause that may be causing dysuria, like vaginal or urethral irritation. Any history regarding risk factors like pregnancy, the possibility of a kidney stone, trauma, tumor, recent urologic procedures, and the possibility of urologic obstruction merit consideration. Patient history should include information regarding associated symptoms like fever, chills, flank pain, low back pain, nausea, vomiting, joint pains, hematuria, nocturia, urgency, frequency, and incontinence. In elderly patients, history regarding changes in mental status is necessary, as many times the most common symptom of a urinary tract infection in older adults is confusion. History regarding recurrence of symptoms is also necessary, and a thorough physical examination should be performed.

A purulent urethral discharge is suggestive of gonorrhea. Isolated dysuria without other symptoms is most likely from chlamydia. Dysuria with genital ulcers suggests possible herpes simplex virus, and balanoposthitis is sometimes associated with Mycobacterium genitalium.[10]

The clinician should also look for physical findings of fever, rash, direct tenderness over the bladder area, and joint pain. Physical findings of increased temperature, rapid pulse, or low blood pressure in the presence of dysuria can indicate systemic infection. Regional lymph nodes should be palpated. Urological obstruction due to a stone or tumor can result in findings of flank pain, hematuria, decreased urination, and bladder spasms. All these physical findings should be looked for carefully. History regarding recent sexual activity is crucial. In women, it is essential to note menstrual history, complaints of vaginal discharge, and whether the patient is using contraception.[2][11] Males can present with different symptoms than females and may have perineal pain or obstructive urinary symptoms and dysuria, which could be caused by prostatitis.[12] Males patients require inspection for a urethral discharge, and the urethral meatus should be checked for redness, crusting, and exudate. Check the inside lining of the underwear for signs of a discharge. If urethritis or a discharge is suspected, the urethra can be milked to elicit a specimen for testing. This is done by placing a gloved finger at the base of the penis on the ventral surface and pressing inwards. Then, slowly move the entire hand forward towards the glans. Any discharge should be collected for culture. 

Evaluation

Evaluation of dysuria starts with detailed history taking and a thorough physical examination. Associated signs and symptoms of hematuria, suprapubic tenderness, urinary frequency, urgency, fever, chills, nausea, vomiting, low back pain, flank pain, joint pain, rash, etc., require close follow-up.

Urinalysis is the most useful test to start the work up in a patient with dysuria. Urinalyses positive for nitrites carries a high predictive value of a positive urine culture (75% to 95%). Positive leukocytes (anything more than a trace positive) is also highly predictive but slightly less than nitrites (65% to 85%). The presence of both positive nitrites and leukocytes on a dipstick is extremely predictive.[13] Dysuria in a patient with only positive leukocyte esterase or pyuria in the urine suggests urethritis.[14] 

Gram stain microscopy showing Gram-negative diplococci is diagnostic for gonorrhea. Typically, microscopic examination of urethral secretions demonstrating 5 WBC or more per oil immersion microscopic field was diagnostic for urethritis, but some have suggested this cutoff be lowered to just 2 WBC.[15][16] The most sensitive test for male gonorrhea or chlamydia is urinary nucleic acid amplification testing (NAAT). The sample should be obtained at least 20 minutes after the most recent void and optimally at least an hour afterward.[17]

Patients who do not respond to initial treatment and those with risk factors for a possible complicated urinary tract infection should have a full urine culture and sensitivity analysis performed. 

It is important to check a complete blood count and a metabolic panel, including serum creatinine, if a systemic infection is suspected, especially if the patient is having nausea, vomiting, fever, or chills. Blood cultures need to be done if there is a suspicion of systemic spread of infection. In severe cases, hospitalization should be considered.[18] 

If sexually transmitted infections are suspected, such as in younger, sexually active patients, then a urethral or vaginal probe should be performed. Samples should be obtained to diagnose Neisseria gonorrhoeae and Chlamydia trachomatis.[19] Women who have vaginal symptoms should have a wet mount examination or a vaginal DNA probe. In male patients where chronic prostatitis is suspected, gentle prostatic massage can help obtain a sample of the expressed prostatic secretions for a urine culture.[20] If the patient has hematuria and bladder cancer is suspected, then urine cytology can be helpful in addition to the usual cystoscopy.[21] Imaging tests like ultrasonography or CT scan may be in order in cases of dysuria where patients show signs of having a complicated urinary tract infection, obstruction, unexplained fevers, flank pain, hydronephrosis, abscess, stones, or tumors.[22] However, imaging is not necessary in most cases of simple dysuria. In selected cases, cystoscopy can be performed to evaluate symptoms of chronic or intractable dysuria resistant to standard therapies, which can be associated with bladder cancer, vesicle stones, prostatitis, or hematuria.[23][24]

