Clinical Medicine 216 - Dysuria
What is dysuria?
Any burning, tingling, stinging, and/or any other sensation of pain or discomfort associated with voiding urine
In males, dysuria is usually felt?
In the distal urethra during voiding and resolves shortly after micturition
Pain at the start of urination in males usually indicates?
A urethral source of inflammation
More severe pain occurring over the suprapubic area on completion of urination in males commonly indicates?
Inflammation of the bladder
What are the main lower urinary tract symptoms?
What are the main obstructive lower urinary tract symptoms?
H = Hesitancy
I = Intermittence
S = Straining
What are the atypical causes of urinary tract infections?
Tuberculosis, Chlamydia trachomatis, candida, herpes, and gonorrhoea
What are the common causes of urinary tract infections?
E= E. coli (most common), other Gram -ve
P= Proteus mirabilis, Pseudomonas
What are the two phases of lower urinary tract function?
Bladder filling and urine storage, and bladder emptying
Is dysuria more common in men or women?
Dysuria in males is most commonly caused by?
Urethritis, prostatitis, cystitis, or mechanical irritation of the urethra
Urinary flow in males may be altered by?
Compression of the urethra as it passes through an enlarged prostate. This may produce hesitancy, slowing of the urinary stream, dribbling, and nocturia.
Roles of the kidney:
1. Excretion of waste products and metabolites
2. Regulation of our water and electrolyte balance/concentrations
3. Regulation of our blood pressure
4. Regulates acid-base balance
5. Regulates red blood cell production
6. Secretes, breaks down, and excretes hormones
What are some possible reasons for failure to void?
1. Outflow obstruction
2. Loss of bladder innervation
What are some anatomical causes of dysuria?
Urethral stricture, urinary diverticulum, and benign prostatic hyperplasia in men
What are some non-inflammatory endocrine causes of dysuria in women?
Atrophic vaginitis (hypoestrogenism) and endometriosis
What are some non-inflammatory idiopathic causes of dysuria?
Chronic bladder pain syndrome / interstitial cystitis
What are some non-inflammatory neoplastic causes of dysuria?
Kidney, bladder, prostate, penile, or vulvovaginal cancers
What are some inflammatory dermatologic causes of dysuria?
Irritant/contact dermatitis, lichen sclerosis, lichen planus, psoriasis, Stevens-Johnson syndrome, and Behcet syndrome
What are some common inflammatory infectious causes of dysuria?
Cystitis, urethritis, pyelonephritis, sexually transmitted diseases, and perineal inflammation
What are some inflammatory infectious causes of dysuria in men?
Prostatitis, epididymitis, and orchitis
What are some inflammatory infectious causes of dysuria in women?
Vulvovaginitis and cervicitis
What are some non-inflammatory psychogenic causes of dysuria?
Anxiety, stress, depression, and somatization disorders
What are some non-infectious inflammatory causes of dysuria?
Foreign body (e.g., stones, stents, and catheters), urethritis (as the result of reactive arthritis/Reiter’s syndrome), drug side effects, and radiation induced
What is urinary diverticulum?
Cystic outpouching-type structure often located just next to the urethra or in the bladder
Clinical features of urinary diverticulum:
Dysuria, dyspareunia, dribbling with voiding, recurrent UTIs, vaginal mass (anterior wall), hematuria, vaginal discharge, and urinary incontinence (can be stress incontinence) and obstructive symptoms.
What is benign prostatic hyperplasia?
A non-cancerous enlargement of the prostate gland. As it grows throughout the transition zone, it will eventually press and pinch the urethra.
What are the complications of benign prostatic hyperplasia?
Hydronephrosis, retention, overflow incontinence, renal insufficiency, infection, gross hematuria, and bladder stones
What is acute dysuria?
Dysuria of less than 1 week in duration
What is internal dysuria?
Dysuria that is localized to the internal genital structures (urethra, bladder, and suprapubic area)
What is external dysuria?
Dysuria that is localized to external genital structures (labia minora and labia majora) and occurs as urine exits the body
What is urgency?
A sudden, compelling need to urinate that is often accompanied by bladder discomfort, with the inability to void more than a minimal quantity of urine.
What is frequency?
Urinating more frequently than usual without an increase in total urine volume due to the bladder's decreased capacity to hold urine.
What is nocturia?
Waking up to urinate 2 or more times during the night
What are voiding symptoms?
Symptoms that occur at the time of urination. These include a slow or intermittent urine stream, difficulty initiating urination (hesitancy), prolonged termination of urination (dribbling), and dysuria.
What are storage symptoms?
Symptoms that occur during bladder storage and filling. These include urinary urgency or frequency, nocturia, and incontinence.
What is an urinary tract infection (UTI)?
An infection of the urethra, prostate, bladder, or kidney
What is a lower urinary tract infection (UTI)?
