1. Gerber GS et al. Evaluation of the urologic patient: history, physical examination, and urinalysis. Wein AJ et al, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Saunders; 2015.
  2. Sanchez GV et al. Antibiotic resistance among urinary isolates from female outpatients in the United States in 2003 and 2012. Antimicrob Agents Chemother. 2016 Apr 22:60(5):2680-3. [PMID: 26883714]
  3. Workowski KA et al; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137. [PMID: 26042815]
  4. Stein DM et al. A geographic analysis of male urethral stricture aetiology and location. BJU Int. 2013 Oct;112(6):830-4. [PMID: 23253867]
  5. Pontari MA. Sexually transmitted diseases. Wein AJ et al, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Saunders; 2015.
  6. Nickel JC. Inflammatory and pain conditions of the male genitourinary tract: prostatitis and related pain conditions, orchitis, and epididymitis. Wein AJ et al, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Saunders; 2015.
  7. Lamm DL et al. Bladder cancer: current optimal intravesical treatment. Urol Nurs. 2005 Oct;25(5):323-6, 331-2. [PMID: 16294610]
  8. Beltran H et al. Primary squamous cell carcinoma of the urinary bladder presenting as peritoneal carcinomatosis. Adv Urol. 2010:179250. [PMID: 20672052]
  9. Hanno PM. Bladder pain syndrome (interstitial cystitis) and related disorders. Wein AJ et al, eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Saunders; 2015.
  10. Nickel JC. Interstitial cystitis: characterization and management of an enigmatic urologic syndrome. Rev Urol. 2002;4(3):112-121. [PMID: 16985667]
  11. Hunner's ulcers. Interstitial Cystitis Association. March 25, 2015; Accessed: March 1, 2017. Available at:
  12. Burke DM et al. The community-based morbidity of flexible cystoscopy. BJU Int. 2002 Mar;89(4):347-9. [PMID: 11872022]
  13. Bachmann GA et al. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician. 2000 May 15;61(10):3090-6. [PMID: 10839558]

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Contributor Information


Josh Palka, DO
Detroit Medical Center
Detroit, MI

Disclosure: Josh Palka, DO, has disclosed no relevant financial relationships.

Christopher Atalla, DO
Detroit Medical Center
Detroit, MI

Disclosure: Christopher Atalla, DO, has disclosed no relevant financial relationships.


Close<< Medscape

Dysuria: When It Hurts to Go With the Flow

Josh Palka, DO; Christopher Atalla, DO  |  March 21, 2017

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Slide 1

Dysuria is defined as pain occurring from urination, typically in conjunction with inflammation. It is frequently associated with urinary frequency and urgency. The pain is commonly referred to the urethra. If pain is appreciated at the initiation of urination, this may indicate that the pathology is located within the urethra. If pain occurs at the end of micturition (stranguria), this commonly indicates bladder pathology.[1]

Image courtesy of Wikimedia Commons.

Slide 2

A 62-year-old woman presents to the office with complaints of dysuria and back pain for the past 2 days. This is her fifth presentation with similar symptoms in the past 8 months. She provides a urine sample (microscopic view shown), and the number of bacteria growing is found to be greater than 105/mL.

Which of the following organisms is the most likely cause of this patient's symptoms?

  1. Staphylococcus aureus
  2. Enterococcus faecalis
  3. Escherichia coli
  4. Staphylococcus saprophyticus
  5. None of the above

Image courtesy of Wikimedia Commons.

Slide 3

Answer: C. Escherichia coli.

Older female patients who present with symptoms of uncomplicated urinary tract infection (UTI; eg, dysuria, hematuria, back pain, and suprapubic discomfort) can be treated with appropriate antibiotics in the outpatient setting. However, routine use of antibiotics, including ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX), has led to rising rates of bacterial resistance to antibiotics. In one study, ciprofloxacin resistance increased in all age groups between 2003 and 2012, with increases especially pronounced among isolates from adults (from 3.6% in 2003 to 11.8% in 2012).[2] The Gram stain in the slide shows pink, rod-shaped organisms (arrow), indicating gram-negative bacteria with features of E coli. E. coli is the most common cause of community-acquired UTIs. Females are more susceptible to UTIs because the urethra is significantly shorter than it is in men. In this patient, who has recurrent UTIs, it would be advisable to obtain a urine culture with susceptibilities to determine whether her symptoms are due to an infection and whether that infection is being treated with the appropriate antibiotics.