Urethral pain syndrome, formerly urethral syndrome, typically presents with dysuria as one of the key symptoms. Other symptoms of urethral pain syndrome include urinary frequency and suprapubic discomfort.[25] The bladder pain is relieved somewhat by voiding.  There may also be hesitancy, slowing of the urinary stream, and a feeling of incomplete bladder emptying. Urine cultures are negative, and the urinary symptoms are usually worse during the day compared to nighttime. The original description of urethral syndrome was urinary frequency and dysuria without evidence of infection. It was thought to be primarily due to urethral stenosis treatable with serial urethral dilations. It is now thought that urethral dilations are only appropriate in a very small minority of patients. Urethral pain syndrome is found predominantly in women aged thirty to fifty years.  In this group of women, vaginal pathology (vaginal infections, atrophic vaginitis, and similar pathology) should be carefully excluded. It is thought that up to one-quarter of all patients, especially women, with lower urinary tract symptoms without a documented infection might actually have urethral pain syndrome.  The diagnosis is primarily one of exclusion. There is clearly an overlap between urethral pain syndrome, interstitial cystitis, and urethral pain syndrome, as there is a definite lack of consensus on specific criteria between these disorders, and they may not be mutually exclusive. The exact cause of urethral pain syndrome is unknown.

Reactive arthritis, formerly called Reiter's syndrome, was historically used to describe the combination of urethritis, conjunctivitis, and arthritis. Arthritis is usually a post-infectious, autoimmune response. Reiter's syndrome reflects only a portion of all patients with reactive arthritis. It is defined as arthritis which follows an infection that cannot be cultured from the affected joint. When triggered by a sexually transmitted organism, the condition is called sexually acquired reactive arthritis. It usually presents in younger adults, with gastrointestinal and genitourinary infections being the most common triggering events. The most common causative genitourinary organism is Chlamydia trachomatis, followed by Chlamydia pneumoniae, Escherichia coli, Ureaplasma urealyticum, and Mycoplasma genitalium. Intravesical Bacillus Calmette-Guerin (BCG), used as an immunotherapy for bladder cancer, has also been identified as a rare cause, affecting about 1% - 2% of treated patients.[26] 

Recently, reactive arthritis cases have been reported following COVID-19 infections.[27][28][29] The arthritis produced is usually acute, non-symmetrical, and typically affects the lower extremities (knees), although it may occur in almost any joint. This arthritis typically follows the original infection by 1-4 weeks.[30] Ocular effects are present in about 20% of all cases of reactive arthritis.[31] The diagnosis is made by clinical suspicion where there is a history of urethritis preceding arthritis and the lack of any evidence for other types of arthritis. Urinary Nucleic Acid Amplification Testing (NAAT) can help identify Chlamydia and Gonococcus in suspected cases. Human Leukocyte Antigen (HLA-B27) testing will be positive in 30% to 50% of patients with reactive arthritis, but a negative test does not rule it out. Appropriate antibiotic treatment is usually recommended for Chlamydia based reactive arthritis if an active infection is present.[32] Antibiotics for chronic infection-related arthritis are more controversial as most randomized trials of long-term antibiotic therapy show little or no improvement.[33][34] Treatment of arthritis includes NSAIDs, intra-articular and systemic glucocorticoids, and other disease-modifying agents such as sulfasalazine and methotrexate. Prognosis is usually good as reactive arthritis typically lasts only 3 to 5 months, and most patients enjoy a complete remission.  

Treatment / Management

Treatment of dysuria depends on the underlying etiology whenever possible. The most common cause of dysuria is a urinary tract infection. Empiric antibiotic therapy based on a patient's history and symptoms is usually the most cost-effective therapy. No further evaluation is necessary in those cases where dysuria from uncomplicated urinary tract infection is suspected.[35] When the clinician suspects a complicated urinary tract infection, as in the presence of associated symptoms like nausea, vomiting, fever, or chills, then along with starting antibiotics, additional testing like blood cultures, a metabolic panel, or a complete blood count are all viable options. In the case of suspected pyelonephritis, stones, or urinary obstruction, imaging with ultrasonography or CT scan can be diagnostic.

