Dysuria Approach.pdf

Approach to Dysuria
Saleh Al-Khalid R3 FM
Supervised by Dr. Shareefah Alshehri

Outline
• Definition
• Epidemiology
• Differential Diagnosis
• Inflammatory
• Non-inflammatory
• Important History & Examination Findings
• Diagnostic Tests
• Approach
• MCQs

Definition
• It is defined as discomfort, burning, or sensation of pain during
micturition.
• Patients may also complain of urethral discomfort not associated with
micturition.
• Dysuria:
• External (i.e., urine irritating the inflamed genital organs)
• Internal (i.e., pain felt in the urethra)

Epidemiology
• Dysuria is one of the most common
reasons to visit a PHC.
• It is generally more common in
women.
• Female:male ratio of 6:1
• Although dysuria is uncommon in
men, incidence increases with
advancing age, > 40 years secondary
to bladder outlet obstruction like in
BPH.

Differential Diagnosis
It can be classified in to:
• Inflammatory
• Non-inflammatory

Investigation
• Urine dipstick test
• Urinalysis and culture
• Urethral, vaginal, or cervical cultures or PCR
• Pregnancy test

Urine Dipstick
• First line of investigation
• Leukocyte esterase: it is produced by neutrophils
and may signal pyuria (Detection of a UTI):
• Sensitivity: 75%
• Specificity: 98%.
• Nitrite: produced by some bacteria that reduce
urinary nitrates to nitrites (Detection of a UTI)
• Sensitivity:30%
• Specificity: 90%
• With combination of the 2 tests, sensitivity up to
88%.

Microscopy
Greater than 10 WBC
per high-powered
field of an unspun
urine* is considered
diagnostic for UTI.
*Quantitative unspun-urine microscopy, confirmed by oil-immersion, is a quick, reliable method
for diagnosis of significant bacteriuria, and is considered to be useful for early diagnosis
of urinary infection

Radiology
• Ultrasound:
• Initial imaging study for most patients when
imaging is indicated
• Useful in patients who have iodinated
contrast media allergy or pregnancy
• Measurement of the bladder residual volume
helps evaluate benign prostatic hyperplasia
• Secondary study in:
• Recurrent UTIs
• Complicated pyelonephritis
• Hematuria

Radiology
• Plain abdominal radiography
(kidneys, ureters, bladder)
• Most useful in known
urolithiasis

Radiology
• CT of abdomen and pelvis with and
without contrast media (CT
urography):
• Hematuria
• Recurrent UTI
• Complicated pyelonephritis

Radiology
• CT of abdomen and pelvis
without contrast media
• Suspected urolithiasis
• Ultrasonography is best initial
study

Radiology
• Cystoscopy
• Voiding symptoms
• Hematuria
• Recurrent UTI
• Urethral diverticula
• Bladder cancer
• Interstitial cystitis

Radiology
• Intravenous urography
• Useful for hematuria
evaluation if CT urography
is unavailable

Radiology
• Magnetic resonance imaging of
abdomen and pelvis with and
without contrast media (MR
urography)
• Most useful for complicated
pyelonephritis
• Helpful, not preferred, for stones
and hematuria

Case 1
An 23-year-old woman is seeing you for back pain, frequency, and
dysuria. She reports being treated for acute cystitis in the past on two
other occasions. She denies vaginal discharge. What is the most
appropriate and cost-effective next step?
A. Empiric 3-day treatment for urinary tract infection (UTI)
B. Treating with a 7 to 10 day course of antibiotics
C. Clean catch urinalysis with treatment depending on results
D. Send urine for culture
E. Testing for a sexually transmitted infection

Answer is A
If a woman with a prior history of uncomplicated UTI presents with
classic symptoms of a UTI, clinicians can consider empirically treating
the patient.

