Dysuria

Question 1

Differential diagnoses of Dysuria

Answer 1

1. UTI - Dysuria Young Female
2. UTI - Dysuria Middle - Old Male
3. UTI - Dysuria Young Male
4. BPH +/- Dysuria Middle - Old Male

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.

Question 2

Dysuria - Key History

Answer 2

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).

Question 3

Dysuria - Key questions

Answer 3

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?

Question 4

Dysuria - Key Examination

Answer 4

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

Question 5

Dysuria - Key Investigations

Answer 5

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

Question 6

Dysuria - Diagnostic Tips

Answer 6

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.