Antibiotic therapy for urethritis depends on the underlying organism, which is most likely to be sexually transmitted.[36] Gonorrhea is treated with ceftriaxone, cefixime, ceftizoxime, cefoxitin, or azithromycin.[37] Quinolones are no longer recommended due to increasing resistance. Non-gonococcal urethritis is usually treated with single-dose azithromycin (1 gram) or doxycycline (100 mg BID for 7 days).[37] This regimen generally has about an 80% overall cure rate.[38] Doxycycline is generally preferred for chlamydia.[39] Mycoplasma, a relatively common cause of persistent urethritis, demonstrates resistance to standard therapy with doxycycline, which now has a high failure rate.[40] Azithromycin appears to be more effective than doxycycline and is currently recommended for Mycoplasma genitalium and Ureaplasma urealyticum.[37][41] An extended azithromycin regimen, which tends to avoid induced macrolide resistance, is also available (500 mg orally to start, then 250 mg daily for the next four days).[42] This is appropriate for those who fail initial doxycycline therapy. If this regimen fails (azithromycin failures), ten days of moxifloxacin 400 mg daily is recommended.[43] Prolonged erythromycin therapy does not appear to be effective and is not recommended. Recurrent symptoms tend to be related to non-compliance, repeat exposure, chronic prostatitis, or infections with Trichomonas vaginalis or Mycoplasma genitalium.

Trichomonas is present in only about 2.5% of male urethritis cases.[44] When present, treatment is with metronidazole 2 grams for the patient and his/her partner. 

Infrequent causes of urethritis include Treponema pallidum (syphilis) and Haemophilus influenzae which can be transmitted during oral sex.[45]

Physicians should be mindful of the possibility of anti-microbial resistance, and optimal antibiotics should be started based on likely pathogens, local resistance patterns, and costs (or insurance coverage) associated with the treatment.[46] When dysuria occurs due to chronic prostatitis in males, appropriate oral antibiotics are recommended after obtaining a urine culture.[47] If the cause of dysuria is renal stones, then various treatment options can be considered depending on the size and location of the calculi. Stones smaller than 5 mm typically pass on their own. Patients should be asked to hydrate themselves and strain the urine to document the evidence of a passed stone. Stones larger than 5 mm are treatable through various modalities, including extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, or percutaneous nephrolithotomy (PCNL), and very rarely open surgery.[48][49][50]

When the patient presents with dysuria and a perinephric abscess is suspected, it should first undergo evaluation with an imaging study like ultrasonography or a CT scan. Once it is confirmed to be an abscess, the patient should be hospitalized, and intravenous antibiotics should be initiated, followed by open surgical drainage or percutaneous catheter drainage, or both.[51] If the cause of dysuria is benign prostatic hypertrophy, then medical treatment with alpha-blockers or 5-alpha reductase inhibitors should be considered. If the patient has no symptomatic improvement after trying the medical therapy, then the surgical option of transurethral resection of the prostate should be considered, but this is typically done for other urinary symptoms rather than for isolated dysuria.[52]

Historically, female urethral dilation has been used for many urological complaints in women, including dysuria, but this practice is rarely used today. Nevertheless, there may be the occasional female patient with actual urethral stenosis who would benefit from dilation.

There will inevitably be cases where no specific cause of dysuria can be found.  In such cases, treatment tends to be symptomatic or holistic. Various generic dysuria treatments include:

Dietary modification. A large variety of foods and beverages have been reported to contribute to dysuria symptoms.  These include alcoholic beverages, highly acidic and spicy foods, hot sauces, condiments, high potassium fruits like bananas, lemons, and tomatoes, fruit juices including cranberry, salad dressings, peppers, chillis, tomato sauces, and ketchup.  As mentioned earlier, a more complete list is available on the Cleveland Clinic website.[2]

Phenazopyridine.  This medication can often relieve the irritation and stinging of dysuria and sometimes the urinary frequency that accompanies it. For best results, it must be taken three times a day.  It has an intense orange color when it passes into the urine and will permanently stain anything it touches, so it is best to warn patients of this.  The most common side effects are dizziness, headache, and nausea.  It is not an antibiotic but a topical analgesic. Since it only provides symptomatic relief and can build up in the body, it is not usually recommended for more than three days continuously. The medication should not be used in patients with known glucose-6-phosphate dehydrogenase deficiency as it can lead to hemolysis.[53]

Calcium glycerophosphate is an OTC medication that purports to reduce urinary acidity to help relieve dysuria. While it appears to help with dysuria in at least some patients, there are no published randomized studies on its efficacy, so evidence on the product is purely anecdotal. It is officially classified as a "medical food" and was originally designed to treat interstitial cystitis. It can be sprinkled over food or taken as a tablet at mealtime. The dietary recommendations are essentially the same as for interstitial cystitis. 

