Dysuria
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
- Genitourinary infection
- Acute cystitis ("UTI")
- Pyelonephritis
- Urethritis
- Chronic cystitis
- Infected nephrolithiasis
- Prostatitis
- Epididymitis
- Renal abscess/perinephric abscess
- Emphysematous pyelonephritis
- Nephrolithiasis
- Urethral issue
- Urethritis
- Urolithiasis
- Urethral foreign body
- Urethral diverticulum
- Allergic reaction (contact dermatitis)
- Chemical irritation
- Urethral stricture or obstruction
- Trauma to vagina, urethra, or bladder
- Gynecologic
- Vaginitis/cervicitis
- PID
- Genital herpes
- Pelvic organ prolapse
- Fistula
- Cystocele
- Other
- Diverticulitis
- Interstitial cystitis
- Behavioral symptom without detectable pathology
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