Image courtesy of Wikimedia Commons.

Slide 4

A 22-year-old man presents to the office with complaints of urethral discharge and dysuria. He currently is sexually active and does not use barrier protection. He states that the dysuria is worst in the morning when he wakes to urinate. He provides a urethral swab, and microscopic examination yields the results shown in the slide.

Which of the following regimens is recommended as first-line therapy for gonococcal urethritis by the Centers for Disease Control and Prevention (CDC)?

  1. Ceftriaxone and azithromycin
  2. Ceftriaxone and ciprofloxacin
  3. Azithromycin and ciprofloxacin
  4. TMP-SMX

Image courtesy of Wikimedia Commons.

Slide 5

Answer: A. Ceftriaxone and azithromycin.

The CDC recommends ceftriaxone 250 mg IM and azithromycin 1 g PO for initial treatment of gonococcal urethritis.[3] Doxycycline 100 mg q12hr for 7 days may be substituted for azithromycin; however, this substitution should be made only if the patient is allergic to azithromycin, given that there have been reports of increased resistance to doxycycline.[3] Because of the high levels of resistance to quinolones, these agents are no longer recommended for treatment of urethritis. Historically, urethral infection was the number one cause of urethral stricture (shown). With improved knowledge and greater availability of medical care, this is no longer the case; however, urethral stricture is still a consideration in certain locations.[4]

Image courtesy of Medscape.

Slide 6

A 30-year-old woman presents to the office with complaints of dysuria for the past 5 days in addition to lesions surrounding her labia. She states that she uses condoms for every sexual encounter. Pelvic examination reveals the findings shown in the slide.

Which of the following is the most likely cause of these lesions and the patient's dysuria?

  1. Human papillomavirus (HPV) infection
  2. Herpes simplex virus (HSV) infection
  3. Syphilis
  4. Vaginitis
  5. Chancroid

Image courtesy of Wikimedia Commons.

Slide 7

Answer: B. Herpes simplex virus (HSV) infection.

HSV-1 and HSV-2 are double-stranded DNA viruses that appear approximately 4-7 days after sexual contact as a cluster of erythematous papules and vesicles on the external genitalia that do not follow a neural distribution.[5] HSV-2 is spread through sexual contact. As many as 80% of women experience dysuria with HSV, in addition to burning, pain, or itching. The diagnosis can be confirmed by obtaining fluid from the base of the genital lesion and sending it for viral culture, HSV antigen detection, or polymerase chain reaction (PCR) assay of HSV DNA. Treatment is aimed at reducing the severity of disease and preventing recurrence; at present, no treatment is available that will eradicate HSV. Acyclovir, famciclovir, or valacylovir can be used in varying regimens, depending on the goals of treatment for a given patient. Because HIV is strongly associated with HSV infection, it is recommended that all patients with HSV be tested for HIV. Additionally, patients with genital HSV-2 infection who are pregnant or plan to be pregnant should be aware that giving birth can lead to serious infection in neonates through vertical transmission and should discuss this risk with their physicians.

Image courtesy of CDC.

Slide 8

A 31-year-old man presents to the clinic with a 2-month history of dysuria, urinary urgency and frequency, and generalized perineal and pelvic discomfort. A sterile urine sample obtained after prostatic massage shows more than 10 white blood cells (WBCs) per high-power field (hpf) on microscopy (shown), and acute bacterial prostatitis is diagnosed.

On the assumption that culture reveals no resistance, which of the following would be the most appropriate antibiotic regimen and duration of therapy?

