Dysuria

Dysuria is pain, burning or discomfort on passing urine. It arises from inflammation or irritation of the urethra, bladder, or the genital tract. The commonest cause in women is acute uncomplicated cystitis; in men, urethritis from sexually transmitted infection and prostatitis.

Mechanisms. Mucosal inflammation exposes sensory nerve endings to acidic urine. Pain at the start of voiding suggests urethral disease; pain at the end suggests bladder disease; external dysuria (burning as urine passes over inflamed vulva) suggests vulvovaginitis or herpes.

Classification.

• Internal (urethral or bladder) and external (vulval).
• Infective (bacterial cystitis, urethritis, pyelonephritis, prostatitis, vulvovaginitis, genital herpes, schistosomiasis, tuberculosis) and non-infective (interstitial cystitis and bladder pain syndrome, drugs, urethral syndrome, atrophic vaginitis, calculi, tumour, trauma, chemical irritants).
• Uncomplicated (non-pregnant women with normal urinary tract) or complicated (men, pregnancy, children, diabetes, immunosuppression, obstruction, catheter, recent instrumentation, healthcare associated).

History.

Onset, duration, character, relation to voiding (initial, terminal, throughout), frequency, urgency, nocturia, suprapubic pain, haematuria, cloudy or malodorous urine.

Fever, rigors, loin pain, vomiting, urethral or vaginal discharge, genital sores or rash, pelvic pain, dyspareunia.

Sexual history (new partner, unprotected sex, symptoms in partners, men who have sex with men), contraception, menstrual cycle and pregnancy, menopause.

Previous urinary tract infection, antibiotics, catheter or instrumentation, diabetes, renal stones, urological abnormalities, immunosuppression, prostatic symptoms.

Travel (schistosomiasis), tuberculosis contact, and irritants (soaps, spermicides, bubble baths, douching).

Drug history. Cyclophosphamide and ifosfamide (haemorrhagic cystitis), tiaprofenic acid, ketamine, sodium glucose cotransporter 2 inhibitors (genital infection), antibiotics (candida), and immunosuppressants.

Examination.

• Temperature, pulse, blood pressure, hydration.
• Abdominal examination: suprapubic tenderness, loin tenderness, palpable bladder, costovertebral angle tenderness.
• External genitalia: vulval erythema, ulcers, vesicles, discharge, atrophy.
• Vaginal and speculum examination when discharge or pelvic pain.
• Urethral discharge and meatal examination.
• Scrotal examination (epididymo-orchitis).
• Digital rectal examination in men: tender boggy prostate in acute prostatitis; avoid vigorous massage.
• Hernia and groin glands.

Red flags

• Fever, rigors, loin pain, vomiting or hypotension (pyelonephritis, sepsis)
• Pregnancy
• Male patient (complicated urinary tract infection; consider prostatitis, epididymo-orchitis)
• Visible haematuria, persistent over 3 months, or age over 45 with unexplained recurrent infection (cancer)
• Urinary retention, severe suprapubic pain or hesitancy
• Genital ulcers, discharge, pelvic pain or pelvic inflammatory disease features
• Child with dysuria (needs urine culture and assessment)
• Catheter, recent instrumentation, immunosuppression or diabetes
• Recurrent infection (3 or more in a year or 2 or more in 6 months)
• Symptoms persisting after treatment

Special groups. Pregnancy: asymptomatic bacteriuria and cystitis need treatment and culture (risk of pyelonephritis and preterm labour). Children: urinary tract infection with fever or poor feeding needs urine culture and renal imaging. Older adults: atypical presentations with confusion; do not treat asymptomatic bacteriuria. Region specific: schistosomiasis (terminal haematuria), tuberculosis, and sexually transmitted infections.

Lower urinary tract infection

• Acute uncomplicated cystitis (Escherichia coli, Staphylococcus saprophyticus, Klebsiella, Proteus, Enterococcus)
• Complicated urinary tract infection (catheter associated, obstruction, stones, diabetes, immunosuppression, resistant organisms), recurrent urinary tract infection
• Urethritis (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, herpes simplex, Ureaplasma, adenovirus)
• Prostatitis (acute and chronic bacterial), epididymo-orchitis

Upper tract and systemic

• Acute pyelonephritis, renal abscess, perinephric abscess, emphysematous pyelonephritis, infected obstructed kidney, urosepsis