Case 2
You are evaluating a 25-year-old woman who reports frequent UTIs since
getting married last year. In the last 12 months, she has had five documented
infections that have responded well to antibiotic therapy. She has tried
voiding after intercourse, she discontinued her use of a diaphragm, and tried
acidification of her urine using oral ascorbic acid, but none of those
measures decreased the incidence of infections. At this point, which of the
following would be an acceptable prophylactic measure?
A. An antibiotic prescription for the usual 3-day regimen with refills, to be used when
symptoms occur
B. Single-dose antibiotic therapy once daily at bedtime for 12 months
C. Single-dose antibiotic therapy once daily at bedtime for 2 years
D. Single-dose antibiotic therapy after sexual intercourse
E. Antibiotics for 3 days after sexual intercourse

Answer is D
• Postcoital UTI: symptoms develop within 24 hours of sexual
intercourse.
• Measures would help decrease the incidence of UTI:
• Voiding after intercourse
• Acidification of the urine
• Discontinuing diaphragm use

Case 3
A 36-year-old woman comes to your office complaining of recurrent dysuria.
This is her fourth episode in the past 10 months. Initially, her symptoms were
classic for a UTI, and she was treated empirically without testing. For the
second episode, her urinalysis was positive for blood only. Her culture was
negative, as was evaluation for nephrolithiasis. The third episode was similar,
also with a negative culture. All episodes have resolved with a standard
course of antibiotic therapy. Which of the following is the most appropriate
next step?
A. Evaluate for somatization disorder
B. Consider cystoscopy
C. Consider potassium iodide sensitivity testing
D. Consider a 14-day regimen of antibiotics
E. Use daily antibiotic therapy for prophylaxis

Answer is C
• Dysuria without pyuria.
• In the postmenopausal years, atrophy is a usual cause.
• In younger women, a careful history can reveal a bladder irritant
• Caffeine and acidic foods are common irritants.
• When hematuria without pyuria is present in patients with recurrent
symptoms, interstitial cystitis should be suspected.
• The potassium iodide sensitivity test is used for diagnosis
• Lack of evidence regarding the benefit of cystoscopy has led to
consensus that it is not needed to confirm the diagnosis of interstitial
cystitis.

• The potassium iodide sensitivity test
• Involves a catheter infusion of sterile water into the bladder, with the patient
rating pain and urgency. After draining, the test is repeated with 40 mg of
potassium solution and 100 mL of water. The test is positive if pain with
infusion of the potassium solution is rated higher.

Case 4
A 31-year-old woman presents with high fever, dysuria, flank
pain, nausea, and vomiting.
The most appropriate treatment is
A. Hospitalization with administration of intravenous fluids and
antibiotics
B. Oral rehydration and oral antibiotics for 10 days
C. Surgical consultation for exploratory laparotomy
D. Extracorporeal shock wave lithotripsy
E. Nothing given orally and nasogastric suction

The answer is A (Acute Complicated Urinary Tract Infection (ACUTI))
• ACUTI is acute UTI with any of the following features, which suggest
that the infection extends beyond the bladder:
• Fever (>99.9°F/37.7°C)
• Signs or symptoms of systemic illness (including chills or rigors, significant
fatigue or malaise beyond baseline).
• Flank pain.
• Costovertebral angle tenderness.
• Pelvic or perineal pain in men, which can suggest accompanying prostatitis.

Case 5
A 21-year-old woman who is 12 weeks pregnant with her first
child presents to your office. A urinalysis shows evidence of
bacteriuria. She is completely asymptomatic. Appropriate
management at this time includes which one of the following?
A. No treatment at this time; repeat urinalysis at her next visit.
B. Reassure the patient that antibiotic administration is not necessary
unless she should develops symptoms.
C. No antibiotic treatment; ask the patient to drink more fluids and
cranberry juice daily.
D. Discontinue urinalysis at OB visits because of the high rate of false
positives.
E. Treat the patient with a 7-day course of amoxicillin.

The Answer is E
• Pregnant with evidence of UTI should be treated even if
asymptomatic because pyelonephritis is one of the most common
serious complications in pregnancy.