An infection of the urethra and/or bladder (i.e., urethrocystitis or cystitis)
What is an upper urinary tract infection (UTI)?
An infection of the kidney (i.e., pyelonephritis)
What is a complicated urinary tract infection (UTI)?
A UTI in individuals with functional or structural abnormalities of the urinary tract. These individuals are at higher risk for treatment failure.
Referred pain from where can lead to dysuria?
The pelvic or abdominal organs
What is atrophic vaginitis?
Thinning, drying, and inflammation of the vaginal walls due to having less estrogen
What is chronic prostatitis?
Inflammation of the prostate typically caused by bacterial infection, which is associated with urinary tract infection, cystitis, urethritis, epididymitis, or acute prostatitis.
Dysuria with an insidious onset raises the possibility of __________?
Rare neoplastic etiologies
Dysuria in the presence of systemic symptoms (e.g., fever or chills, abdominal or flank pain, nausea and vomiting) should prompt consideration of _________?
Acute bacterial causes of dysuria such as pyelonephritis, acute prostatitis, epididymitis, or pelvic inflammatory disease
In women, the likelihood of pyelonephritis increases with __________?
Recent spermicide use, new incontinence in the past month, UTI in the past year, diabetes, a history of UTI in the patient's mother, and sexual intercourse more than once per week.
What is a serious cause of dysuria with fever and chills?
What are common causes of dysuria with fever and chills?
Pyelonephritis, epididymitis, and acute prostatitis
What is a common cause of dysuria with flank pain?
What is a common cause of dysuria with flank pain with hematuria?
What is a serious cause of dysuria with flank pain with hematuria?
What is a serious cause of dysuria with hematuria?
What is a common cause of dysuria with hematuria?
What is a serious cause of dysuria with penile discharge, mass or ulcer, and pain at the tip of the penis?
What is a common cause of dysuria with penile discharge, mass or ulcer, and pain at the tip of the penis?
Urethritis (chlamydia, gonorrhoea, or herpes simplex virus)
What is a serious cause of dysuria with pelvic pain and dyspareunia?
Endometriosis and pelvic inflammatory disease
What is a serious cause of dysuria with vaginal bleeding?
Vaginal cancer and pelvic inflammatory disease
What is a common cause of dysuria with vaginal bleeding?
What is a common cause of dysuria with scrotal pain and/or swelling?
What is a common cause of dysuria with painful genital ulcers?
Herpes simplex virus
What is a serious cause of dysuria with painful genital ulcers?
Behcet's syndrome, is a rare disorder that causes ________ throughout your body. The disease can lead to numerous signs and symptoms that can seem unrelated at first. They can include mouth sores, eye inflammation, skin rashes and lesions, and genital sores.
Blood vessel inflammation
What is a serious cause of dysuria with painful oral ulcers, arthritis, and eye findings?
Behcet's syndrome and reactive arthritis
________ is a painful form of inflammatory arthritis (joint disease due to inflammation). It occurs in reaction to an infection by certain bacteria. Most often, these bacteria are in the genitals (Chlamydia trachomatis) or the bowel (Campylobacter, Salmonella, Shigella, and Yersinia).
What are some serious causes of dysuria with suprapubic pain, incontinence, and obstructive urinary symptoms (weak stream, hesitancy)?
Neurological disease (multiple sclerosis) and Parkinson's disease
What are common causes of dysuria with suprapubic pain, incontinence, and obstructive urinary symptoms (weak stream, hesitancy)?
Bladder outlet obstruction due to benign prostatic hyperplasia or urethral stricture.
What could cause dysuria with painful urination that lasts for 1-2 days?
Bacterial cystitis, acute bacterial prostatitis, and bacterial epididymitis
What could cause dysuria with painful urination that lasts for 2-7 days?
Urethritis / epididymitis (gonorrhoea, chlamydia, or herpes simplex virus)
What could cause dysuria with painful urination that lasts for more than 14 days?
Chlamydia infection (in women)
What could cause painful urination that lasts for weeks to months?
Interstitial cystitis, chronic bacterial prostatitis, chronic prostatitis/pelvic pain syndrome (men), and vulvodynia (women)
_______ is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. For the diagnosis to be made symptoms must last at least 3 months.
What could cause cyclic menstrual pain several days before onset of menstruation?
What could cause pain during or immediately after the onset of menstruation?
Pelvic inflammatory disease
What could cause pain at the beginning of urination?
What could cause pain at the end of urination?
Cystitis or prostatitis
What could cause one to urinate more frequently than usual during the day?
Decreased bladder capacity (bladder inflammation or infection) or incomplete bladder emptying (benign prostatic hyperplasia or neurologic disease)
What could cause pain that gets worse after consuming food and drink?
Interstitial cystitis or painful bladder syndrome
Interstitial cystitis or painful bladder syndrome causes pain to ________ when the bladder is full and to ________ after urination?