Genital causes

• Vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, genital herpes, atrophic vaginitis, vulval dermatoses (lichen sclerosus), contact dermatitis, pelvic inflammatory disease, cervicitis, genital warts

Non-infective urological

• Urinary calculi, bladder tumour and carcinoma in situ, interstitial cystitis and bladder pain syndrome, radiation and haemorrhagic cystitis (cyclophosphamide, ifosfamide), urethral stricture, urethral diverticulum, urethral caruncle and prolapse, bladder foreign body, trauma, ketamine cystitis, chemical irritants

Tropical and chronic

• Schistosomiasis haematobium, genitourinary tuberculosis, filariasis, and fungal infection

Other

• Reactive arthritis, Behcet disease, Stevens Johnson syndrome, and psychogenic dysuria

Reasoning. In a non-pregnant woman with typical symptoms (dysuria, frequency, urgency, no vaginal discharge), the diagnosis is clinical, and urine dipstick supports it. Culture and further testing are needed for men, pregnancy, complicated disease, treatment failure and recurrence. Sexually transmitted infection testing is needed for those at risk.

First line. Urine dipstick for leukocyte esterase and nitrite, pregnancy test, temperature and abdominal examination. Nitrite positive, or leucocyte esterase and blood positive, supports infection. Negative leucocytes and nitrite make infection unlikely, with negative predictive value about 90 percent in women with typical symptoms.

Targeted tests.

• Midstream urine culture and sensitivity for: pregnancy, men, suspected pyelonephritis, treatment failure, recurrent infection, catheter, immunosuppression, diabetes, healthcare exposure, recent antibiotics, or abnormal urinary tract.
• Significant bacteriuria is 100,000 colony forming units/mL or more of a single organism in a midstream sample. 1,000 to 10,000 colony forming units/mL may be significant in symptomatic women or in catheter specimens or suprapubic aspirates.
• Nucleic acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae (first pass urine in men, vulvovaginal swab in women), Mycoplasma genitalium and Trichomonas vaginalis.
• Herpes simplex polymerase chain reaction from lesions, HIV and syphilis serology, and hepatitis B and C when risk exists. Microscopy and culture of high vaginal swab for vaginitis.
• Blood tests in systemic illness: full blood count, C reactive protein, urea, creatinine, electrolytes, glucose, and blood cultures in sepsis or pyelonephritis. Prostate specific antigen is not measured in acute prostatitis.
• Renal tract ultrasound for pyelonephritis not improving in 48 to 72 hours, recurrent infection, men, haematuria, or suspected obstruction.
• CT urogram or contrast CT for suspected stone, abscess, emphysematous infection, or complicated disease. Plain film and non-contrast CT KUB for stones.
• Cystoscopy and imaging for visible haematuria, persistent microscopic haematuria, or suspected tumour, interstitial cystitis or stricture. Urine cytology.
• Schistosomiasis: terminal urine sample (10 to 14 hours) microscopy for eggs, serology. Tuberculosis: three early morning urine samples for acid fast bacilli culture and polymerase chain reaction.
• Post-void residual (bladder scan) for obstruction or incomplete emptying; urodynamics when indicated.

Limitations. Dipstick and culture are less reliable in older adults, catheterised patients, and when symptoms are atypical. Contaminated specimens are common in women.

General measures. Fluids, simple analgesia, and avoidance of irritants.

• Paracetamol 1 g orally every 4 to 6 hours, maximum 4 g in 24 hours.
• Ibuprofen 400 mg orally every 6 to 8 hours with food, maximum 2.4 g in 24 hours. Avoid NSAIDs in renal impairment, heart failure, peptic ulcer and the third trimester.
• Potassium citrate or sodium bicarbonate sachets (3 g sodium citrate sachet in water three times daily for up to 48 hours) for symptom relief only; evidence is limited. Avoid in renal impairment, heart failure and hypertension.

Acute uncomplicated cystitis in non-pregnant women (empirical treatment; adjust to local resistance and culture).