Case 6
A young African American woman at 34 weeks’ gestation presents with
fever and chills and complains of dysuria and flank pain. You diagnose
pyelonephritis and decide to treat with which one of the following
antibiotics?
A. Ceftriaxone
B. Ciprofloxacin
C. Nitrofurantoin
D. Tetracycline
E. Trimethoprim/sulfamethoxazole

The Answer is A
• Pregnant women with acute pyelonephritis should be hospitalized
and treated initially with a second- or third-generation cephalosporin,
such as ceftriaxone 1 g every 12 hours, and then assessed to
determine whether further treatment as an outpatient is appropriate.
• A regimen of ampicillin (2 g IV every 6 hours) and gentamicin (1.5 mg/kg
every 8 hours) is an acceptable alternative.
• Periodic fetal monitoring should be instituted.
• Pyelonephritis increases the risk of premature labor.
• Pyelonephritis is commonest to present in the third trimester.
• Follow-up cultures are indicated to ensure eradication.

Antibiotics in Pregnancy
• Quinolone antibiotics (e.g., ciprofloxacin):
• Interfere with fetal cartilage development and should be avoided.
• Nitrofurantoin:
• It can induce hemolysis in G6PD patients, a condition that affects
approximately 2% of African Americans.
• Sulfonamides (e.g., trimethoprim/sulfamethoxazole):
• Contraindicated in the third trimester of pregnancy because of the risk of
kernicterus in newborns.
• Tetracyclines:
• Contraindicated because they can cause yellowish discoloration in the child’s
teeth.

Case 7
A young woman complains of dysuria and her urine dipstick is positive
for leukocyte esterase, yet her subsequent urine culture is negative.
The presence of sterile pyuria in a sexually active individual such as
this is most commonly associated with which one of the following
infectious agents?
A) Chlamydia
B) Neisseria gonorrhoeae
C) Herpes simplex
D) HPV
E) Treponema pallidum

The Answer is A
• Pyuria is the presence of 10 or more WBCs per cubic millimeter in a urine specimen or a
urinary dipstick test that is positive for leukocyte esterase.
• Sterile pyuria refers to finding white cells in the urine in the absence of bacteria.
• The presence of sterile pyuria in a sexually active individual should raise the suspicion of
chlamydia which account for 50% of nongonococcal urethritis or cervicitis.
• Diagnosis:
• Immunologic studies performed on urine, vaginal or cervical secretions
• Culture.
• The presence of gonorrhea must be ruled out and patients should be treated for
gonorrhea if chlamydia is found and vice versa.
• First-line regimens for treatment of chlamydia infection:
• Single-dose therapy with azithromycin 1 g orally
• 7-day course of doxycycline

Antibiotic Info. In Treating Chlamydia
• Erythromycin and Quinolones:
• Alternative regiments used to treat C trachomatis.
• Erythromycin is less efficacious than the recommended regimens
• Quinolones are as effective as the recommended regimens but offer no
dosing or cost advantages.
• Doxycycline and fluoroquinolones are contraindicated in pregnant
women.

Case 8
A 23-year-old sexually active woman visits a free clinic reporting a
sudden onset of dysuria that began 2 days ago. On further questioning,
she also reports urinary frequency, some back pain, and a pink
discoloration to her urine. She denies vaginal discharge or irritation and
has been afebrile. The clinic has no microscope or urine dipsticks
available. Based on this history, what is her most likely diagnosis?
A. Acute bacterial cystitis
B. Urethritis
C. Pyelonephritis
D. Interstitial cystitis
E. Vulvovaginitis

The Answer is A
• In a meta-analysis found that:
• 4 factors correlate significantly with a diagnosis of acute bacterial cystitis:
• Frequency
• Hematuria
• Dysuria
• Back pain
• 4 factors decrease the likelihood of UTI:
• Absent dysuria
• Absent back pain
• History of vaginal discharge
• History of vaginal irritation
• Women with any combination of the positive and negative symptoms have
a more than 90% probability of a UTI.

Other Not Correct Answers Justification
• Urethritis is more likely with a gradual onset.
• Patients with pyelonephritis often have fever.
• Interstitial cystitis tends to be more chronic in nature and is generally
not associated with back pain.
• Vulvovaginitis is associated with vaginal irritation or discharge.

