Dysuria: Difference between revisions

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(Expanded with concise EM-focused content: cystitis vs STI distinction, red flags, evaluation by sex, antibiotic regimens, disposition)
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==Background==
==Background==
*Painful urination
*Painful or burning urination — one of the most common ED complaints
**due to inflammation of urethra, bladder, or prostate
*Most commonly caused by [[UTI]] (cystitis) in women and [[urethritis]]/[[STI]] in young men
*Dysuria is uncommonly used to describe difficult urination
*The EM goal is to identify the cause and rule out complications (pyelonephritis, sepsis, urinary retention)


==Clinical Features==
==Clinical Features==
*Pain with urination
===History===
*Additional features dependent on underlying cause
*Internal dysuria (urethral burning) vs. external dysuria (urine contacting irritated skin — vulvovaginitis)
*Frequency, urgency, hematuria (cystitis)
*Flank pain, fever, nausea/vomiting (pyelonephritis)
*Vaginal/penile discharge (STI, vaginitis)
*New sexual partner, unprotected sex (STI risk)
*Urinary retention, hesitancy, poor stream (prostatic obstruction)
*Recent catheterization or instrumentation
 
===Red Flags===
*Fever + dysuria = [[pyelonephritis]] or complicated UTI
*Suprapubic mass / urinary retention = obstruction
*Dysuria in men <50 = STI until proven otherwise


==Differential Diagnosis==
==Differential Diagnosis==
{{Dysuria DDX}}
{{Dysuria DDX}}
===Infectious===
*'''[[Cystitis]]''' (most common in women)
*'''[[Pyelonephritis]]''' (fever, flank pain, CVA tenderness)
*'''[[Urethritis]]''' (STI — gonorrhea, chlamydia)
*'''[[Prostatitis]]''' (men — perineal pain, tender prostate)
*'''[[Epididymitis]]''' (scrotal pain + dysuria)
*'''Vulvovaginitis''' (external dysuria, discharge)
*'''[[HSV]]''' (ulcerative lesions, severe dysuria)
===Non-Infectious===
*[[Kidney stones|Nephrolithiasis]]
*Interstitial cystitis
*Urethral trauma / foreign body
*Atrophic vaginitis (postmenopausal)
*Medication-related (cyclophosphamide → hemorrhagic cystitis)


==Evaluation==
==Evaluation==
*[[UA]]
*'''[[Urinalysis]]''' ± urine culture
 
*GC/CT NAAT (urine or swab) if STI suspected
===Men===
*Wet prep if vaginitis suspected
*Men <50 yr: symptoms usually due to [[STI]]
*[[BMP]] if pyelonephritis or concern for renal impairment
*Men >50 yr: incidence of [[acute cystitis]] rises dramatically due to prostatic obstruction
*Blood cultures if systemic signs of infection
*Consider imaging (CT or renal US) if complicated UTI, obstruction, or abscess suspected
*Men <50: STI testing first-line; men >50: UA/culture for cystitis (prostatic obstruction increases UTI risk)


==Management==
==Management==
*'''Uncomplicated cystitis''' (women): nitrofurantoin 100 mg BID x 5 days OR TMP-SMX DS BID x 3 days OR fosfomycin 3g single dose
*'''Pyelonephritis''': see [[Pyelonephritis]] — outpatient fluoroquinolone or IV antibiotics if admitting
*'''Urethritis (STI)''': [[ceftriaxone]] 500 mg IM + [[doxycycline]] 100 mg BID x 7 days (or [[azithromycin]] 1g single dose)
*'''Prostatitis''': fluoroquinolone or TMP-SMX x 4-6 weeks; see [[Prostatitis]]
*'''Symptomatic relief''': phenazopyridine 200 mg TID x 2 days (warn about orange urine)


==Disposition==
==Disposition==
*Discharge: uncomplicated cystitis, mild urethritis, stable prostatitis
*Admit: pyelonephritis with sepsis or intractable vomiting, urinary obstruction, prostatic abscess
*Return precautions: fever, flank pain, inability to urinate, worsening symptoms


==See Also==
==See Also==
*[[UTI]]
*[[Pyelonephritis]]
*[[Urethritis]]
*[[STI]]
*[[Prostatitis]]


==References==
==References==
<references/>
<references/>


[[Category:Urology]]
[[Category:Urology]]
[[Category:Symptoms]]

Revision as of 00:46, 21 March 2026

Background

  • Painful or burning urination — one of the most common ED complaints
  • Most commonly caused by UTI (cystitis) in women and urethritis/STI in young men
  • The EM goal is to identify the cause and rule out complications (pyelonephritis, sepsis, urinary retention)

Clinical Features

History

  • Internal dysuria (urethral burning) vs. external dysuria (urine contacting irritated skin — vulvovaginitis)
  • Frequency, urgency, hematuria (cystitis)
  • Flank pain, fever, nausea/vomiting (pyelonephritis)
  • Vaginal/penile discharge (STI, vaginitis)
  • New sexual partner, unprotected sex (STI risk)
  • Urinary retention, hesitancy, poor stream (prostatic obstruction)
  • Recent catheterization or instrumentation

Red Flags

  • Fever + dysuria = pyelonephritis or complicated UTI
  • Suprapubic mass / urinary retention = obstruction
  • Dysuria in men <50 = STI until proven otherwise

Differential Diagnosis

Dysuria

Infectious

  • Cystitis (most common in women)
  • Pyelonephritis (fever, flank pain, CVA tenderness)
  • Urethritis (STI — gonorrhea, chlamydia)
  • Prostatitis (men — perineal pain, tender prostate)
  • Epididymitis (scrotal pain + dysuria)
  • Vulvovaginitis (external dysuria, discharge)
  • HSV (ulcerative lesions, severe dysuria)

Non-Infectious

  • Nephrolithiasis
  • Interstitial cystitis
  • Urethral trauma / foreign body
  • Atrophic vaginitis (postmenopausal)
  • Medication-related (cyclophosphamide → hemorrhagic cystitis)

Evaluation

  • Urinalysis ± urine culture
  • GC/CT NAAT (urine or swab) if STI suspected
  • Wet prep if vaginitis suspected
  • BMP if pyelonephritis or concern for renal impairment
  • Blood cultures if systemic signs of infection
  • Consider imaging (CT or renal US) if complicated UTI, obstruction, or abscess suspected
  • Men <50: STI testing first-line; men >50: UA/culture for cystitis (prostatic obstruction increases UTI risk)

Management

  • Uncomplicated cystitis (women): nitrofurantoin 100 mg BID x 5 days OR TMP-SMX DS BID x 3 days OR fosfomycin 3g single dose
  • Pyelonephritis: see Pyelonephritis — outpatient fluoroquinolone or IV antibiotics if admitting
  • Urethritis (STI): ceftriaxone 500 mg IM + doxycycline 100 mg BID x 7 days (or azithromycin 1g single dose)
  • Prostatitis: fluoroquinolone or TMP-SMX x 4-6 weeks; see Prostatitis
  • Symptomatic relief: phenazopyridine 200 mg TID x 2 days (warn about orange urine)

Disposition

  • Discharge: uncomplicated cystitis, mild urethritis, stable prostatitis
  • Admit: pyelonephritis with sepsis or intractable vomiting, urinary obstruction, prostatic abscess
  • Return precautions: fever, flank pain, inability to urinate, worsening symptoms

See Also

References

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