What is the approach to diagnosing and treating dysuria in adult women?

Workup of Dysuria in Women

Begin with urinalysis in all women presenting with dysuria, and obtain urine culture when there are complicating features, recurrent symptoms, or when empiric treatment fails. 1, 2

Initial Clinical Assessment

Key Historical Features to Elicit

• Vaginal symptoms (discharge, irritation, odor): Their presence significantly decreases likelihood of UTI and suggests vaginitis or cervicitis 1, 2
• Sexual activity and new partners: Indicates risk for sexually transmitted infections including chlamydia, gonorrhea, and herpes 1, 3
• Complicating factors: Male sex, pregnancy, diabetes, immunosuppression, urologic obstruction, recent urologic procedures, or history of kidney stones 1, 2
• Upper tract symptoms: Fever, flank pain, nausea/vomiting suggest pyelonephritis requiring more aggressive workup 4, 1
• Irritant exposure: New soaps, douches, spermicides, or feminine hygiene products 3, 5
• Timing of symptoms: External dysuria (pain before urine contacts urethra) suggests vulvar pathology; internal dysuria suggests bladder/urethral source 1, 3

Physical Examination Focus

• External genitalia inspection: Look for vulvar lesions (herpes), erythema, or trauma 1, 3
• Urethral examination: Assess for discharge, masses, or tenderness 6
• Pelvic examination when indicated: Perform if vaginal symptoms present, sexually active with risk factors for STI, or if initial urine culture negative with persistent symptoms 6, 5

Diagnostic Algorithm

Uncomplicated Presentation (No Complicating Features)

Women with isolated dysuria and urinary frequency/urgency without vaginal symptoms can be treated empirically for cystitis without urinalysis or culture. 1, 2

• This applies to otherwise healthy, non-pregnant women with classic UTI symptoms 1
• Empiric treatment reduces cost and delays without compromising outcomes 2

When to Obtain Urinalysis

Perform urinalysis for: 1, 2

• Any complicating features listed above
• Presence of vaginal symptoms (to differentiate from UTI)
• Recurrent dysuria
• Uncertain diagnosis
• Male patients
• Persistent symptoms after initial treatment

When to Obtain Urine Culture

Obtain pretreatment urine culture in these scenarios: 7, 4, 2

• Suspected pyelonephritis (back pain, fever, systemic symptoms)
• Recurrent UTI (≥2 infections in 6 months or ≥3 in one year)
• Complicated UTI (pregnancy, male sex, structural abnormalities, immunosuppression)
• Failed empiric therapy
• Persistent symptoms despite treatment
• To guide antibiotic selection in areas with high resistance rates

Critical pitfall: Do NOT treat asymptomatic bacteriuria in non-pregnant women, as this fosters antimicrobial resistance and increases recurrent UTI episodes 7

Additional Testing Based on Clinical Scenario

If Vaginal Symptoms Present

• Wet mount and vaginal pH: Evaluate for bacterial vaginosis, candidiasis, or trichomoniasis 1, 3
• Cervical testing: Nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia if sexually active 2
• Mycoplasma genitalium testing: If persistent urethritis/cervicitis with negative initial STI testing 2

If Urethral Discharge Present

• Urethral culture and Gram stain: Identify gonorrhea or other urethral pathogens 6
• NAAT for chlamydia and gonorrhea 2

If Recurrent or Persistent Symptoms

• Repeat urine culture: Assess for ongoing bacteriuria before prescribing additional antibiotics 7
• Post-void residual: Consider if incomplete emptying suspected 7
• Imaging (ultrasound or CT): If symptoms persist after 48-72 hours of appropriate therapy, to rule out complications like abscess or obstruction 4

Common Diagnostic Pitfalls

• Treating based on symptoms alone without considering STIs: Always assess sexual history and risk factors, as 8% of dysuria cases are due to gonorrhea 6
• Missing vaginitis: 17% of dysuria cases are due to vaginitis (candida, trichomonas); vaginal discharge makes UTI less likely 6, 2
• Over-reliance on virtual visits: Evaluation without laboratory testing increases recurrent symptoms and unnecessary antibiotic courses 2
• Assuming pyuria equals UTI: Pyuria alone does not definitively predict cystitis and can occur with urethritis or vaginitis 6
• Treating asymptomatic bacteriuria: This increases resistance and recurrent infections; only treat symptomatic infections 7

Non-Infectious Causes to Consider

When infection ruled out, consider: 1, 3

• Interstitial cystitis/bladder pain syndrome: Chronic pelvic pain, urinary urgency without infection
• Atrophic vaginitis: In postmenopausal women; consider vaginal estrogen 7
• Urethral trauma: Recent sexual activity, catheterization
• Chemical irritants: Soaps, spermicides, douches
• Dermatologic conditions: Lichen sclerosus, lichen planus
• Urethral diverticulum or mass: Requires imaging if suspected
• Nephrolithiasis: Consider if hematuria present without infection 7