Dysuria

Probability diagnosis

UTI (esp. cystitis)

Urethritis

Urethral syndrome—abacterial cystitis (female)

Vaginitis

Serious disorders not to be missed

Neoplasia:

• bladder

• prostate

• urethra

Infection:

• gonorrhoea

• chlamydia/others

• genital herpes

• prostatitis

Reactive arthritis

Calculi (e.g. bladder)

Pitfalls (often missed)

Menopause syndrome

Adenovirus urethritis

Prostatitis

Foreign bodies in lower urinary tract

Acidic urine

Acute fever

Interstitial cystitis

Urethral caruncle/diverticuli

Vaginal prolapse

Obstruction:

• benign prostatic hyperplasia

• urethral stricture

• phimosis

• meatal stenosis

Masquerades checklist

Depression

Diabetes

Drugs

UTI

Is the patient trying to tell me something?

Consider psychosexual problems, anxiety and hypochondriasis.

Key history

It is important to determine whether dysuria is really genitourinary in origin and not attributable to functional disorders, such as psychosexual problems. Disturbances of micturition are uncommon in the young male and if present suggest sexually transmitted infection (STIs).

Key questions:

• Could you describe the discomfort?

• What colour is your urine?

• Does it have a particular odour?

• Have you noticed a discharge?

• If so, could it be sexually acquired?

• Do you find intercourse painful or uncomfortable (women)?

• Have you any fever, sweats or chills?

Key examination

• General inspection looking for evidence of kidney disease and vital signs

• Abdominal palpation to focus on the loins and suprapubic areas

• The possibility of STIs should be considered and this includes vaginal examination in the female and rectal and genital examination in the male

• In the menopausal female the cause may be evident from a dry atrophic urethral opening, a urethral caruncle or urethral prolapse

Key investigations

• Dipstick testing of the urine

• Microscopy or culture (midstream specimen of urine or suprapubic puncture in children)

• Urethral swabs or first pass urine for STIs

• Further investigations depend on findings

Diagnostic tips

• Urethritis causes pain at the onset of micturition and cystitis at the end.

• Suprapubic discomfort is a feature of bladder infection (cystitis).

• Unexplained dysuria could be a pointer to chlamydia urethritis.