Dysuria resident survival guide
Dysuria Resident Survival Guide |
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Overview |
Causes |
Diagnosis |
Women |
Men |
Treatment |
Women |
Men |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.
Overview
Dysuria is typically described to be a burning, tingling, or stinging sensation of the urethra and meatus associated with voiding. Dysuria refers to painful urination. It is most often a result of an infection of the urinary tract. Noninfectious inflammatory causes include a foreign body in the urinary tract and dermatologic conditions such as herpes, irritant dermatitis, erosive, lichen planus, contact dermatitis. It may also be due to an sexually transmitted diseases, bladder stones, bladder tumors and any condition of the prostate. It can also occur as a side effect of medications. It is one of the constellations of irritative bladder symptoms, which includes the frequency of urination and haematuria.
Causes
Life Threatening Causes
Life-threatening causes of dysuria include:
The aforementioned conditions may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Common causes include: [1]
- Acute Cystitis
- Urethritis from sexually transmitted infections
- Female genital structure related[1]
- Male genital Structure related[1]
- Foreign Body in urinary tract[1]
- Indwelling Foley catheter
- Stone
- Urethral or ureteral stent
- Pyelonephritis
- Urethral Stricture
- Dermatological[1]
- Local trauma
- Medication use
- Neoplasia
Diagnosis
- Shown below are two algorithms summarizing the diagnosis of Dysuria
Diagnostic Approach in Women
Algorithm showing the diagnosis of dysuria in woman: [2] [3]
Abbreviations: ER:Emergency room,KUB USS :Kidney and Bladder Ultrasound study,PVR: Post-void residual urine,USG : Ultrasonography
Woman with dysuria | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Take complete history | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of: ❑ Comcomitant fever
❑ Nausea | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Refer the patient to ER | Urine Dipstick for Nitrites and Leukocytes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Nitrite Postitive | Leukocytes positive,Nitrite negative | Both Nitrite and Leukocyte negative | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Urine culture | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Empirical Antibiotic Therapy | Urine Culture | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Positive | Negative | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treat with Specific Antibiotic | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Postive | Negative | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of any Urethral discharge/Itching | Acid urine pH/history of Tuberculosis | Treat with Specific antibiotic | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do Swab test | Urine speicific test for tuberculosis | Think of any other non-infectious urogenital disease or vulvo-vaginal disease | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Refer the patient to urologist/gynaecologist | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If the female patient presents with a slow urine stream without any pain or burning sensation, then the algorithm below can be used to treat the patient
Female patient with only voiding symptoms | |||||||||||||||||||||||||||||||||||||
Take complete history Ask about voidal habits: ❑Urinary frequency ❑Interval between two consecutive micturation | |||||||||||||||||||||||||||||||||||||
❑Physical examination Suprapubic palpation and Vaginal examination | |||||||||||||||||||||||||||||||||||||
❑Urine culture ❑ Kidney and Bladder Ultrasound study (KUB USS) | |||||||||||||||||||||||||||||||||||||
Increased Detrusor wall thickness | Bladder diverticula | Increased post void residual(>100) | Hydronephrosis | ||||||||||||||||||||||||||||||||||
Refer to urologist | |||||||||||||||||||||||||||||||||||||
Diagnostic Approach in Men
Algorithm showing the diagnosis of dysuria in Male patients: [3]
Abbreviations: ER:Emergency room, KUB USS :Kidney and Bladder Ultrasound study, PVR: Post-void residual urine, USG : Ultrasonography, NAAT: Nucleic Acid Amplification Test, PCR: Polymerase chain reaction, ESR:Erythrocyte sedimentation rate, CRP: C-reactive protein , HLA:Human leukocyte antigen
Male patient with dysuria | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Take complete history | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of urethral discharge | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ask about the discharge | Presence Of Genital Lesion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Profuse,purulent discharge Yellowish green colour | Thin,mucoid/mucopurulent discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Swab test | Swab test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gram negative Diplococci | NAAT/PCR test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gonorrhoea | Chlamydia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Inflammation of the glans penis | Ulcer | Painful Vesicles | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Balanitis | Herpes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of: ❑ Firm, painless, non-itchy skin ulceration ❑ Multiple sores ❑ A diffuse rash involving the palms of the hands and soles of the feet ❑ Presence of gummas | Presence of: ❑ Painless genital ulcer ❑ Anorectal pain ❑ Tenesmus ❑Rectal discharge ❑ Rectal discharge,Inguinal lymphadenopathy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Syphilis | Lymphogranuloma venereum (LGV) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presence of any Localized Pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑Suprapubic pain | ❑Flank pain ❑Costovertebral angle tenderness ❑Fever | Joint pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Urine Analysis | USG | ❑X-ray ❑ESR/CRP ❑HLA-B27 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cystitis | Pyelonephritis | Spondyloarthropathy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Treatment in Women
