Dysuria resident survival guide

Dysuria Resident Survival Guide
Overview
Causes
Diagnosis
Women
Men
Treatment
Women
Men
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Overview

Dysuria is typically described to be a burning, tingling, or stinging sensation of the urethra and meatus associated with voiding. Dysuria refers to painful urination. It is most often a result of an infection of the urinary tract. Noninfectious inflammatory causes include a foreign body in the urinary tract and dermatologic conditions such as herpes, irritant dermatitis, erosive, lichen planus, contact dermatitis. It may also be due to an sexually transmitted diseases, bladder stones, bladder tumors and any condition of the prostate. It can also occur as a side effect of medications. It is one of the constellations of irritative bladder symptoms, which includes the frequency of urination and haematuria.

Causes

Life Threatening Causes

Life-threatening causes of dysuria include:

• Stevens–Johnson syndrome
• Toxic epidermal necrolysis

The aforementioned conditions may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Common causes include:

• Acute Cystitis
• Urethritis from sexually transmitted infections
  • Gonorrhea
  • Chlamydia
  • Trichomoniasis
• Female genital structure related
  • Vulvo-Vaginitis
    • Trichomoniasis
    • Bacterial vaginosis
    • Candidal infections
    • Atrophic vaginitis
  • Cervicitis
  • Pelvic Inflammatory Disease
• Male genital Structure related
  • Balanitis
  • Prostatitis
  • Epididymo-orchitis
  • Benign prostatic hyperplasia
• Foreign Body in urinary tract
  • Indwelling Foley catheter
  • Stone
  • Urethral or ureteral stent
• Pyelonephritis
• Urethral Stricture
• Dermatological
  • Herpes
  • Irritant dermatitis
  • Erosive lichen planus
  • Contact Dermatitis
• Local trauma
• Medication use
  • Cyclophosphamide
• Neoplasia
  • Bladder Carcinoma
  • Renal Cell Carcinoma

Diagnosis

• Shown below are two algorithms summarizing the diagnosis of Dysuria

Diagnostic Approach in Women

Algorithm showing the diagnosis of dysuria in woman:

Abbreviations: ER:Emergency room,KUB USS :Kidney and Bladder Ultrasound study,PVR: Post-void residual urine,USG : Ultrasonography

Woman with dysuria

Take complete history

Presence of: ❑ Comcomitant fever ❑ Flank pain ❑ Abnormal vital signs: ❑ Tachycardia ❑ Tachypnea ❑ Hypotension ❑ Nausea ❑ Vomiting

Yes

No

Refer the patient to ER

Urine Dipstick for Nitrites and Leukocytes

Nitrite Postitive

Leukocytes positive,Nitrite negative

Both Nitrite and Leukocyte negative

Urine culture

Empirical Antibiotic Therapy

Urine Culture

Positive

Negative

Treat with Specific Antibiotic

Postive

Negative

Presence of any Urethral discharge/Itching

Acid urine pH/history of Tuberculosis

Treat with Specific antibiotic

Do Swab test

Urine speicific test for tuberculosis

Think of any other non-infectious urogenital disease or vulvo-vaginal disease

Refer the patient to urologist/gynaecologist

Urethritis due to: ❑ Chlamydia trachomatis ❑ Neisseria gonorrhea ❑ Herpes simplex virus

If the female patient presents with a slow urine stream without any pain or burning sensation, then the algorithm below can be used to treat the patient

Female patient with only voiding symptoms

Take complete history Ask about voidal habits: ❑Urinary frequency ❑Interval between two consecutive micturation

❑Physical examination Suprapubic palpation and Vaginal examination

❑Urine culture ❑ Kidney and Bladder Ultrasound study (KUB USS)

Increased Detrusor wall thickness

Bladder diverticula

Increased post void residual(>100)

Hydronephrosis

Refer to urologist

Diagnostic Approach in Men

Algorithm showing the diagnosis of dysuria in Male patients:

Abbreviations: ER:Emergency room, KUB USS :Kidney and Bladder Ultrasound study, PVR: Post-void residual urine, USG : Ultrasonography, NAAT: Nucleic Acid Amplification Test, PCR: Polymerase chain reaction, ESR:Erythrocyte sedimentation rate, CRP: C-reactive protein , HLA:Human leukocyte antigen

Male patient with dysuria

Take complete history

Presence of urethral discharge

Yes

No

Ask about the discharge

Presence Of Genital Lesion

Yes

NO

Profuse,purulent discharge Yellowish green colour

Thin,mucoid/mucopurulent discharge

Swab test

Swab test

Gram negative Diplococci

NAAT/PCR test

Gonorrhoea

Chlamydia

Inflammation of the glans penis

Ulcer

Painful Vesicles

Balanitis

Herpes

Presence of: ❑ Firm, painless, non-itchy skin ulceration ❑ Multiple sores ❑ A diffuse rash involving the palms of the hands and soles of the feet ❑ Presence of gummas

