Dysuria is the symptom of painful micturition. It is a very common presentation in primary care. Treatment depends on identifying the underlying cause. See separate related articles on Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women.
- Abdominal causes: dysuria can occur with emergency causes of abdominal pain such as appendicitis and ectopic pregnancy (due to irritation of nearby urinary structures).
- Urinary tract causes:
- Urinary tract infection (UTI):
- Bacterial UTI.
- Urethritis - eg, chlamydia, gonococcus or non-gonococcal urethritis; in men aged <35, this is a common cause of dysuria.
- Urinary schistosomiasis.
- Interstitial cystitis.
- Obstruction: prostatic enlargement, urethral stricture.
- Kidney stones in the bladder or urethra.
- Malignancy - eg, carcinoma of the bladder or urethral tumours.
- Urinary tract infection (UTI):
- Genital causes:
- Urethral or vaginal trauma, including sexual abuse or a foreign body.
- Genital herpes simplex.
- Women: vaginitis - eg, vaginal candidiasis, atrophic vaginitis, bacterial vaginosis.
- Men: prostatitis, epididymo-orchitis, epididymitis.
- Other disease:
- Spondyloarthropathy - eg, reactive arthritis or Behçet's disease.
- Compression from a pelvic mass.
- Drugs - eg, cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other non-steroidal anti-inflammatory drugs.
- Chemical irritants: allergic or irritant reaction to soaps, vaginal lubricants, spermicides, contraceptive foams and sponges, tampons and toilet paper.
- Mechanical irritation - eg, from a poorly fitting contraceptive diaphragm or vaginal ring pessary.
- Radiation or chemical exposure.
Depending on the situation, possible questions are:
- Pain symptoms:
- Onset and duration of dysuria.
- Whether there is abdominal pain. If it is present, consider abdominal pain causes - eg, appendicitis and ectopic pregnancy.
- Radiation of pain (eg, to loin or back, suggesting upper urinary tract pathology).
- Other symptoms:
- Fever, rigors or malaise - suggest pyelonephritis.
- Haematuria - occurs with infection, stones, neoplasms and renal disease.
- Urethral or vaginal discharge - consider genital tract infection.
- Odour - suggests bacterial infection.
- Pruritus - common with genital candidiasis.
- Frequency and urgency - indicate bladder irritation.
- Urine volume and flow - consider obstruction.
- Medical history:
- Possible pregnancy.
- Past history: previous UTI, other genitourinary disease, pelvic surgery or irradiation, other general illness, medication.
- Recent sexual history; method of contraception; bear in mind the possibility of child sexual abuse.
- Occupation: exposure to dyes and solvents is a risk factor for bladder cancer.
May not be required for simple situations - eg, if the history suggests uncomplicated lower UTI. If relevant, examine for:
- Fever, tachycardia and loin tenderness (pyelonephritis).
- Abdominal/pelvic tenderness, guarding, masses or adnexal tenderness; enlarged bladder.
- Vaginal discharge, candidiasis, genital herpes simplex or vaginitis.
- An enlarged prostate may be felt on rectal examination.
- If child sexual abuse is suspected, specialist assessment is required.
Consider the appropriate level of investigation for the clinical picture, or whether to treat empirically. Investigations are generally required for children and men with dysuria but not always for women.
Possible investigations for dysuria
Depending on the clinical picture, these include:
- Urine dipstick, microscopy and culture.
- Considering whether a pregnancy test is needed.
- Investigation for sexually transmitted infection (STI) - or referral to an STI clinic.
- Ultrasound of the urinary tract, pelvis or abdomen if there is suspicion of obstruction or masses.
- Plain kidney, ureters and bladder (KUB) X-ray if renal tract stones are suspected.
- Urodynamic studies.
- Urine cytology.
- Further tests (eg, cystoscopy) require a specialist setting.
Further reading and references
Wilbanks MD, Galbraith JW, Geisler WM; Dysuria in the Emergency Department: Missed Diagnosis of Chlamydia trachomatis. West J Emerg Med. 2014 Mar15(2):227-30. doi: 10.5811/westjem.2013.12.18989.
Schmiemann G, Kniehl E, Gebhardt K, et al; The diagnosis of urinary tract infection: a systematic review. Dtsch Arztebl Int. 2010 May107(21):361-7. doi: 10.3238/arztebl.2010.0361. Epub 2010 May 28.
Macaluso CR, McNamara RM; Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 20125:789-97. doi: 10.2147/IJGM.S25936. Epub 2012 Sep 26.
Rothberg MB, Wong JB; All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms. J Gen Intern Med. 2004 May19(5 Pt 1):433-43.
Kim SD, Kim SW, Yoon BI, et al; The Relationship between Clinical Symptoms and Urine Culture in Adult Patients with Acute Epididymitis. World J Mens Health. 2013 Apr31(1):53-7. doi: 10.5534/wjmh.2013.31.1.53. Epub 2013 Apr 23.
Manikandan R, Kumar S, Dorairajan LN; Hemorrhagic cystitis: A challenge to the urologist. Indian J Urol. 2010 Apr26(2):159-66. doi: 10.4103/0970-1591.65380.
Diagnosis of UTI; British Infection Association and Health Protection Agency
Guidelines on Urological Infections; European Association of Urology (2015)
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