Hydration. Many patients with dysuria will tend to drink less, so they will have to void less often. However, this tends to increase urinary concentrations and ultimately leads to worse burning. Patients should be encouraged to drink more, not less.

Trial of doxycycline, if not used previously. Doxycycline is a tetracycline-based antibiotic with a unique spectrum of activity that includes many unusual and uncommon organisms. A trial of this antibiotic may cure some patients of otherwise intractable dysuria from an unusual organism.[54]

Trial of azithromycin as Mycoplasma genitalium is a common cause of persistent or intractable urethritis.[43]

A clinical trial of estrogen cream in postmenopausal women is a reasonable therapy to try as at least some patients will benefit.[55]

Other treatments of dysuria to consider include topical anesthetics, tricyclic antidepressants (such as imipramine or amitriptyline), muscle relaxants, alpha-blockers, urothelial barrier protection enhancement drugs (such as pentosan polysulfate), local steroids, and antibiotics.

Some success has also been reported with behavioral therapy such as biofeedback, meditation, hypnosis, dietary therapy (to increase urinary pH and avoid high urinary potassium as well as other known bladder irritants), acupuncture, botox injections, gabapentin (300 to 600 mg daily) and sertraline (50 - 200 mg daily) therapy.[56] Intravesical gentamicin plus betamethasone has also been reported to be of benefit in some dysuria patients.[57] Tolterodine can act as both a bladder antispasmodic and anesthetic.  A combination of atropine, hyoscyamine methenamine, methylene blue, phenyl salicylate, and benzoic acid is another option; it has both mildly anesthetic and antispasmodic effects. It also will inhibit bacterial growth. It gives the urine a blue-green color. 

There is generally no specific surgical treatment for dysuria, but Nd:Yag laser ablation has shown some promise in carefully selected female patients with symptoms refractory to medical therapy. Laser ablation of squamous metaplasia of the trigone and bladder neck areas has shown success in some patients with trigonitis.[58] The initial necrotic tissue coagulation immediately after laser ablation is followed by regrowth of normal urothelium.[58]

Summary of Dysuria Treatments

  • Antibiotics as appropriate for UTIs, urethritis, and/or prostatitis)
  • Dietary therapy (avoidance of alcohol, caffeine, hot spices, processed and high potassium foods)
  • Second-line antibiotics (doxycycline, azithromycin)
  • Third line antibiotics (moxifloxacin)
  • Vaginitis therapy (metronidazole, miconazole, fluconazole, etc.)
  • Estrogen for atrophic vaginitis
  • Alpha-blockers and overactive bladder medications (tolterodine)
  • Symptomatic therapy (phenazopyridine, calcium glycerophosphate, and similar)
  • Amitriptyline
  • Gabapentin
  • Sertraline
  • Oral or intravesical elmiron
  • Female urethral dilation

Differential Diagnosis

Differential diagnoses broadly divide into two categories. Inflammatory and non-inflammatory.[2][59]

Inflammatory 

  1. Infectious causes - Cystitis, urethritis, pyelonephritis, sexually transmitted infections. In females, vulvovaginitis and cervicitis can be the causes of dysuria, while in males, it can result from prostatitis and epididymo-orchitis.
  2. Dermatologic - Contact dermatitis, psoriasis, Behcet syndrome, lichen sclerosis, lichen planus, Stevens-Johnson syndrome
  3. Noninfectious causes - Stone, a urethral or ureteral stent

Non-inflammatory 

  1. Trauma - Foreign body, surgery, urinary tract instrumentation, pelvic radiation.
  2. Endocrine - Atrophic vaginitis, endometriosis
  3. Drugs - Cyclophosphamide, Ketamine
  4. Anatomic - Benign prostatic hypertrophy, urethral stricture.
  5. Neoplastic - Renal cell cancer, bladder cancer, lymphoma, vaginal cancer, vulvar cancer, prostate cancer, penile cancer, metastatic cancer. 
  6. Idiopathic - Interstitial cystitis, urethral pain syndrome

