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

See Also

• UTI
• Pyelonephritis
• Urethritis
• STI
• Prostatitis