Dysuria

Diagnostic approach

• Targeted clinical evaluation
• Urinalysis
• Urine culture if concern for complicated infections
• Urine β-hCG in individuals who can become pregnant
• STI testing (e.g., NAAT for chlamydia and gonorrhea) if indicated
• CBC and BMP if concern for pyelonephritis
• Abdominal and pelvic imaging (CT or ultrasound) for, e.g., complicated pyelonephritis, nephrolithiasis, gross hematuria

Management checklist

• Target suspected cause based on clinical evaluation and initial test results.
• Empiric antibiotics for suspected bacterial infection
• Pain management (e.g., NSAIDs, acetaminophen)
• Hydration (PO or IV) if needed
• Admit for sepsis, hemodynamic instability, complicated pyelonephritis, obstruction, inability to tolerate oral intake.
• Consult urology for complicated pyelonephritis or nephrolithiasis, obstruction, suspected malignancy, recent GU procedure.

Red flag features

• Fever
• Hypotension
• Vomiting
• Flank pain
• Gross hematuria
• Urinary retention
• Immunocompromised state
• Pregnancy
• Recent GU instrumentation or surgery

Dysuria is pain or discomfort during urination. It is more common in female than male individuals and can occur at any age. The most common causes of dysuria in female individuals are acute bacterial urinary tract infections (UTIs) and lower genital tract infections (e.g., vaginitis, urethritis) often related to sexually transmitted infections (STIs). In male individuals, bacterial prostatitis and urethritis due to STIs are the most common causes. A focused history, physical examination, and targeted tests, such as urinalysis, help identify the underlying condition and guide further management.

Infectious ^[1][2]

• Lower UTI
• Lower genital tract infections (often STI-related), e.g.:
  • Urethritis
  • Vaginitis
  • Genital ulceration
• Prostatitis
• Pyelonephritis

The most common causes of dysuria are infectious, i.e., UTIs and STIs. ^[1]

Noninfectious ^[1][2]

• Dermatologic
  • Contact dermatitis (e.g., due to soaps, sanitary products)
  • Lichen sclerosus
  • Behcet disease
• Inflammatory
  • Reactive arthritis
  • Interstitial cystitis
• Obstructive
  • Benign prostatic hyperplasia
  • Urethral anatomical abnormality (e.g., stricture, diverticulum)
  • Nephrolithiasis
• Malignant
  • Bladder cancer
  • Urethral cancer
  • Renal cancer
  • Prostate or penile cancer
  • Vulvar or vaginal cancer
• Medication-induced
  • Chemotherapeutic agents (e.g., cyclophosphamide, ifosfamide)
  • Medications causing urinary retention (see “Drug-induced urinary retention”)
  • Topical agents (e.g., spermicides)
• Iatrogenic
  • Radiation-induced cystitis
  • Genitourinary instrumentation
  • Foreign body (e.g., stent)
• Gynecologic
  • Vulvovaginal atrophy
  • Endometriosis

Focused history ^[1][2]

• Urinary symptoms
  • Onset: acute or gradual
  • Location (e.g., suprapubic pain, flank pain)
  • Other lower urinary tract symptoms (LUTS)
    • Irritative LUTS (e.g., urinary frequency and/or urinary urgency)
    • Obstructive LUTS (e.g., hesitancy, poor stream, and/or dribbling)
  • Associated findings
    • Urethral or vaginal discharge
    • Cloudy or malodorous urine
• Nonurinary symptoms
  • Fever, rigors
  • Constitutional symptoms
  • Features of systemic disease (e.g., arthralgia, back pain, and/or ocular symptoms)
• Pregnancy status
• Past medical history
  • UTIs
  • STIs
  • Nephrolithiasis
  • Immunocompromised state
  • Procedural history (e.g., recent genitourinary instrumentation, pelvic irradiation)
  • Recent hospitalizations and/or antibiotic exposure
  • Known anatomical abnormalities of the urinary tract
  • Personal and/or family history of polycystic kidney disease
• Risk factors
  • Medications and topical agents that may cause dysuria
  • Risk factors for STIs
  • Risk factors for urinary tract cancers (e.g., smoking history, occupational or environmental exposures)

Focused examination ^[1][2]

• Examination of the abdomen and back: Assess for localized tenderness, palpable masses, or bladder distention.
• Examination of external genitalia: Assess for discharge, ulceration, and/or rash.
• Pelvic examination
• Digital rectal examination (DRE) and scrotal examination
• Examine joints for effusions.

Red flags for dysuria include features of systemic infection and risk factors for complicated UTIs. ^[1][2]

General principles

• Clinical evaluation is usually sufficient to determine the cause of dysuria.
• Urinalysis helps to confirm a diagnosis of UTI and may also indicate alternative causes of dysuria.
• STI testing should be considered in individuals with risk factors and suggestive clinical features.
• Imaging is not routinely indicated but should be considered for specific indications (e.g., complicated pyelonephritis).

Initial studies

• Urinalysis (UA) ^[1]
  • Indication: initial test in individuals with dysuria
  • Findings
    • Urinary nitrites and/or leukocyte esterase: typically positive in UTI
    • Isolated positive urinary leukocyte esterase: suggests urethritis if clinical features are consistent
    • Hematuria (see “Etiology of hematuria.”)
• Urine culture
  • Indications ^[1]
    • Suspected complicated UTI or pyelonephritis
    • Unsuccessful initial antibiotic treatment for UTI
    • Risk of antibiotic-resistant infections
    • Age ≥ 65 years
  • Findings: infectious cause confirmed by bacteriuria (i.e., ≥ 10⁵ CFU/mL in a midstream urine sample)
• STI testing: e.g., POC urethral smear microscopy, NAAT, vaginal wet mount
• Pregnancy test: urine β-hCG in individuals who can become pregnant

A UTI can be diagnosed in female patients with acute dysuria, frequency, and/or urgency but no vaginal discharge, without further investigation. ^[1]

Additional studies

• Blood tests: CBC, BMP, and blood cultures if pyelonephritis is suspected
• Abdominal and pelvic imaging
  • Consider for specific indications, e.g.: ^[1]
    • Complicated acute pyelonephritis
    • Suspected anatomical anomaly or obstruction
    • Recurrent UTIs
    • Nephrolithiasis
    • Hematuria (see “Approach to hematuria.”)
  • Modalities
    • CT abdomen and pelvis: preferred modality (use of contrast determined by suspected diagnosis)
    • Renal and bladder ultrasound: Consider during pregnancy or for contrast allergy.

The management setting and need for referral depend on the clinical presentation and suspected cause. ^[9]

• Inpatient management
  • Sepsis or hemodynamic instability
  • Complicated pyelonephritis
  • Need for urological intervention
  • Inability to tolerate oral antibiotics
• Urology referral
  • Complicated nephrolithiasis or pyelonephritis
  • Urinary tract obstruction
  • Suspected or confirmed urinary tract malignancy
  • Recent genitourinary intervention

Outpatient management is appropriate for most patients with dysuria.