Lindee Abe, APRN
Dysuria is a frequent patient presentation across all settings. While this seems straightforward, providers should consider all the potential causes of dysuria when this patient presents to see them. Suppose we fail to think through possible diagnoses and go for the most straightforward without considering other possibilities. In that case, we can miss the correct diagnoses, and this can lead to poor patient outcomes. This discussion about other possible causes of dysuria is not all-inclusive but rather a refresher on the possible diagnoses that can cause dysuria.
Urinary Tract Infections and Dysuria
The number one diagnosis that comes to mind with dysuria is urinary tract infection. Dysuria is the most common presenting symptom of urinary tract infection. The problem is that urinary tract infection is technically a clinical diagnosis. If a point-of-care urinalysis is positive for leukocytes and nitrites, it would likely be consistent with the urinary tract diagnosis. However, leukocytes in the urine can also be due to a specimen that was not a clean catch, especially if the amount of leukocytes is small. Patients with an increased risk for complicated UTI should have a urine culture also sent for a positive point of care urinalysis to ensure the selected treatment will cover the bacteria present. Even with the straightforward diagnosis of urinary tract infection, the diagnosis of pyelonephritis should be considered and ruled out. While the treatment for urinary tract infections and pyelonephritis is similar, pyelonephritis requires longer antibiotics.
Exam findings
Every patient with dysuria should have an abdominal exam. This includes listening to bowel sounds, palpating the abdomen, and checking for costovertebral angle tenderness. Females should also have a vaginal exam if there is any report of vaginal discharge. Technically, urinary tract infection is a clinical diagnosis, and no testing is warranted for the diagnosis in patients at low risk for complications. However, an adequate physical exam would still be advisable. Vaginal infections can also cause dysuria. I will ask all females with dysuria about vaginal discharge and sexual activity. If sexually active, I will also discuss testing for gonorrhea and chlamydia. If vaginal discharge is present, then a pelvic exam is warranted, and testing for bacterial vaginosis, yeast, trichomonas, gonorrhea, and chlamydia.
Contact Dermatitis
Contact dermatitis can also cause dysuria. Asking patients about using new detergents, lotions, or body wash can lead the examiner to this diagnosis. If the patient has irritation or itching, this would also cause the examiner to consider this diagnosis. An external vaginal exam looking at skin findings may also support the diagnosis of dermatitis. A patient can also have dysuria when they are dehydrated. Specifically, the patient may have a higher specific gravity when looking at the point of care urinalysis. This would lead to the possible ideology of dehydration. The patient’s history is also evaluated for dehydration causes (e.g., recent illness, decreased oral intake).
Herpes and Dysuria
Herpes can also cause dysuria, depending on the location of the lesions. The patient history should be reviewed for a history of herpes, and the patient should be questioned about any lesions in the genital area or risks for herpes. There should also be a physical exam for lesions consistent with herpes diagnosis.
Abdominal Causes of Dysuria
Several abdominal pathologies can also cause dysuria. Anything that causes peritoneal inflammation can also cause dysuria. Many patients with urinary tract infections will complain of suprapubic tenderness. Patients who have both suprapubic tenderness and dysuria will often come in, stating they have a urinary tract infection. However, if the patient has appendicitis and has right lower quadrant tenderness, they may mistake that for super pubic tenderness. This is why the physical exam is critical to ensuring the correct diagnosis for this patient. If you miss appendicitis, this can result in poor outcomes for the patient.
Kidney and bladder stones can also cause dysuria. The pain that accompanies kidney and bladder stones is often colicky, but not every patient has the typical pain associated with it. This diagnosis should also be considered in any patient who has recurrent urinary tract infections that are treated with antibiotics but do not seem to resolve when other sources of potential infection (e.g., wiping from front to back, voiding after intercourse) are eliminated. I was this patient. I had approximately one urinary tract infection per month over a year that was treated with antibiotics. It wasn’t until I had a urinary tract infection that I was treated with oral antibiotics. I developed pyelonephritis that was investigated further, and after an inpatient stay with IV antibiotics, I was diagnosed with a ureteral stone that had to be surgically removed.
Males and Prostatitis
In school, I was always taught to be suspicious of a male with dysuria and the straightforward diagnosis of urinary tract infection. Especially when they are younger, urinary tract infections in males are not typical and should be investigated to find the source of infection. Approximately 60% of male patients with dysuria will have an infection. In older males, benign prostatic hypertrophy is a common cause of dysuria as well. Benign prostatic hypertrophy can also lead to dysuria and can lead to incomplete emptying of the bladder, making the patient more susceptible to infection. Bacterial prostatitis is also A cause of dysuria in males. This can be confirmed with a digital rectal exam finding an edematous and tender prostate.
Female-Specific Dysuria
An additional consideration in female patients is the chance of pregnancy. The patient should be asked about their last menstrual cycle and any chance of pregnancy. While dysuria is not a typical symptom of pregnancy, pregnant patients are at higher risk for developing urinary tract infections.
Older women can also suffer from atrophic vaginitis. This can cause pain in the genital area, which may be increased with urination. This may lead the patient to believe they have pain with urination as it is increased during that time. The patient may have increased pain if there was a recent increase in sexual intercourse irritating the area.
Trauma
Trauma, while not a common cause, can also lead to dysuria. This can be intentional and unintentional. Patients may be embarrassed or scared to discuss this, but if there isn’t another identifiable cause, the discussion regarding possible sources of trauma to the genital area can be necessary.
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Summary
If the patient has ongoing dysuria and no identifiable cause has been determined, the patient should be referred to urology for further evaluation. Dysuria is not a normal finding and should be addressed, and the underlying cause should be determined. Dysuria can decrease the quality of life for patients and is essential for us to address as healthcare providers.
References:
Meyrier A, Fekete T. Acute bacterial prostatitis. Post TW, ed. UpToDate. UpToDate Inc.
Accessed October 20, 2023. https://www.uptodate.com/contents/acute-bacterialprostatitis?search=dysuria&topicRef=86698&source=related_link#H13503301
Michels TC, Sands JE. (2015). Dysuria: evaluation and differential diagnosis in adults. American
Family Physician, 92 (9), 778-788.
Roberts RG, Hartlaub PP. (1999). Evaluation of dysuria in men. American Family Physician, 60
(3), 865-872.