• Nitrofurantoin 100 mg modified release orally twice daily for 3 days (or 50 mg four times daily). Do not use if creatinine clearance is under 45 mL/min. Avoid at term of pregnancy and in glucose 6 phosphate dehydrogenase deficiency. Long courses cause pulmonary and hepatic adverse effects.
• Alternative: trimethoprim 200 mg orally twice daily for 3 days. Avoid in the first trimester of pregnancy, with methotrexate, and when local resistance is over 20 percent. Monitor potassium and creatinine in renal impairment.
• Alternative: pivmecillinam 400 mg orally as a first dose then 200 mg three times daily for 3 days (or 400 mg three times daily for 3 days).
• Alternative: fosfomycin 3 g orally as a single dose (sachet in water).
• Delayed prescribing and symptomatic treatment (ibuprofen 400 mg three times daily) is an option for mild symptoms, because up to half resolve without antibiotics. Review at 48 hours for no improvement and send urine for culture.

Men with lower urinary tract infection. Urine culture first. Give nitrofurantoin 100 mg modified release orally twice daily for 7 days (creatinine clearance 45 mL/min or more), or trimethoprim 200 mg orally twice daily for 7 days (14 days if prostatitis is suspected). Then review. Assess for prostatitis and obstruction, and arrange ultrasound when recurrent.

Pregnancy. Treat symptomatic and asymptomatic bacteriuria after culture.

• Cefalexin 500 mg orally twice daily for 7 days (or 250 mg four times daily).
• Or nitrofurantoin 100 mg modified release twice daily for 7 days (not at term; avoid in the third trimester when near delivery).
• Or amoxicillin 500 mg orally three times daily for 7 days when susceptible.
• Avoid trimethoprim in the first trimester and avoid fluoroquinolones.

Repeat culture after treatment (test of cure) and monitor monthly.

Acute pyelonephritis (fever, loin pain, vomiting).

• Mild to moderate and able to take oral therapy, non-pregnant: ciprofloxacin 500 mg orally twice daily for 7 days (adjust to creatinine clearance; tendon, QT and central nervous system warnings; avoid in pregnancy and children).
• Alternatives: co-amoxiclav 625 mg orally three times daily for 7 to 10 days, or cefalexin 500 mg to 1 g orally three times daily for 7 to 10 days, or trimethoprim 200 mg twice daily for 14 days when susceptible. Review within 48 hours.
• Severe, vomiting, sepsis, pregnancy, or unable to take oral drugs: admit. Give ceftriaxone 1 to 2 g IV once daily (or gentamicin 5 to 7 mg/kg IV once daily adjusted to creatinine clearance and levels; or co-amoxiclav 1.2 g IV every 8 hours) and take blood cultures.
• Give IV fluids: crystalloid 500 mL boluses reassessed, 30 mL/kg for septic shock with noradrenaline for mean arterial pressure under 65 mmHg.
• Step down to oral therapy after 48 hours of improvement to complete 7 to 14 days.
• Resistant organisms: carbapenem (meropenem 1 g IV every 8 hours) by specialist advice.
• Urgent decompression (nephrostomy or ureteric stent) for infected obstructed kidney.

Prostatitis (acute bacterial). Admit if systemically unwell.

• Ceftriaxone 1 to 2 g IV daily or gentamicin plus ciprofloxacin 400 mg IV every 12 hours.
• Oral therapy: ciprofloxacin 500 mg twice daily for 14 days (up to 28 days), or trimethoprim 200 mg twice daily for 28 days, or doxycycline 100 mg twice daily for 28 days.
• Analgesia, and an alpha blocker (tamsulosin 400 micrograms orally once daily) for voiding symptoms.
• Suprapubic catheter rather than urethral for retention.

Epididymo-orchitis. Age under 35 or sexually active: ceftriaxone 1 g IM single dose plus doxycycline 100 mg orally twice daily for 10 to 14 days. Older or enteric organisms: ciprofloxacin 500 mg twice daily for 10 to 14 days or ofloxacin 200 mg twice daily. Exclude torsion in acute scrotal pain.

Urethritis and sexually transmitted infection.

• Gonorrhoea: ceftriaxone 1 g IM as a single dose (test of cure at 2 weeks, partner notification and treatment, abstain from sex for 7 days).
• Chlamydia: doxycycline 100 mg orally twice daily for 7 days (azithromycin 1 g orally as a single dose only when doxycycline is unsuitable, including pregnancy).
• Mycoplasma genitalium: doxycycline 100 mg orally twice daily for 7 days then moxifloxacin 400 mg orally daily for 7 days (resistance testing where available).
• Non-gonococcal non-chlamydial urethritis: doxycycline 100 mg twice daily for 7 days.
• Trichomoniasis: metronidazole 400 to 500 mg orally twice daily for 7 days (or 2 g as a single dose in men and when adherence is a concern). Partner treatment. No alcohol during and for 48 hours after.
• Genital herpes (first episode): aciclovir 400 mg orally three times daily for 5 to 7 days (or valaciclovir 500 mg orally twice daily for 5 to 10 days). Lidocaine 5 percent ointment for pain. Urethral catheter for retention.
• Genital herpes, suppressive therapy for frequent recurrence: aciclovir 400 mg twice daily or valaciclovir 500 mg once daily.
• Pelvic inflammatory disease: ceftriaxone 1 g IM single dose plus doxycycline 100 mg orally twice daily and metronidazole 400 mg orally twice daily for 14 days.
• Test for HIV, syphilis and hepatitis; partner services.

