What is the management approach for a 9-year-old pediatric female patient with dysuria (painful urination) not caused by a urinary tract infection (UTI)?

Management of Dysuria Not Caused by UTI in a 9-Year-Old Female

The management of dysuria in a 9-year-old female without UTI should focus on urotherapy, which includes education, routine hydration, regular voiding regimens, bowel programs, and pelvic floor muscle awareness, as this approach has shown a high rate of success in treating lower urinary tract dysfunction. 1

Initial Assessment

• Evaluate for dysfunctional voiding, which is a common cause of non-UTI dysuria in children and involves abnormal contraction of the urethral sphincter during voiding 1
• Assess for bowel dysfunction by asking about bowel habits and behavior during defecation, as constipation frequently coexists with urinary symptoms 1
• Consider using symptom scores such as the dysfunctional voiding symptom score or the wetting and functional voiding disorder score to provide objective evaluation 1
• Perform uroflow studies with or without EMG to identify pelvic floor dysfunction associated with voiding phase dysfunction 1
• Ultrasound assessment may reveal thickened bladder wall, residual urine, or rectal impaction 1

Treatment Approach

First-Line: Urotherapy

• Provide education to the child and family about bladder/bowel dysfunction 1
• Implement timed voiding schedule to establish regular bladder emptying patterns 1
• Ensure adequate fluid intake throughout the day 1
• Teach correct toilet posture: secure sitting position with buttock support, foot support, and comfortable hip abduction to enable relaxed voiding 1
• Address constipation aggressively with initial disimpaction using oral laxatives followed by maintenance bowel management 1
• Implement hygiene measures including changing wet clothing, proper skin care, and correct wiping technique after toileting 1

Second-Line: Biofeedback Training

• If initial urotherapy is unsuccessful (which occurs in approximately 20% of cases), escalate to biofeedback training 1
• Biofeedback may use uroflow pattern, auditory stimulus, or noninvasive abdominal or perineal EMG to enhance pelvic floor awareness and control 1
• Transabdominal ultrasound can serve as a noninvasive biofeedback tool 1
• Multiple biofeedback sessions may be required to achieve optimal results 1

Additional Considerations

• For persistent symptoms, consider evaluation for other causes of dysuria including skin irritation, vulvovaginitis, or chemical irritants 2, 3
• In cases with persistent lower urinary tract dysfunction despite urotherapy, further evaluation may be needed 1
• Behavioral and emotional aspects should be assessed as they may contribute to symptoms 1

Follow-up and Monitoring

• Use bowel diaries and the Bristol Stool Scale to monitor treatment response 1
• Schedule regular follow-up visits to assess symptom improvement 1
• Consider repeat uroflow studies to document improvement in voiding patterns 1
• Monitor for recurrence of symptoms, which may indicate need for longer treatment duration 1

Important Caveats

• Avoid assuming UTI is the cause of dysuria without proper urine culture confirmation, as this can lead to unnecessary antibiotic treatment 4
• Be aware that treatment may need to be maintained for many months, particularly for bowel management, as parents often cease treatment too soon 1
• Recognize that approximately 7% of patients may experience worsening of symptoms with behavioral therapy alone, indicating need for more comprehensive management 1
• Consider that dysuria without UTI in children may be part of a broader dysfunctional elimination syndrome requiring a comprehensive approach 1