Prognosis

The prognosis for dysuria depends upon the cause of dysuria. Most of the etiologies of dysuria, including inflammatory and non-inflammatory, demonstrate a good long-term prognosis, but early detection and treatment of the underlying causes of the dysuria are essential. Sepsis occurring due to urinary tract infections can lead to higher morbidity and mortality than systemic infections of other organs or systems although urosepsis still has a better overall prognosis.[60] Long-term complications can occur due to stones, chronic infections, or benign prostatic hypertrophy, potentially leading to renal failure and, in severe cases, end-stage renal disease. During pregnancy, both maternal and fetal complications can arise if urinary tract infections do not receive treatment timely and adequately.[9] Prognosis of dysuria occurring from neoplastic causes like renal cancers or bladder cancers depends upon the stage and type of cancer when it gets diagnosed. Early diagnosis and quick follow-up with adequate treatment carry a good prognosis, while a delayed diagnosis is associated with higher recurrence and poor prognosis.[61]

Complications

Depending on the cause of dysuria, short-term complications can include acute renal failure, development of systemic infection and sepsis, acute anemia from hematuria, urethral strictures with urinary retention, and emergent hospitalizations. Long-term complications consist of developing end-stage renal disease, infertility, long-term disability from recurrent infections, strictures or urinary tract cancers, and even death from severe systemic infections or advanced urinary tract cancers. Patients with complicated urinary tract infections can develop recurrences with greater antibiotic resistance, leading to higher rates of hospitalizations and increased morbidity and mortality.[62]

Deterrence and Patient Education

Patient education is crucial in preventing recurrent cases of dysuria. If women have dysuria due to recurrent urinary tract infections or vaginitis, they should be educated not to use douches, maintaining perineal hygiene, and using correct wiping techniques. Patients who are experiencing recurrent sexually transmitted infections should be educated about safe sex practices, the use of condoms, and urinating right after sex. Patients who get recurrent urinary tract infections due to uncontrolled diabetes should be educated about the importance of controlling their blood sugars. Patients with dysuria from atrophic vaginitis can benefit from education and the use of hormone replacement therapy. Male patients suspected of having dysuria from benign prostatic hypertrophy should be educated about routine prostate exams and taking medications to control the related urinary symptoms. All patients should understand the importance of early detection and treatment of infections, which can present with dysuria as the earliest sign, and should be encouraged to seek proper follow-up and treatment.

Enhancing Healthcare Team Outcomes

Using these recommendations, the interprofessional health care team can modify their approach to diagnose and treat patients with dysuria. It will also benefit in terms of increasing efficiency and reducing unnecessary testing. It will improve patient outcomes by educating them about the importance of early detection, adequate follow-up, and timely treatment. 

Given the broad spectrum of possible etiologies for dysuria, all healthcare team members must collaborate and function as a unit. The clinician who first encounters the complaint must order appropriate testing, which will often form the basis for referrals. Diagnosis and management can include specialists from several different disciplines. Nursing can serve as a primary contact point for patient questions and offer counsel, while pharmacists can help with medication recommendations, check for interactions, and counsel the patient on proper dosing and administration. Prompt interprofessional care will help discover the underlying cause, allowing earlier, proper treatment, leading to better patient outcomes. [Level 5]


Article Details

Article Author

Parth Mehta

Article Author

Stephen Leslie

Article Editor:

Anil Kumar Reddy Reddivari

Updated:

5/26/2021 4:40:52 PM

PubMed Link:

Dysuria

References

[1]

Dysuria: What You Should Know About Burning or Stinging with Urination. American family physician. 2015 Nov 1     [PubMed PMID: 26554482]

[2]

Michels TC,Sands JE, Dysuria: Evaluation and Differential Diagnosis in Adults. American family physician. 2015 Nov 1;     [PubMed PMID: 26554471]

[3]

Geerlings SE, Clinical Presentations and Epidemiology of Urinary Tract Infections. Microbiology spectrum. 2016 Oct     [PubMed PMID: 27780014]

[4]

Stamm WE, Chlamydia trachomatis infections: progress and problems. The Journal of infectious diseases. 1999 Mar     [PubMed PMID: 10081511]

[5]

Gaydos C,Maldeis NE,Hardick A,Hardick J,Quinn TC, Mycoplasma genitalium compared to chlamydia, gonorrhoea and trichomonas as an aetiological agent of urethritis in men attending STD clinics. Sexually transmitted infections. 2009 Oct     [PubMed PMID: 19383597]

[6]

Horner P,Blee K,O'Mahony C,Muir P,Evans C,Radcliffe K,Clinical Effectiveness Group of the British Association for Sexual Health and HIV., 2015 UK National Guideline on the management of non-gonococcal urethritis. International journal of STD & AIDS. 2016 Feb     [PubMed PMID: 26002319]

[7]

