What is dysuria?

Dysuria: Definition and Clinical Significance

Dysuria is defined as pain, burning, or discomfort during urination and is a cardinal symptom of urinary tract infection, though it can also be caused by various other conditions. 1

Pathophysiology and Clinical Presentation

Dysuria occurs when there is inflammation or irritation of the urethral mucosa, which can result from:

• Infectious causes:

  • Urinary tract infections (most common cause)
  • Sexually transmitted infections
  • Prostatitis (in men)

• Non-infectious causes:

  • Bladder irritants
  • Skin lesions
  • Chronic pain conditions
  • Genitourinary malignancy
  • Renal calculi
  • Hypoestrogenism
  • Interstitial cystitis
  • Medication side effects

The sensation is typically described as:

• Burning pain during urination
• Discomfort that may be localized to the urethra
• Pain that can occur at the beginning, during, or after urination 2, 3

Associated Symptoms

Dysuria often presents with other urinary symptoms:

• Frequency - increased need to urinate
• Urgency - sudden, compelling desire to urinate
• Nocturia - need to urinate at night
• Hematuria - blood in urine
• Suprapubic pain - pain in lower abdomen
• Cloudy or foul-smelling urine 4, 5

Demographic Considerations

• Women: More commonly affected than men, particularly younger women due to sexual activity
• Men: Dysuria increases with age due to prostatic hyperplasia with accompanying inflammation and infection
• Elderly patients: May present with atypical symptoms such as confusion, changes in mental status, and weakness rather than classic dysuria 6, 2, 7

Diagnostic Approach

When evaluating dysuria, clinicians should:

1. Take a detailed history focusing on:

   • Onset and duration of symptoms
   • Associated symptoms (frequency, urgency, hematuria)
   • Sexual activity
   • Previous UTIs
   • Presence of vaginal discharge (decreases likelihood of UTI)
   • Recent use of potential bladder irritants

2. Perform urinalysis in most patients with dysuria to:

   • Detect pyuria (white blood cells in urine)
   • Identify bacteriuria
   • Check for nitrites (more sensitive and specific for UTI)
   • Look for hematuria 4, 1, 5

3. Obtain urine culture when:

   • Recurrent UTIs are suspected
   • Complicated UTI is likely
   • Initial treatment fails
   • Symptoms persist despite therapy 1, 5

Differential Diagnosis

• Urinary tract infection: Most common cause, especially in women
• Sexually transmitted infections: Particularly in younger, sexually active individuals
• Prostatitis or prostatic hyperplasia: Common in older men
• Urethritis: Inflammation of the urethra
• Vaginitis/cervicitis: Can cause external dysuria in women
• Interstitial cystitis: Chronic bladder pain syndrome
• Bladder or urethral cancer: More common in older adults
• Renal calculi: May cause intermittent dysuria with flank pain
• Medication-induced: Certain drugs can irritate the urinary tract 1, 2, 7

Clinical Pearls

• Dysuria is a symptom, not a diagnosis, and requires proper evaluation to determine the underlying cause
• The presence of vaginal discharge decreases the likelihood of UTI and suggests other causes like cervicitis
• In elderly patients, dysuria may present atypically with confusion or behavioral changes
• Persistent symptoms after initial treatment warrant further investigation for both infectious and non-infectious causes
• Virtual evaluation of dysuria without laboratory testing may increase recurrent symptoms and unnecessary antibiotic use 1, 5

Understanding dysuria's various presentations and causes is essential for accurate diagnosis and appropriate treatment, ultimately improving patient outcomes and reducing unnecessary antibiotic use.