Vulvovaginal candidiasis. Fluconazole 150 mg orally as a single dose (avoid in pregnancy) or clotrimazole 500 mg pessary as a single dose or 1 percent cream.

Bacterial vaginosis: metronidazole 400 mg orally twice daily for 5 to 7 days (or 2 g single dose) or clindamycin 2 percent cream.

Atrophic vaginitis and urethral syndrome. Vaginal oestrogen: estradiol 10 microgram pessary daily for 2 weeks then twice weekly, or estriol 0.5 mg cream applied nightly for 2 weeks then twice weekly. Review at 3 months.

Interstitial cystitis and bladder pain syndrome. Specialist diagnosis after exclusion of infection and tumour.

• Dietary modification (avoid caffeine, alcohol, acidic and spicy foods) and bladder training.
• Amitriptyline 10 mg at night increased by 10 mg weekly to 25 to 75 mg.
• Pentosan polysulfate 100 mg orally three times daily (specialist; retinal maculopathy warning).
• Bladder instillation (hyaluronic acid, dimethyl sulphoxide) by urologists.

Calculi. Analgesia (diclofenac 75 mg IM or 50 mg orally, or ibuprofen 400 mg; avoid in renal impairment), tamsulosin 400 micrograms daily as medical expulsive therapy for distal stones of 5 to 10 mm, and urological referral.

Schistosomiasis. Praziquantel 40 mg/kg orally as a single dose (or 60 mg/kg divided in 2 or 3 doses), repeated at 4 to 6 weeks. Ultrasound for hydronephrosis.

Genitourinary tuberculosis. Isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg (maximum 2 g) and ethambutol 15 mg/kg daily for 2 months. Then isoniazid and rifampicin for 4 months, with pyridoxine 10 to 25 mg daily and liver monitoring. Urological assessment for strictures.

Haemorrhagic cystitis. Mesna with cyclophosphamide and ifosfamide prophylaxis, hydration, bladder irrigation for clots, and urological care.

Recurrent urinary tract infection (3 or more each year).

• Behavioural measures: hydration, post-coital voiding, avoid spermicides.
• Vaginal oestrogen in postmenopausal women.
• Cranberry products (evidence is mixed).
• Methenamine hippurate 1 g orally twice daily.
• Continuous or post-coital antibiotic prophylaxis: nitrofurantoin 50 to 100 mg orally at night or trimethoprim 100 mg orally at night, or cefalexin 125 to 250 mg at night (review at 6 months).
• Urological assessment for stones, obstruction and incomplete emptying.

Catheter associated urinary tract infection. Culture before antibiotics. Treat only when symptomatic. Replace the catheter. Avoid treating asymptomatic bacteriuria.

Monitoring. Review at 48 to 72 hours if no improvement. Use culture and sensitivity to guide change of therapy. Repeat culture after treatment in pregnancy. Follow up sexually transmitted infection results and partner notification.

Referral and escalation. Immediate admission for sepsis, pyelonephritis with obstruction, pregnancy with pyelonephritis, or emphysematous disease. Urology for recurrent infection, stones, haematuria and suspected tumour. Sexual health service for sexually transmitted infection. Gynaecology for pelvic inflammatory disease. Paediatric services for children.

Admission criteria. Sepsis, severe pyelonephritis, vomiting with inability to take oral drugs, pregnancy with pyelonephritis, infected obstructed system, immunosuppression, acute prostatitis with systemic illness, or failure of oral therapy.

Discharge and safety netting. Advise on fluids, hygiene, completion of antibiotics, and abstinence from sex until treated (sexually transmitted infection). Return for fever, loin pain, vomiting, visible blood in urine, retention, confusion, no improvement in 48 hours, or recurrent symptoms.