Case 9
You suspect acute cystitis in an otherwise healthy woman. Which of the
following features decrease the likelihood of a urinary tract infection
(UTI)?
A. Absence of fever
B. Absence of urgency
C. Absence of frequency
D. Absence of dysuria
E. Absence of vaginal discharge

The Answer is D
• In a meta-analysis found that:
• 4 factors correlate significantly with a diagnosis of acute bacterial cystitis:
• Frequency
• Hematuria
• Dysuria
• Back pain
• 4 factors decrease the likelihood of UTI:
• Absent dysuria
• Absent back pain
• History of vaginal discharge
• History of vaginal irritation
• Women with any combination of the positive and negative symptoms have
a more than 90% probability of a UTI.

Case 10
A screening urinalysis in a female patient reveals asymptomatic
bacteriuria. In which of the following patients would treatment be
indicated?
A. A sexually active teenager
B. A pregnant 26-year-old woman
C. A 45-year-old woman with uncontrolled hypertension
D. A menopausal woman
E. An otherwise healthy 80-year-old woman

The Answer is B
• The American College of Obstetrics and Gynecology recommends
treating asymptomatic bacteriuria in pregnancy:
• 20% to 35% of the cases may develop into overt UTIs then eventually 2%
develop pyelonephritis.

Case 11
25 years old Pregnant lady in 36 weeks of gestation came with dysuria
and suprapubic pain. You diagnose UTI Which of the following
antibiotic is contraindicated in ?
A. TMP-SMX
B. Nitrofurantoin
C. Cephalexin
D. Ampicillin

The answer is A
• All previous choices drug category B except TMP –SMX which
category C and shown to be teratogenic.

Case 12
A 78-year-old man presents to the ER with abdominal discomfort and
decreased urine output. He was fine until yesterday when he was
unable to urinate after dinner which is unusual for him. He has not
passed any urine in the eight hours since then. His medications include
tamsulosin, metoprolol and a daily aspirin. Vital signs include
temperature 98.7ºF, heart rate 98 beats per minute and blood pressure
157/86 mm Hg. What is the most likely cause of his lack of urine
output?
A. Acute renal failure
B. Benign prostatic hyperplasia
C. Prostate cancer
D. Urinary tract infection

The Answer is B
• The most common cause of acute urinary retention is obstruction of the
urinary tract distal to the bladder. In men, most common is BPH.
• Most patients with urinary retention due to BPH report a sudden inability
to pass urine and suprapubic pain and pressure due to a distended bladder.
• Rectal exam will reveal a enlarged, smooth, firm prostate.
• Treatment consists of bladder decompression with a foley catheter.
• Urinalysis should be ordered to rule out infection or hematuria.
• Evaluation of renal function is needed if there is concern for long-standing
obstruction that may have resulted in hydronephrosis and obstructive
uropathy.

• Most patients with acute renal failure (A) have oliguria, or decreased
urine output, not an inability to pass any urine.
• Prostate cancer (C) is another cause of urinary retention and may
present with similar symptoms. However, patients often have
associated constitutional symptoms (e.g. weight loss, bone pain) as
well.
• A urinary tract infection (D) can also cause urinary retention but
patients often present with symptoms of dysuria, frequency, fever or
flank pain.

Case 13
A 40-year-old man presents to the ER with two days of severe scrotal pain
and redness. He denies any trauma. He says the pain was initially colicky but
now has become more constant and severe. He reports a subjective fever
and mild dysuria, and he is sexually active. Vital signs show HR 116, BP
114/68, RR 16, T 37.9℃. Examination shows diffuse redness, ulceration and
sloughing of the scrotal skin with significant tenderness, edema, and
crepitus. What is the most appropriate treatment of this patient?
A. Apply ice, encourage scrotal elevation, and begin treatment with NSAID
B. Begin antibiotic treatment with IM ceftriaxone and oral azithromycin and
levofloxacin and discharge to follow-up with urology
C. Begin antibiotic treatment with IV piperacillin-tazobactam and Vancomycin and
consult urology for surgical debridement
D. Consult urology for emergent detorsion and fixation of the testes