  1. Nitrofurantoin for 5 days
  2. Double-strength TMP-SMX for 5 days
  3. Nitrofurantoin for 30 days
  4. Double-strength TMP-SMX for 30 days
  5. Ciprofloxacin for 3 days

Image courtesy of Medscape.

Slide 9

Answer: D. Double-strength TMP-SMX for 30 days.

Prostatitis is the most common urologic diagnosis in men younger than 50 years and the third most common urologic diagnosis in men older than 50 years (after benign prostatic hyperplasia [BPH] and prostate cancer). The most common pattern of inflammation is a lymphocytic infiltrate in the stroma immediately adjacent to the prostatic acini (shown). Nitrofurantoin is a poor antibiotic choice for prostatitis because it has poor tissue penetration. The preferred initial therapy is double-strength TMP-SMX for 30 days, if good response is seen. This regimen helps prevent chronic bacterial prostatitis and the formation of prostatic abscesses.[6]

Image courtesy of Medscape.

Slide 10

A 51-year-old man presents with a complaint of generalized genital and rectal pain for the past month that has acutely worsened over the past 4 days. He reports dark amber urine, frequency, occasional urgency, dysuria, decreased force of stream, and feelings of incomplete emptying. He reports sexual activity with multiple partners. He states that he experiences pain with defecation as well. Digital rectal examination (shown) reveals a boggy, tender prostate. Appropriate antibiotic therapy is started, a Foley catheter is placed, and urine culture grows pansensitive E coli; however, the patient continues to spike fevers.

Which of the following is the most likely cause of this patient's clinical condition?

  1. Bladder stone
  2. Sexually transmitted disease
  3. Acute prostatic abscess
  4. Chronic pain syndrome
  5. Crohn disease

Image courtesy of Wikimedia Commons.

Slide 11

Answer: C. Acute prostatic abscess.

Acute bacterial prostatitis typically responds quickly to properly selected antibiotics. If a patient continues to spike fevers, further investigation is warranted because this raises concerns about a possible prostatic abscess. The preferred imaging modality for making this diagnosis is transrectal ultrasonography (US) of the prostate, but computed tomography (CT) of the abdomen and pelvis can also be performed (shown). The patient described in the preceding slide underwent transurethral resection of his prostate abscess—the optimal treatment modality—without complications. In some cases, percutaneous needle drainage may be attempted first, but this would not be recommended with an abscess of this size.

Image courtesy of Josh Palka, DO.

Slide 12

A 65-year-old woman presents to the clinic with a complaint of dysuria. She states that she has had multiple UTIs in the past year, which were diagnosed at multiple different urgent care centers. By her account, these UTIs were diagnosed solely on the basis of her irritative voiding symptoms, and no urine cultures were obtained. In addition to her dysuria, the patient reports hematuria and vague lower back pain. She has a history of smoking and worked at a textile manufacture as a young adult. You refer her to a urologist, who performs a cystoscopy, with the results shown in the slide.

Which of the following is the most appropriate next step in treatment?

  1. Chemotherapy
  2. Radiation therapy
  3. Biopsy
  4. Observation
  5. None of the above

Image courtesy of Medscape.

Slide 13

Answer: C. Biopsy.

This is a classic presentation of carcinoma in situ (CIS) of the bladder. This stage of bladder cancer is, by definition, a high-grade disease variant, and it may masquerade as a recurrent UTI. The patient described in the preceding slide has multiple risk factors, including her age, smoking history, and experience of working in a textile factory where aniline dyes were likely used. Patients who continue to have multiple UTIs or intractable dysuria may need further evaluation of their bladder to determine whether cancer may be present. The mainstay of therapy for CIS of the bladder is bacillus Calmette-Guerin (BCG) instilled intravesically; other forms of intravesical chemotherapy may also be used.[7]

Image courtesy of NIH | Beltran H et al.[8]

Slide 14

A 35-year-old woman presents to the office with complaints of bladder pain, dysuria, and urinary frequency. She underwent workup multiple times in the past, but no obvious source of her symptoms was found. She was referred to a urologist, who diagnosed her with interstitial cystitis after she observed the lesion shown on cystoscopy (Hunner ulcer).