Black V,Magooa P,Radebe F,Myers M,Pillay C,Lewis DA, The detection of urethritis pathogens among patients with the male urethritis syndrome, genital ulcer syndrome and HIV voluntary counselling and testing clients: should South Africa's syndromic management approach be revised? Sexually transmitted infections. 2008 Aug;     [PubMed PMID: 18192290]

[8]

Miklovic T,Davis P, Dysuria, Rebound Tenderness, and a Palpable Mass-A Ticking Time Bomb. Military medicine. 2021 Apr 30     [PubMed PMID: 33929544]

[9]

Wrenn K, Dysuria, Frequency, and Urgency 1990;     [PubMed PMID: 21250134]

[10]

Horner PJ,Taylor-Robinson D, Association of Mycoplasma genitalium with balanoposthitis in men with non-gonococcal urethritis. Sexually transmitted infections. 2011 Feb;     [PubMed PMID: 20852310]

[11]

Sinnott JD,Howlett DC, Urinary frequency and dysuria in an older woman. BMJ (Clinical research ed.). 2016 Sep 13     [PubMed PMID: 27625371]

[12]

Rees J,Abrahams M,Doble A,Cooper A, Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU international. 2015 Oct;     [PubMed PMID: 25711488]

[13]

Little P,Turner S,Rumsby K,Jones R,Warner G,Moore M,Lowes JA,Smith H,Hawke C,Leydon G,Mullee M, Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women. The British journal of general practice : the journal of the Royal College of General Practitioners. 2010 Jul     [PubMed PMID: 20594439]

[14]

Bellazreg F,Abid M,Lasfar NB,Hattab Z,Hachfi W,Letaief A, Diagnostic value of dipstick test in adult symptomatic urinary tract infections: results of a cross-sectional Tunisian study. The Pan African medical journal. 2019;     [PubMed PMID: 31558930]

[15]

Orellana MA,Gómez-Lus ML,Lora D, Sensitivity of Gram stain in the diagnosis of urethritis in men. Sexually transmitted infections. 2012 Jun     [PubMed PMID: 22308534]

[16]

Rietmeijer CA,Mettenbrink CJ, Recalibrating the Gram stain diagnosis of male urethritis in the era of nucleic acid amplification testing. Sexually transmitted diseases. 2012 Jan;     [PubMed PMID: 22183839]

[17]

Kwan B,Ryder N,Knight V,Kenigsberg A,McNulty A,Read P,Bourne C, Sensitivity of 20-minute voiding intervals in men testing for Chlamydia trachomatis. Sexually transmitted diseases. 2012 May     [PubMed PMID: 22504609]

[18]

Artero A,Esparcia A,Eiros JM,Madrazo M,Alberola J,Nogueira JM, Effect of Bacteremia in Elderly Patients With Urinary Tract Infection. The American journal of the medical sciences. 2016 Sep     [PubMed PMID: 27650231]

[19]

Wagenlehner FM,Brockmeyer NH,Discher T,Friese K,Wichelhaus TA, The Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections. Deutsches Arzteblatt international. 2016 Jan 11     [PubMed PMID: 26931526]

[20]

Ateya A,Fayez A,Hani R,Zohdy W,Gabbar MA,Shamloul R, Evaluation of prostatic massage in treatment of chronic prostatitis. Urology. 2006 Apr     [PubMed PMID: 16566972]

[21]

Comploj E,Trenti E,Palermo S,Pycha A,Mian C, Urinary cytology in bladder cancer: why is it still relevant? Urologia. 2015 Oct-Dec;     [PubMed PMID: 26219472]

[22]

Brisbane W,Bailey MR,Sorensen MD, An overview of kidney stone imaging techniques. Nature reviews. Urology. 2016 Nov;     [PubMed PMID: 27578040]

[23]

DeGeorge KC,Holt HR,Hodges SC, Bladder Cancer: Diagnosis and Treatment. American family physician. 2017 Oct 15     [PubMed PMID: 29094888]

[24]

Bremnor JD,Sadovsky R, Evaluation of dysuria in adults. American family physician. 2002 Apr 15     [PubMed PMID: 11989635]

[25]

Abrams P,Cardozo L,Fall M,Griffiths D,Rosier P,Ulmsten U,Van Kerrebroeck P,Victor A,Wein A, The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003 Jan;     [PubMed PMID: 12559262]

[26]