The Answer is C
• Necrotizing fasciitis of the perineum and scrotum usually begins as a
benign infection or simple abscess that quickly becomes virulent.
• Diabetics and immunocompromised patients are particularly at risk.
• It is usually a mixed aerobic and anaerobic infection
• Treatment consists of:
• Early antibiotic therapy
• Piperacillin-tazobactam or Imipenem plus vancomycin
• Hemodynamic support
• Aggressive surgical exploration and debridement of necrotic tissue

Case 14
65-year old man presents with of 3 days of fever, fatigue and malaise.
He also complains of increased urinary frequency and perineal pain. His
prostate is swollen and boggy. Which of the following is true regarding
this condition?
A. Antibiotics are ineffective in treating this condition
B. Prostatic massage is therapeutic
C. The most common pathogen is Pseudomonas
D. Urine culture will often reveal the causative pathogen

The Answer is D
• The patient is suffering from acute bacterial prostatitis, which is
characterized by fever, lower back pain, and perineal pain. Constitutional
symptoms may include malaise, fatigue, myalgias and arthralgias. Patients
may also experience increased urinary frequency, urgency and dysuria, as
well as urinary retention.
• Prostate exam reveals a tender, swollen and boggy prostate.
• Nontoxic patients can be discharged on a 4-6 week course of oral
ciprofloxacin or trimethoprim-sulfamethoxazole.
• Patient with signs of systemic toxicity should be admitted and started on
intravenous ciprofloxacin or ceftriaxone with or without gentamicin.
Patients should be evaluated by a urologist.

• Antibiotic therapy should be started immediately (A) and often
requires 4-6 weeks of therapy.
• Prostatic massage should be limited (B) as palpation may lead to
bacteremia and sepsis.
• The most common cause of acute bacterial prostatitis is Escherichia
coli. The other less common causes include Klebsiella, Pseudomonas
(C), Enterobacter and Proteus.
• Most commonly caused by:
• < 35 y/o: N. gonorrhoeae, C. trachomatis. Treatment: Ceftriaxone or ofloxacin and
doxycycline
• > 35 y/o: E. Coli. Treatment: Ciprofloxacin or TMP/SMX

Case 15
Which of the following symptoms is the most common presentation of
urinary bladder cancer?
A. Colicky abdominopelvic pain and hematochezia
B. Gross, painless hematuria
C. Lumbosacral pain
D. Nocturia, dysuria and urinary hesitancy

The Answer is B
• Urinary bladder cancer is the 2nd most common genitourinary cancer:
• Men more than women
• The mean age at diagnosis is 65 years
• Risk factors:
• Cigarette smoking (60%)
• Exposure to industrial dyes or solvents (15%)
• Arsenic exposure
• Chronic cystitis
• Schistosomiasis
• Radiation
• Cyclophosphamide use.
• Urothelial (Transitional) cell carcinoma is most common.
• Painless hematuria is the most common presenting symptom.
• Diagnosis is made by cystoscopy

Case 16
A 63-year-old male presents to the ED with a 2-day history of fever, urinary
frequency, dysuria, and difficulty initiating the urinary stream. He also relates
having some perineal pain. On exam, his vitals are stable except for a
temperature of 102°F. His rectal exam is remarkable for a tender, warm,
edematous prostate. There are no perirectal masses and the stool is heme-
negative. He has no penile lesions, discharge, scrotal masses, or tenderness.
He does not exhibit any costovertebral angle tenderness. His UA is positive
for 10 WBCs/HPF, +1 nitrite, +1 leukocyte esterase. What is the most likely
diagnosis in this patient?
A. Pyelonephritis.
B. Perirectal abscess.
C. Epididymitis.
D. Acute prostatitis

The Answer is D
• Acute prostatitis

References
• BMJ
• AAPF
• MCQ collection

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