Which of the following statements regarding interstitial cystitis/bladder pain syndrome (IC/BPS) is false?

  1. IC/BPS is associated with fibromyalgia
  2. IC/BPS is a disease of exclusion
  3. Transurethral fulguration (cauterization) of Hunner lesions can relieve IC/BPS
  4. IC/BPS is associated with diabetes

Image courtesy of Medscape.

Slide 15

Answer: D. IC/BPS is associated with diabetes.

IC/BPS is a clinical diagnosis based primarily on chronic symptoms of pain that are perceived by the patient to emanate from the bladder, the pelvis, or both; are associated with urinary urgency or frequency; and occur in the absence of another identified cause for the symptoms.[9,10] To date, no relationship between diabetes and IC/BPS has been established. Between 5% and 10% of patients with IC/BPS will have the ulcerative type, whereby Hunner lesions can be identified on cystoscopic evaluation. Cauterization of these lesions can relieve the patient's pain.[11]

Image courtesy of Medscape after Nickel JC.[10]

Slide 16

A 60-year-old man presents to the emergency department (ED) with a complaint of dysuria. He denies experiencing fevers, chills, nausea, or vomiting. He reports that he was at his urologist's office this morning to undergo a surveillance cystoscopy for bladder cancer, and he states that the dysuria began after the cystoscopy was performed. Urinalysis reveals microhematuria with 2-5 red blood cells (RBCs)/hpf, but otherwise there are no signs of infection.

Which of the following medications would be most beneficial for helping to manage the patient's symptoms?

  1. Ciprofloxacin
  2. Nitrofurantoin
  3. Butalbital-acetaminophen-caffeine (Fioricet)
  4. Phenazopyridine

Image courtesy of Wikimedia Commons.

Slide 17

Answer: D. Phenazopyridine.

A study of 420 patients who underwent flexible cystoscopy found that 190 (49.5%) of the 384 evaluable patients experienced dysuria within 24 hours of cystoscopic evaluation, and 22 (6%) had symptoms lasting longer than 48 hours.[12] Phenazopyridine can be used as an analgesic for these symptoms and can be given as 100 mg or 200 mg q8hr for a maximum of 2 days. The patient should be warned that phenazopyridine can change the color of the urine to orange (shown), which can stain certain fabrics.

Image courtesy of Wikimedia Commons.

Slide 18

A 73-year-old woman presents to the office with a complaint of a burning sensation on urination. Urinalysis detects no signs of infection. The patient is given a trial of antibiotic therapy but returns to the office with persistent urinary symptoms. Urine culture shows no growth. Physical examination reveals a poorly estrogenized vagina.

Which of the following is the most likely cause of this patient's symptoms?

  1. Drug-resistant UTI
  2. Atrophic vaginitis
  3. Urothelial cancer
  4. IC/BPS

Image courtesy of Wikimedia Commons.

Slide 19

Answer: B. Atrophic vaginitis.

Atrophic vaginitis is a common problem for postmenopausal women. Before menopause, estrogen maintains a thick and well-lubricated epithelial lining. After menopause, estrogen levels decline dramatically, and the vaginal epithelium becomes thin and dry. Patients typically present with complaints of vaginal dryness, dyspareunia, itching, and burning. They may also have urinary complaints, including urinary frequency, urgency, dysuria, and sometimes even hematuria.

On physical examination, the vagina appears pale, smooth, and shiny. The tissue also may be very friable, with areas of inflammation and petechiae. The mainstay of treatment for patients with atrophic vaginitis is hormonal replacement therapy (HRT).[13] Estrogen may be administered systemically or locally to the vagina by means of various creams or pessaries. For patients who are opposed to HRT or have contraindications to it, lubricants may be used to help alleviate some of the symptoms.

Image courtesy of Science Source.

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