Taniguchi Y,Nishikawa H,Karashima T,Yoshinaga Y,Fujimoto S,Terada Y, Frequency of reactive arthritis, uveitis, and conjunctivitis in Japanese patients with bladder cancer following intravesical BCG therapy: A 20-year, two-centre retrospective study. Joint bone spine. 2017 Oct     [PubMed PMID: 27825571]

[27]

Saricaoglu EM,Hasanoglu I,Guner R, The first reactive arthritis case associated with COVID-19. Journal of medical virology. 2021 Jan     [PubMed PMID: 32652541]

[28]

Yokogawa N,Minematsu N,Katano H,Suzuki T, Case of acute arthritis following SARS-CoV-2 infection. Annals of the rheumatic diseases. 2020 Jun 26;     [PubMed PMID: 32591356]

[29]

Ono K,Kishimoto M,Shimasaki T,Uchida H,Kurai D,Deshpande GA,Komagata Y,Kaname S, Reactive arthritis after COVID-19 infection. RMD open. 2020 Aug     [PubMed PMID: 32763956]

[30]

Carter JD,Hudson AP, Reactive arthritis: clinical aspects and medical management. Rheumatic diseases clinics of North America. 2009 Feb;     [PubMed PMID: 19480995]

[31]

Kvien TK,Gaston JS,Bardin T,Butrimiene I,Dijkmans BA,Leirisalo-Repo M,Solakov P,Altwegg M,Mowinckel P,Plan PA,Vischer T,EULAR., Three month treatment of reactive arthritis with azithromycin: a EULAR double blind, placebo controlled study. Annals of the rheumatic diseases. 2004 Sep     [PubMed PMID: 15308521]

[32]

Bardin T,Enel C,Cornelis F,Salski C,Jorgensen C,Ward R,Lathrop GM, Antibiotic treatment of venereal disease and Reiter's syndrome in a Greenland population. Arthritis and rheumatism. 1992 Feb     [PubMed PMID: 1734908]

[33]

Laasila K,Laasonen L,Leirisalo-Repo M, Antibiotic treatment and long term prognosis of reactive arthritis. Annals of the rheumatic diseases. 2003 Jul;     [PubMed PMID: 12810429]

[34]

Putschky N,Pott HG,Kuipers JG,Zeidler H,Hammer M,Wollenhaupt J, Comparing 10-day and 4-month doxycycline courses for treatment of Chlamydia trachomatis-reactive arthritis: a prospective, double-blind trial. Annals of the rheumatic diseases. 2006 Nov     [PubMed PMID: 17038453]

[35]

Barry HC,Ebell MH,Hickner J, Evaluation of suspected urinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies. The Journal of family practice. 1997 Jan     [PubMed PMID: 9010371]

[36]

Workowski KA,Bolan GA,Centers for Disease Control and Prevention., Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 2015 Jun 5     [PubMed PMID: 26042815]

[37]

Garcia MR,Wray AA, Sexually Transmitted Infections StatPearls. 2021 Jan     [PubMed PMID: 32809643]

[38]

Manhart LE,Gillespie CW,Lowens MS,Khosropour CM,Colombara DV,Golden MR,Hakhu NR,Thomas KK,Hughes JP,Jensen NL,Totten PA, Standard treatment regimens for nongonococcal urethritis have similar but declining cure rates: a randomized controlled trial. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2013 Apr     [PubMed PMID: 23223595]

[39]

Seña AC,Lensing S,Rompalo A,Taylor SN,Martin DH,Lopez LM,Lee JY,Schwebke JR, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: predictors and persistence after therapy. The Journal of infectious diseases. 2012 Aug 1;     [PubMed PMID: 22615318]

[40]

Wikström A,Jensen JS, Mycoplasma genitalium: a common cause of persistent urethritis among men treated with doxycycline. Sexually transmitted infections. 2006 Aug     [PubMed PMID: 16877573]

[41]

Mena LA,Mroczkowski TF,Nsuami M,Martin DH, A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2009 Jun 15;     [PubMed PMID: 19438399]

[42]

Weinstein SA,Stiles BG, Recent perspectives in the diagnosis and evidence-based treatment of Mycoplasma genitalium. Expert review of anti-infective therapy. 2012 Apr     [PubMed PMID: 22512757]

[43]

Manhart LE,Broad JM,Golden MR, Mycoplasma genitalium: should we treat and how? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2011 Dec     [PubMed PMID: 22080266]

[44]

Wetmore CM,Manhart LE,Lowens MS,Golden MR,Whittington WL,Xet-Mull AM,Astete SG,McFarland NL,McDougal SJ,Totten PA, Demographic, behavioral, and clinical characteristics of men with nongonococcal urethritis differ by etiology: a case-comparison study. Sexually transmitted diseases. 2011 Mar;     [PubMed PMID: 21285914]

