Dysuria resident survival guide: Difference between revisions

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{{Family tree | | | | | B02 | | | |B02= Presence of Comcomitant fever,flank pain, abnormal vital signs(Tachycardia,Tachypnea,Hypotension),nausea,vomiting}}
{{Family tree | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 12em; width: 19em; padding:1em;"> '''Presence of:'''<br>
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Comcomitant [[fever]] <br> ❑ [[flank pain]] <br> ❑ abnormal vital signs([[Tachycardia]],[[Tachypnea]],[[Hypotension]]) <br> ❑ [[Nausea]]  <br> ❑ [[Vomiting]] </div>}}
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{{Family tree |D04| | | | | | | |R08|D04=Refer the patient to ER|R08=Urine Dipstick for Nitrites and Leukocytes| }}
{{Family tree |D04| | | | | | | |R08|D04='''Refer the patient to ER'''|R08=[[Urine Dipstick]] for [[Nitrites]] and Leukocytes| }}
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{{Family tree | | | |R09| | |,|-|^|-|-|.| | | | | | | |U09| | | | |R09=Empirical Antibiotic Therapy|U09=Urine Culture| | | | | | | | | |}}
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{{Family tree | | | | | | | |P08| | | | | | |O08| | |p09| | | |!|P08= Presence of any Urethral discharge/Itching|O08=Acid urine pH/history of Tuberculosis|p09= Treat with Specific antibiotic}}
{{Family tree | | | | | | | |P08| | | | | | |O08| | |p09| | | |!|P08= Presence of any [[Urethral discharge]]/Itching|O08=Acid urine pH/history of [[Tuberculosis]]|p09= Treat with Specific antibiotic}}
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{{Family tree | | | | | | | |R09| | | | |P09| | | | | | | | | | |i09|i09=Think of any other non-infectious urogenital disease or vulvo-vaginal disease|R09=Do Swab test|P09=Urine speicific test for Tuberculosis}}
{{Family tree | | | | | | | |R09| | | | |P09| | | | | | | | | | |i09|i09=Think of any other non-infectious urogenital disease or [[vulvo-vaginal disease]]|R09=Do Swab test|P09=Urine speicific test for Tuberculosis}}
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{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |p09| | |p09=Refer the patient to urologist/gynaecologist}}
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Revision as of 15:05, 13 August 2020

Dysuria
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] 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 STD, bladder stones, bladder tumors and any condition of the prostate. It can also occur as a side effect of medications. It is one of a constellation of irritative bladder symptoms, which includes frequency of urination and haematuria.

Causes

Life Threatening Causes

Life-threatening causes of dysuria include

These conditions may result in death or permanent disability within 24 hours if left untreated

Common Causes

Diagnosis

  • Shown below is two algorithms summarizing the diagnosis of Dysuria
  • Algorithm showing diagnosis of dysuria in woman


 
 
 
 
Woman with dysuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of:

❑ Comcomitant fever
flank pain
❑ abnormal vital signs(Tachycardia,Tachypnea,Hypotension)
Nausea
Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urethritis(Chlamydia trachomatis,Neisseria gonorrhoeae or Herpes simplex virus)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

If the female patient presents with 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 cnsecutive 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
 
 
 
 


Algorithm showing diagnosis of dysuria in Male patients

 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Firm, painless, non-itchy skin ulceration with multiple sores OR
A diffuse rash involving the palms of the hands and soles of the feet
OR
Presence of gummas
 
 
Painless genital ulcer,anorectal pain, tenesmus, and 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

Shown below is an algorithm summarizing the treatment of Dysuria in female patients


|}}
 
 
 
 
 
 
 
Symptoms of lower urinary tract
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non recurrent
 
 
 
 
 
 
 
Recurrent
( Atleast 3 episodes of uncomplicated UTI in 12 months,
with atleast one positive by urine culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncomplicated
Without any risk factors
 
Complicated :Presence of any of the following risk factors:

❑ Presence of indwelling catheter
Vesicoureteric reflux
❑ Increased post void residual urine
❑ Increased post void residual urine
❑ Presence of diseases: Renal insufficiency, Diabetes mellitus, Immunodeficiency Presence of diseases: Renal insufficiency, Diabetes mellitus, Immunodeficiency
❑ Obstructive Uropathy
 
 
 
 
 
Modify Lifestyle to intervene modifiable riskfactors and take prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment with short term antibiotic therapy
First line includes
❑3g oral dose of Fosfomycin trometamol

or
Pivmecillinam 400 mg twice a day for 3 days
or
Nitrofurantoin 100mg twice a day for 5-7days
or
In case of <20% resistance rates for E.coli

Cotrimoxazole 160/800 mg twice a day for 3 days
or
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

Do's

    • Patient should always stay hydrated
    • Patient should urinate after sexual intercourse
    • Patient should always wipe front to back
    • Patient should wear cotton/comfortable underwear
    • Patient should use menstrual cups, sanitary pads, or clean period-proof underwear
    • Maintain personal hygiene

Don'ts

  • Patient should avoid delays in urinating
  • Patient should try to decrease the inatke of
    • Caffeinated sodas
    • Alcohol
    • Spicy foods
    • Acidic fruits

References


Template:WikiDoc Sources