From the Guidelines
This patient should be evaluated for interstitial cystitis/bladder pain syndrome (IC/BPS) given the chronic nature of his symptoms, including dysuria and lower abdominal pain, despite a negative urine dip weeks ago. The clinical diagnosis of IC/BPS requires a careful history, physical examination, and laboratory examination to document basic symptoms that characterize the disorder and exclude infections or other confusable disorders, as outlined in the AUA guideline on diagnosis and treatment of IC/BPS 1.
Key Considerations
- A thorough history should document the number of voids per day, sensation of constant urge to void, and the location, character, and severity of pain, pressure, or discomfort.
- The patient's symptoms, including dysuria and lower abdominal pain, should be present for at least six weeks with documented negative urine cultures.
- A brief neurological exam to rule out an occult neurologic problem and an evaluation for incomplete bladder emptying to rule out occult retention should be done.
- A proper hematuria workup should be performed in patients with un-evaluated hematuria, and considered in patients with tobacco exposure given the high risk of bladder cancer in smokers.
Recommendations
- I recommend referral to a urologist for further assessment, including the diagnostic use of cystoscopy to rule out other conditions such as bladder cancer, bladder stones, and intravesical foreign bodies.
- In the meantime, symptom relief measures such as warm sitz baths for 10-15 minutes twice daily and avoiding bladder irritants (caffeine, alcohol, spicy foods) may be beneficial.
- Anti-inflammatory medications like ibuprofen 400-600 mg three times daily with food can also reduce pain and inflammation.
- The patient should be reassured that while IC/BPS can be a chronic and frustrating condition, it is manageable with appropriate treatment, and further diagnostic tests and specialized medications may be considered if symptoms persist.
From the Research
Possible Causes of Dysuria
- Dysuria, or pain during urination, can be caused by various factors, including urinary tract infections (UTIs), sexually transmitted infections (STIs), bladder irritants, skin lesions, and chronic pain conditions 2, 3, 4.
- In men, dysuria can be caused by prostatic hyperplasia, inflammation, and infection, especially in older men 3.
- Noninfectious causes of dysuria include inflammation or trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, and psychogenic disorders 3, 4.
Evaluation and Diagnosis
- A comprehensive history and physical examination can often reveal the cause of dysuria 3, 4.
- Urinalysis may not be needed in healthier patients with uncomplicated medical histories and symptoms, but it can help determine the presence of infection and confirm a suspected diagnosis 3, 4.
- Urine cultures and other laboratory tests can help identify the causative agent and guide appropriate antibiotic use 2, 4.
- In patients with persistent symptoms, further workup for infectious and noninfectious causes is necessary 2, 4.
Urine Dipstick Test
- The urine dipstick test can be used as a simple diagnostic test in limited resource settings for rapid diagnosis and initiation of empirical antibiotic therapy 5.
- The test has good specificity, especially for nitrite, and can be used in combination with clinical symptoms such as fever, dysuria, and lower abdominal pain to increase specificity 5.
Next Steps
- Given the patient's negative urine dipstick test weeks ago but persistent dysuria and lower abdominal pain, further evaluation and workup for infectious and noninfectious causes are necessary 2, 4.
- A urine culture and other laboratory tests may be necessary to guide appropriate antibiotic use and treatment 2, 4.