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Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023
| Contributor Information
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Image courtesy of Wikimedia Commons.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
Dysuria is defined as pain occurring from urination. It is frequently associated with urinary frequency and urgency. 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.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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?
Staphylococcus aureus
Enterococcus faecalis
Escherichia coli
Staphylococcus saprophyticus
None of the above
Image courtesy of Wikimedia Commons.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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)?
Ceftriaxone
Azithromycin
Ciprofloxacin
TMP-SMX
Image courtesy of Medscape.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
Answer: A. Ceftriaxone.
For initial treatment of uncomplicated gonococcal urethritis, the CDC recommends ceftriaxone in a single IM dose of 500 mg for patients weighing less than 150 kg or 1 g for those weighing 150 kg or more.[3] If chlamydial infection has not been excluded, doxycycline 100 mg PO q12hr for 7 days should be given for treatment of Chlamydia. If ceftriaxone is not available or not feasible, an alternative is cefixime 800 mg PO in a single dose; again, doxycycline is given if chlamydial infection has not been excluded.[3] Another alternative if ceftriaxone is not available or not feasible consists of gentamicin 240 mg IM in a single dose plus azithromycin 2 g PO in a single dose.[3] Because of the high levels of resistance to quinolones such as ciprofloxacin, 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 Wikimedia Commons.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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?
Human papillomavirus (HPV) infection
Herpes simplex virus (HSV) infection
Syphilis
Vaginitis
Chancroid
Image courtesy of CDC.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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 Josh Palka, DO.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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 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. A computed tomography (CT) scan of the pelvis is obtained (shown).
Which of the following is the most likely cause of this patient's clinical condition?
Bladder stone
Sexually transmitted disease
Acute prostatic abscess
Chronic pain syndrome
Crohn disease
Image courtesy of Josh Palka, DO.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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 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 without complications. In some cases, percutaneous needle drainage may be attempted as well.
Image courtesy of Medscape.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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 several 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. She is seen by her urologist, who performs a cystoscopy, with the results shown in the slide.
Which of the following is the most appropriate next step in treatment?
Chemotherapy
Radiation therapy
Biopsy
Observation
None of the above
Image courtesy of NIH | Beltran H et al.[6]
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
Answer: C. Biopsy.
This is a classic presentation of carcinoma in situ (CIS) of the bladder.[6] 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 to have been 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-Guérin (BCG) instilled intravesically; other forms of intravesical chemotherapy may also be used.[7]
Image courtesy of Medscape.
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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?
IC/BPS is associated with fibromyalgia
IC/BPS is a disease of exclusion
Transurethral fulguration (cauterization) of Hunner lesions can relieve IC/BPS
IC/BPS is associated with diabetes
Image courtesy of Medscape after Nickel JC.[9]
Dysuria: When It Hurts to Go With the Flow
Josh Palka, DO; Christopher Atalla, DO | March 10, 2023 | Contributor Information
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.[8,9] 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.[10] Cauterization of these lesions can relieve the patient's pain.
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Contributor Information
Josh Palka, DO
Urologist
Michigan Institute of Urology
West Bloomfield, 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.
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References
Gerber GS, Brendler C. Evaluation of the urologic patient: history, physical examination, and urinalysis. Partin AW, Dmochowski RR, Kavoussi LR, et al, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 1.
Sanchez GV, Babiker A, Master RN, 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
Stein DM, Thum DJ, Barbagli G, et al. A geographic analysis of male urethral stricture aetiology and location. BJU Int. 2013 Oct;112(6):830-4. PMID: 23253867
Beltran H, Robinson BD, Tagawa ST. Primary squamous cell carcinoma of the urinary bladder presenting as peritoneal carcinomatosis. Adv Urol. 2010:179250. PMID: 20672052
Lamm DL, McGee WR, Hale K. Bladder cancer: current optimal intravesical treatment. Urol Nurs. 2005 Oct;25(5):323-6, 331-2. PMID: 16294610
Hanno PM. Bladder pain syndrome (interstitial cystitis) and related disorders. Partin AW, Dmochowski RR, Kavoussi LR, et al, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 14.
Nickel JC. Interstitial cystitis: characterization and management of an enigmatic urologic syndrome. Rev Urol. 2002;4(3):112-121. PMID: 16985667
Taneja R, Pandey S, Priyadarshi S, et al. Diagnostic and therapeutic cystoscopy in bladder pain syndrome/interstitial cystitis: systematic review of literature and consensus on methodology. Int Urogynecol J. 2023 Jan 28. PMID: 36708406
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