Presence of: ❑ Painless genital ulcer ❑ Anorectal pain ❑ Tenesmus ❑Rectal discharge ❑ Rectal discharge,Inguinal lymphadenopathy

Syphilis

Lymphogranuloma venereum (LGV)

Presence of any Localized Pain

Yes

No

❑Suprapubic pain

❑Flank pain ❑Costovertebral angle tenderness ❑Fever

Joint pain

Urine Analysis

USG

❑X-ray ❑ESR/CRP ❑HLA-B27

Cystitis

Pyelonephritis

Spondyloarthropathy

Treatment

Treatment in Women

Shown below is an algorithm summarizing the treatment of Dysuria in female patients:

Symptoms of lower urinary tract

Non recurrent

Recurrent ❑ At least 3 episodes of uncomplicated UTI in 12 months ❑ With at least one positive by urine culture

Uncomplicated Without any risk factors

Complicated :Presence of any of the following risk factors: ❑ Presence of indwelling catheter ❑ Vesico-ureteric reflux ❑ Increased post void residual urine ❑ Increased post void residual urine ❑ Presence of diseases: ❑ Renal insufficiency ❑ Diabetes mellitus ❑ Immunodeficiency ❑ Obstructive Uropathy

Modify Lifestyle to intervene modifiable riskfactors and take prophylaxis

Treatment with short term antibiotic therapy First line includes ❑ 3g oral dose of Fosfomycin trometamol ❑ Pivmecillinam 400 mg twice a day for 3 days ❑ Nitrofurantoin 100mg twice a day for 5-7days In case of <20% resistance rates for E.coli ❑ Cotrimoxazole 160/800 mg twice a day for 3 days ❑Trimethoprim 200 mg twice a day for 5 days

❑ Specific antibiotic depending on urine culture ❑ Long Empeirical long term antibiotic(Fluoroquinolones,Third generation Cephalosporins,Aminoglycosides) for 10-14 days

Measurements to prevent recurrent UTI ❑ Low dose Antimicrobial prophylaxis continuously or after sexual intercourse ❑ Interventions on modifiable risk factors: 1.Avoid using spermicide 2.Maintain blood glucose level 3.Improving the treatment of urinary incontinence 4.Unspecific prophylaxis with cranberry extracts 5.Local hormonal therapy in case of post menopausal women

Repeat urine culture in nonresponsive cases and pregnant women

Repeat urine culture after treatment,KUB ultrasound with PVR measurement

Refer the patient to urologist

If all of the above fails

Refer to urologist

Treatment in Men

Treatment of dysuria in male patient:

Male patient with dysuria

Look for infection

Presence of infection

No infection

❑ Treatment with specific antibiotic for 7 days ❑ If sensitivity tests are not available empirical treatment with Quinolone

Further investigate to exclude Bladder cancinoma if ❑ Patient is smoker or ❑ H/o exposure to carcinogen or ❑ Presence of Storage symptoms

Recurrent UTI or prostatitis

Look for other non infective causes

Refer to Urologist

Treat according to the specific cause

No specific cause found, Suspect chronic pelvic pain syndrome (CPPS)

Quinolone-naive treatment

Previously had treatment with Quinolones

No response for 4 weeks

Response

Apply UPOINT classification

Apply UPOINT classification

Response

Response

No response

Refer to specialized pain clinic in Hospital

No response

Refer to specialized pain clinic in Hospital

UPOINT CLASSIFICATION

Phenotype Domains	Clinical Features
Urinary	Lower urinary tract symptoms that creates discomfort or High post-micturation residual volume
Psychological	Patient with depression or severe anxiety thinking the worst will happen to them
Organ-specific	Tenderness in Prostate, Presence of blood in ejaculation,Leukocytes in prostatic fluid or post-massage urine
Infectious	Infection with gram negative bacilli or Enterococci localized to prostate or presence of Ureaplasma in urine
Systemic	Pain anywhere else in the body except abdomen or pelvis or having a diagnosis of fibromyalgia, chronic fatigue or irritable bowel syndrome
Tenderness	Presence of palpable muscle spams in abdomen or pelvic floor

Do's

Instruct the female patients to:

• Lose weight (if they are overweight or obese).
• Always stay hydrated.
• Urinate after sexual intercourse.
• Always wipe front to back.
• Wear cotton/comfortable underwear.
• Use menstrual cups, sanitary pads, or clean period-proof underwear.
• Maintain personal hygiene.

Don'ts

• Instruct the female patients not to delay in urinating.
• Avoid Smoking
• Avoid drinking the following items a lot:
  • Caffeinated sodas
  • Alcohol
  • Spicy foods
  • Acidic fruits

References