Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely common symptom in women, but it can occur in men and can occur at any age.
Pathophysiology of Dysuria
Dysuria results from irritation of the bladder trigone or urethra. Inflammation or stricture of the urethra causes difficulty in starting urination and burning on urination. Irritation of the trigone causes bladder contraction, leading to frequent and painful urination. Dysuria most frequently results from an infection and inflammation in the lower urinary tract, but it could also be caused by an upper urinary tract infection (UTI) and kidney stones.
Etiology of Dysuria
Dysuria is typically caused by urethral or bladder inflammation, although perineal lesions in women (eg, from vulvovaginitis or herpes simplex virus infection) can be painful when exposed to urine. Most cases are caused by infection, but sometimes noninfectious inflammatory disorders are responsible (see table Some Causes of Dysuria). Some patients have dysuria with certain foods or drinks. Common irritants can include alcohol, caffeine, and spicy or acidic foods (eg, citrus fruits).
Overall, the most common causes of dysuria are
Cystitis
Urethritis due to a sexually transmitted infection (STI)
Some Causes of Dysuria
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Infectious disorders* | ||
Often cervical discharge History of unprotected intercourse | STI testing | |
Typically urinary frequency and urgency Sometimes bloody or malodorous urine Bladder tenderness | Clinical evaluation with or without urinalysis unless red flags† are present | |
Tender, swollen epididymis | Clinical evaluation | |
Enlarged, tender prostate Often history of obstructive symptoms | Clinical evaluation | |
Usually visible discharge History of unprotected intercourse | STI testing | |
Vaginal discharge Erythema of labia and introitus | Clinical evaluation, urinalysis, and culture to rule out UTI Consideration of catheterization to minimize contamination of specimen | |
Inflammatory disorders | ||
External inflammation Clinical history Family history | Clinical evaluation Urinalysis Imaging of the urinary tract and pelvis | |
Chronic symptoms No other, more common causes found | ||
Spondyloarthropathies (eg, reactive arthritis, Behçet syndrome) | Preceding GI or joint symptoms or both Sometimes skin and mucosal lesions | Clinical evaluation STI testing |
Other disorders | ||
Postmenopausal (including estrogen deficiencies due to medications, surgery, or radiation) Often dyspareunia Atrophy or erythema of vaginal folds | Clinical evaluation | |
Tumors (usually bladder, prostate, or urethral cancer) | Long-standing symptoms Usually hematuria without pyuria or infection | Cystoscopy, urine cytology Possible prostate biopsy or bladder biopsy |
* Common pathogens include nonsexually transmitted bacteria (mostly Escherichia coli, Staphylococcus saphrophyticus, Enterococcus, Klebsiella, and Proteus) and sexually transmitted pathogens (eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, herpes simplex virus). | ||
† Red flags are fever, flank pain or tenderness, recent instrumentation of the genitourinary tract, immunocompromised state, recurrent episodes, known urologic abnormalities, and male sex. | ||
GI = gastrointestinal; STI = sexually transmitted infection; UTI = urinary tract infection. | ||
Evaluation of Dysuria
History
History of present illness should cover duration of symptoms and whether they have occurred in the past. Important accompanying symptoms include fever, flank pain, urethral or vaginal discharge, and symptoms of bladder irritation (frequency, urgency) or obstruction (hesitancy, dribbling). Patients should be asked whether the urine is bloody, cloudy, or malodorous and the nature of any discharge (eg, thin and watery or thick and purulent). Clinicians should also ask whether patients have recently engaged in unprotected intercourse, have applied potential irritants to the perineum, have had recent urinary instrumentation (eg, cystoscopy, catheterization, surgery), or might be pregnant.
Review of systems should seek symptoms of a possible cause, including back or joint pain and eye irritation (connective tissue disorder) and gastrointestinal symptoms, such as diarrhea (reactive arthritis). Review of food or drink that can cause symptoms is also necessary.
Past medical history should note prior urinary infections (including those during childhood) and any known abnormality of the urinary tract, including congenital urinary tract anomalies or a history of kidney stones. As with any potentially infectious illness, a history of an immunocompromised state (including HIV infection) or recent hospitalization is important.
Physical examination
Examination begins with review of vital signs, particularly to note the presence of fever.
