Dysuria

Dysuria is pain, burning or discomfort on urination. It is a symptom rather than a diagnosis and may arise from inflammation or irritation of the bladder, urethra or periurethral tissues.

Common causes

• Women: cystitis, pyelonephritis, urethritis, vulvovaginitis, cervicitis, pelvic inflammatory disease, genitourinary syndrome of menopause, interstitial cystitis, stones, bladder tumour, chemical irritation and vulval dermatoses.
• Men: urethritis, prostatitis, epididymo-orchitis, balanitis, urethral stricture, bladder stones, complicated urinary tract infection, bladder cancer and schistosomiasis in endemic regions.
• Children: urinary tract infection, vulvovaginitis, balanitis, meatal stenosis, phimosis, threadworm and hypercalciuria.

External burning as urine passes over inflamed genital skin suggests vulval or penile disease, whereas internal urethral or suprapubic burning suggests lower urinary tract disease.

• Ask about onset, relation to the urinary stream, frequency, urgency, nocturia, haematuria, suprapubic pain, flank pain, fever, rigors, vomiting, urethral or vaginal discharge, itching, sexual exposure, pregnancy possibility, menopause, medications and prior urinary disease.
• Acute cystitis: abrupt dysuria with frequency and urgency without vaginal discharge.
• Urethritis: dysuria with urethral discharge and meatal erythema.
• Vaginitis: external dysuria, itching, discharge, odour and dyspareunia.
• Prostatitis: perineal or suprapubic pain, obstructive symptoms, fever and a tender boggy prostate.
• Pyelonephritis: fever, flank pain, costovertebral angle tenderness and vomiting.
• Interstitial cystitis: chronic bladder pain relieved by voiding with repeatedly negative cultures.
• Urolithiasis: colicky flank pain and haematuria.

Examine vital signs, abdomen and flanks, external genitalia, perform pelvic examination when indicated, and digital rectal examination in men if prostatitis is suspected.

Red flags include sepsis, pregnancy, persistent haematuria, recurrent infection in men, obstruction, immunosuppression, recent instrumentation, pelvic pain with cervical motion tenderness, persistent symptoms after treatment and safeguarding concerns in children.

• In healthy non-pregnant women with classic cystitis symptoms and no vaginal symptoms, clinical diagnosis may be sufficient.
• Urinalysis with leukocyte esterase and nitrites supports bacterial infection.
• Urine culture is indicated in pregnancy, men, diabetes, pyelonephritis, recurrent or complicated infection, catheter use, treatment failure and unclear diagnosis.
• NAAT testing for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium when sexually transmitted infection is possible.
• Wet mount, pH and microscopy for vaginitis; HSV PCR from lesions.
• Pregnancy testing in women of reproductive age.
• Renal and bladder ultrasound or CT for obstruction, stones, recurrent infection or haematuria.
• Cystoscopy for persistent dysuria with negative cultures, haematuria or suspected bladder pathology.
• Investigate sterile pyuria for tuberculosis, schistosomiasis and other causes according to epidemiology.

Treat the underlying cause, taking pregnancy and sexually transmitted infection into account.

Symptomatic relief

• Hydration, paracetamol 1 g every 6 hours as needed, and short-course ibuprofen 400 mg every 8 hours when appropriate.
• Phenazopyridine 200 mg three times daily with food for no more than 2 days can reduce burning; avoid in renal impairment and G6PD deficiency.

Uncomplicated cystitis in non-pregnant women

• Nitrofurantoin 100 mg modified release twice daily for 5 days.
• Fosfomycin 3 g single dose.
• Trimethoprim 200 mg twice daily for 3 days, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days when resistance patterns permit.
• Pivmecillinam 400 mg three times daily for 3 to 5 days where available.

Selected other causes

• Gonorrhoea: ceftriaxone single dose according to local protocol, plus doxycycline 100 mg twice daily for 7 days if chlamydia has not been excluded.
• Chlamydia: doxycycline 100 mg twice daily for 7 days; azithromycin is an alternative in pregnancy.
• Trichomoniasis: metronidazole 500 mg twice daily for 7 days in women.
• Herpes: valaciclovir or aciclovir plus local analgesia.
• Genitourinary syndrome of menopause: topical vaginal oestrogen and moisturisers.
• Acute bacterial prostatitis: culture-directed antibiotics, commonly ciprofloxacin 500 mg twice daily or trimethoprim-sulfamethoxazole for 2 to 4 weeks; severe cases need IV treatment.
• Interstitial cystitis: bladder training, dietary modification, pelvic floor therapy and selected agents such as amitriptyline.

Reassess if symptoms persist beyond 48 to 72 hours or recur soon after therapy, and obtain cultures or investigate alternative diagnoses.