Shown below is an algorithm summarizing the treatment of Dysuria in female patients: [3]
Symptoms of lower urinary tract | |||||||||||||||||||||||||||||||||||
Non recurrent | Recurrent ❑ At least 3 episodes of uncomplicated UTI in 12 months ❑ With at least one positive by urine culture | ||||||||||||||||||||||||||||||||||
Uncomplicated Without any risk factors | Complicated :Presence of any of the following risk factors: ❑ Presence of indwelling catheter | Modify Lifestyle to intervene modifiable riskfactors and take prophylaxis | |||||||||||||||||||||||||||||||||
Treatment with short term antibiotic therapy First line includes ❑ 3g oral dose of Fosfomycin trometamol ❑ Pivmecillinam 400 mg twice a day for 3 days ❑ Nitrofurantoin 100mg twice a day for 5-7days In case of <20% resistance rates for E.coli ❑ Cotrimoxazole 160/800 mg twice a day for 3 days ❑Trimethoprim 200 mg twice a day for 5 days | ❑ Specific antibiotic depending on urine culture ❑ Long Empeirical long term antibiotic(Fluoroquinolones,Third generation Cephalosporins,Aminoglycosides) for 10-14 days | Measurements to prevent recurrent UTI ❑ Low dose Antimicrobial prophylaxis continuously or after sexual intercourse ❑ Interventions on modifiable risk factors: 1.Avoid using spermicide 2.Maintain blood glucose level 3.Improving the treatment of urinary incontinence 4.Unspecific prophylaxis with cranberry extracts 5.Local hormonal therapy in case of post menopausal women | |||||||||||||||||||||||||||||||||
Repeat urine culture in nonresponsive cases and pregnant women | Repeat urine culture after treatment,KUB ultrasound with PVR measurement | ||||||||||||||||||||||||||||||||||
Refer the patient to urologist | If all of the above fails | ||||||||||||||||||||||||||||||||||
Refer to urologist | |||||||||||||||||||||||||||||||||||
Treatment in Men
Treatment of dysuria in male patient: [3]
Male patient with dysuria | |||||||||||||||||||||||||||||||||||||||||||||
Look for infection | |||||||||||||||||||||||||||||||||||||||||||||
Presence of infection | No infection | ||||||||||||||||||||||||||||||||||||||||||||
❑ Treatment with specific antibiotic for 7 days ❑ If sensitivity tests are not available empirical treatment with Quinolone | Further investigate to exclude Bladder cancinoma if ❑ Patient is smoker or ❑ H/o exposure to carcinogen or ❑ Presence of Storage symptoms | ||||||||||||||||||||||||||||||||||||||||||||
Recurrent UTI or prostatitis | Look for other non infective causes | ||||||||||||||||||||||||||||||||||||||||||||
Refer to Urologist | |||||||||||||||||||||||||||||||||||||||||||||
Treat according to the specific cause | No specific cause found, Suspect chronic pelvic pain syndrome (CPPS) | ||||||||||||||||||||||||||||||||||||||||||||
Quinolone-naive treatment | Previously had treatment with Quinolones | ||||||||||||||||||||||||||||||||||||||||||||
No response for 4 weeks | Response | Apply UPOINT classification | |||||||||||||||||||||||||||||||||||||||||||
Apply UPOINT classification | Response | ||||||||||||||||||||||||||||||||||||||||||||
Response | No response | Refer to specialized pain clinic in Hospital | |||||||||||||||||||||||||||||||||||||||||||
No response | Refer to specialized pain clinic in Hospital | ||||||||||||||||||||||||||||||||||||||||||||
UPOINT CLASSIFICATION
Phenotype Domains | Clinical Features |
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Urinary | Lower urinary tract symptoms that creates discomfort or High post-micturation residual volume |
Psychological | Patient with depression or severe anxiety thinking the worst will happen to them |
Organ-specific | Tenderness in Prostate, Presence of blood in ejaculation,Leukocytes in prostatic fluid or post-massage urine |
Infectious | Infection with gram negative bacilli or Enterococci localized to prostate or presence of Ureaplasma in urine |
Systemic | Pain anywhere else in the body except abdomen or pelvis or having a diagnosis of fibromyalgia, chronic fatigue or irritable bowel syndrome |
Tenderness | Presence of palpable muscle spams in abdomen or pelvic floor |
Do's
Instruct the female patients to:[4]
- Lose weight (if they are overweight or obese).
- Always stay hydrated.
- Urinate after sexual intercourse.
- Always wipe front to back.
- Wear cotton/comfortable underwear.
- Use menstrual cups, sanitary pads, or clean period-proof underwear.
- Maintain personal hygiene.
Don'ts
- Instruct the female patients not to delay in urinating.[4]
- Avoid Smoking[4]
- Avoid drinking the following items a lot:[4]
- Caffeinated sodas
- Alcohol
- Spicy foods
- Acidic fruits
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Michels TC, Sands JE (November 2015). "Dysuria: Evaluation and Differential Diagnosis in Adults". Am Fam Physician. 92 (9): 778–86. PMID 26554471.
- ↑ "Dysuria, Frequency, and Urgency - Clinical Methods - NCBI Bookshelf".
- ↑ 3.0 3.1 3.2 3.3 Gontero, Paolo; Kirby, Roger S.; Carson III, Culley C. (2013). doi:10.1007/978-1-4471-4634-6. Missing or empty
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(help) - ↑ 4.0 4.1 4.2 4.3 Gungor, Ilkay; Beji, Nezihe Kizilkaya (2011). "Lifestyle changes for the prevention and management of lower urinary tract symptoms in women". International Journal of Urological Nursing. 5 (1): 3–13. doi:10.1111/j.1749-771X.2011.01112.x. ISSN 1749-7701.