Skin, mucosa, and joints are examined for lesions suggesting reactive arthritis (eg, conjunctivitis, oral ulcers, vesicular or crusting lesions of palms, soles, and around nails, joint tenderness). The flank is percussed for tenderness over the kidneys. The abdomen is palpated for tenderness over the bladder.
Women should have a pelvic examination to detect perineal inflammation or lesions and vaginal or cervical discharge (see Cervicitis). Swabs for testing for STIs and wet mount should be obtained at this time rather than doing a second examination.
Men should undergo external inspection to detect penile lesions and discharge; the area under the foreskin should be examined. The epididymis and testes are palpated to detect tenderness or swelling. Rectal examination is done to palpate the prostate for size, consistency, and tenderness.
Red flags
The following findings are of particular concern:
Fever
Flank pain or tenderness
Recent instrumentation
Immunocompromised state
Recurrent episodes (including frequent childhood infections)
Known urinary tract abnormality
Male sex
Interpretation of findings
Some findings are highly suggestive (see table Some Causes of Dysuria). In young, healthy women with dysuria and significant symptoms of bladder irritation, cystitis is the most likely cause. Visible urethral or cervical discharge suggests an STI. Thick purulent material is usually gonococcal; thin or watery discharge is nongonococcal. Vaginitis and the ulcerative lesions of herpes simplex virus infection are typically apparent on inspection. In men, a very tender prostate suggests prostatitis, and a tender, swollen epididymis suggests epididymitis.
Other findings also are helpful but may not be diagnostic; eg, women with findings of vulvovaginitis may also have a urinary tract infection (UTI) or another cause of dysuria. Diagnosis of UTI based on symptoms is less accurate in older patients.
Findings suggestive of infection are more concerning in patients with red flag findings. Fever, flank pain, or both suggest an accompanying pyelonephritis. History of frequent UTIs should raise concern for an underlying anatomic abnormality or compromised immune status. Infections following hospitalization or instrumentation may indicate an atypical or resistant pathogen.
Testing
No single approach is uniformly accepted. Many clinicians presumptively give antibiotics for cystitis without any testing (sometimes not even urinalysis) in young, otherwise healthy women presenting with classic dysuria, frequency, and urgency and without red flag findings. Others evaluate everyone with a clean-catch midstream urine sample for urinalysis and culture. Urine culture is recommended in patients with risk factors for multidrug-resistant infections. Some clinicians defer culture unless dipstick testing detects white blood cells (WBCs). In women of childbearing age, a pregnancy test is done (UTI during pregnancy is of concern because it may increase the risk of preterm labor or premature rupture of the membranes). Vaginal discharge warrants a wet mount. Many clinicians routinely obtain samples of cervical (women) or urethral (men) exudate for STI testing (gonococcus and chlamydia culture or polymerase chain reaction [PCR]) because many infected patients do not have a typical presentation.
A finding of > 105 bacteria colony-forming units (CFU)/mL suggests infection. In symptomatic patients, sometimes counts as low as 102 or 103 CFUs indicate UTI. WBCs detected with urinalysis in patients with sterile cultures are nonspecific and may occur with an STI, vulvovaginitis, prostatitis, tuberculosis (TB), tumor, interstitial nephritis, or other causes. Red blood cells detected with urinalysis in patients with no WBCs and sterile cultures may be due to cancer, calculus, foreign body, glomerular abnormalities, or recent instrumentation of the urinary tract.
Cystoscopy and imaging of the urinary tract may be indicated to check for obstruction, anatomic abnormalities, cancer, or other problems in patients who have no response to antibiotics, recurrent symptoms, or hematuria without infection. Rectovesicular fistula should be considered in men with recurrent lower urinary tract infections or those with polymicrobial infections. Pregnant patients, males, older patients, and patients with prolonged or recurrent dysuria need closer attention and a more thorough investigation.
Treatment of Dysuria
Treatment of interstitial cystitis/bladder pain syndrome includes nonpharmacologic behavioral interventions, oral medications, bladder instillations, urologic procedures, and major surgery (1).
Acute, intolerable dysuria due to cystitisEscherichia coli.
Treatment reference
1. Clemens JQ, Erickson DR, Varela NP, et al: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 208(1):34-42, 2022. doi: 10.1097/JU.0000000000002756
Key Points
Dysuria is not always caused by a bladder infection.
STIs and cancer should also be considered.