[45]

Ito S,Hatazaki K,Shimuta K,Kondo H,Mizutani K,Yasuda M,Nakane K,Tsuchiya T,Yokoi S,Nakano M,Ohinishi M,Deguchi T, Haemophilus influenzae Isolated From Men With Acute Urethritis: Its Pathogenic Roles, Responses to Antimicrobial Chemotherapies, and Antimicrobial Susceptibilities. Sexually transmitted diseases. 2017 Apr     [PubMed PMID: 28282645]

[46]

Bader MS,Hawboldt J,Brooks A, Management of complicated urinary tract infections in the era of antimicrobial resistance. Postgraduate medicine. 2010 Nov;     [PubMed PMID: 21084776]

[47]

Coker TJ,Dierfeldt DM, Acute Bacterial Prostatitis: Diagnosis and Management. American family physician. 2016 Jan 15;     [PubMed PMID: 26926407]

[48]

Shafi H,Moazzami B,Pourghasem M,Kasaeian A, An overview of treatment options for urinary stones. Caspian journal of internal medicine. 2016 Winter     [PubMed PMID: 26958325]

[49]

Leslie SW,Sajjad H,Murphy PB, Renal Calculi 2020 Jan;     [PubMed PMID: 28723043]

[50]

Patti L,Leslie SW, Acute Renal Colic StatPearls. 2021 Jan     [PubMed PMID: 28613743]

[51]

Edelstein H,McCabe RE, Perinephric abscess. Modern diagnosis and treatment in 47 cases. Medicine. 1988 Mar     [PubMed PMID: 3352513]

[52]

Tanguay S,Awde M,Brock G,Casey R,Kozak J,Lee J,Nickel JC,Saad F, Diagnosis and management of benign prostatic hyperplasia in primary care. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2009 Jun     [PubMed PMID: 19543429]

[53]

Frank JE, Diagnosis and management of G6PD deficiency. American family physician. 2005 Oct 1     [PubMed PMID: 16225031]

[54]

Phillip H,Okewole I,Chilaka V, Enigma of urethral pain syndrome: why are there so many ascribed etiologies and therapeutic approaches? International journal of urology : official journal of the Japanese Urological Association. 2014 Jun;     [PubMed PMID: 24447292]

[55]

YOUNGBLOOD VH,TOMLIN EM,WILLIAMS JO, Senile urethritis in women. Gynaecologia. International monthly review of obstetrics and gynecology. Revue internationale mensuelle d'obstetrique et de gynecologie. Monatsschrift fur Geburtshilfe und Gynakologie. 1960     [PubMed PMID: 13846661]

[56]

Cakici �U,Hamidi N,�rer E,Okulu E,Kayigil O, Efficacy of sertraline and gabapentin in the treatment of urethral pain syndrome: retrospective results of a single institutional cohort. Central European journal of urology. 2018;     [PubMed PMID: 29732211]

[57]

Palleschi G,Carbone A,Ripoli A,Silvestri L,Petrozza V,Zanello PP,Pastore AL, A prospective study to evaluate the efficacy of Cistiquer in improving lower urinary tract symptoms in females with urethral syndrome. Minerva urologica e nefrologica = The Italian journal of urology and nephrology. 2014 Dec     [PubMed PMID: 25034330]

[58]

Costantini E,Zucchi A,Del Zingaro M,Mearini L, Treatment of urethral syndrome: a prospective randomized study with Nd:YAG laser. Urologia internationalis. 2006     [PubMed PMID: 16493214]

[59]

FERGUSON JD, The differential diagnosis of dysuria. The Practitioner. 1952 Oct;     [PubMed PMID: 13003775]

[60]

Qiang XH,Yu TO,Li YN,Zhou LX, Prognosis Risk of Urosepsis in Critical Care Medicine: A Prospective Observational Study. BioMed research international. 2016;     [PubMed PMID: 26955639]

[61]

Yaxley JP, Urinary tract cancers: An overview for general practice. Journal of family medicine and primary care. 2016 Jul-Sep;     [PubMed PMID: 28217578]

[62]

Bleidorn J,Hummers-Pradier E,Schmiemann G,Wiese B,Gágyor I, Recurrent urinary tract infections and complications after symptomatic versus antibiotic treatment: follow-up of a randomised controlled trial. German medical science : GMS e-journal. 2016;     [PubMed PMID: 26909012]