What could cause dysuria with bladder incontinence?
Bladder inflammation as seen in acute cystitis, upper motor neuron lesion, detrusor muscle instability, and obstruction or irritation by bladder tumours
What could cause dysuria with a decreased amount of urine output?
Bladder inflammation from infection, irritants, systemic disease, or interstitial cystitis
What can cause painful urination without frequency or urgency in men?
What can cause dysuria with fever and painful or swollen testicles?
Bacterial epidiymitis or prostatitis
What can cause dysuria with fever and flank pain or nausea and vomiting?
What can cause dysuria with fever and rectal discomfort, pain, or discharge?
Prostatitis (pain only), proctitis due to gonorrhoea, chlamydia, or herpes simplex virus
What can cause dysuria with fever and swollen lymph nodes in the groin area or dysuria with a new headache?
Primary genital herpes simplex virus
What can cause dysuria with hematuria?
Hemorrhagic cystitis (acute onset), bladder cancer, and benign prostatic hyperplasia (intermittent or chronic)
What can cause dysuria with hematuria and pain in the mid-back (flank pain)?
Nephrolithiasis (usually acute onset) or renal cell cancer (chronic)
What can cause dysuria with purulent or mucopurulent discharge?
Urethritis or cervicitis due to gonorrhoea or chlamydia. Most women with these infections will be asymptomatic.
What can cause burning or pain in the external genital area of women?
What can cause dysuria with lower abdominal pain or vaginal bleeding in women?
Pelvic inflammatory disease
What can cause dysuria in men with bloody discharge?
Kidney and bladder neoplasms often produce?
What can cause dysuria with unintentional weight loss?
Bladder or renal cancer
What can cause dysuria with vaginal dryness?
What can cause dysuria with a feeling of discomfort or a sensation that something is in the vagina during urination?
What is a cystocele?
A weakness of the anterior vaginal wall causing the bladder to protrude into the vagina during urination. (Herniation of the urinary bladder into the vagina)
What can cause dysuria as a result of sexual activity?
Chlamydia, gonorrhoea, and trichomoniasis
Dyspareunia during initial vaginal penetration in women suggests?
Vulvovaginitis, atrophic vaginitis, or urethritis
Dyspareunia during deep vaginal penetration in women suggests?
What surgical-related treatment can cause dysuria?
Catheterization, instrumentation, and urethral stents
What is dyspareunia?
Occurrence of pain during sexual intercourse
What is urosepsis?
Septic poisoning from retained and absorbed urinary substances
What can cause urosepsis?
Infection from extravasated urine, obstruction of infected urine, or an urinary tract infection
What is cystitis?
Inflammation of the urinary bladder
What is urethritis?
Inflammation of the urethra; which is the passageway that connects the bladder with the exterior of the body
What is endometriosis?
A condition in which small amounts of tissue similar to the lining of the uterus grow in other parts of the body
What is pelvic inflammatory disease?
A term used to describe any infection in the lower female reproductive tract that spreads to the upper female reproductive tract
What is interstitial cystitis?
Inflammation of the bladder believed to be associated with an autoimmune or allergic response. The bladder wall becomes inflamed, ulcerated, and scarred, causing frequent painful urination.
What is orchitis?
Inflammation of the testis, which can be accompanied by swelling, pain, fever, and/or a sensation of heaviness in the affected area
What is proctitis?
Inflammation of the rectum
Where is prostatic pain felt?
In the perineum and occasionally in the rectum
What is hematuria?
Blood in the urine
What is gross hematuria?
Blood in the urine that is visible to the naked eye
What is microscopic hematuria?
Blood in the urine that is detected only during microscopic urinalysis
Kidney pain or flank pain is located __________?
At or below the posterior costal margin near the costovertebral angle. It may radiate anteriorly toward the umbilicus.
What is kidney pain?
A visceral-type pain usually produced by distention of the renal capsule and typically is dull, aching, and steady
What is ureteral pain?
Usually severe and colicky, originating at the costovertebral angle and radiating around the trunk into the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or labium.
What can ureteral pain result from?
Sudden distention of the ureter and associated distention of the renal pelvis
You are seeing a 67-year old man who reports mild dysuria for the past 3 months. Which symptom would be least concerning for bladder cancer?
Associated symptoms of difficulty initiating urination and a weak urinary stream
A woman presents to your office with dysuria and has not had a medical evaluation for over a year. What condition would not need to be tested for chlamydia?
A woman who has not been sexually active for over a year
What can cause dysuria with costovertebral angle tenderness?
Pyelonephritis, nephrolithiasis, or obstruction with hydronephrosis
What can cause dysuria with urethral mass or tenderness in women?
Urethral diverticulum or endometriosis
What can cause dysuria with cervical motion tenderness and/or mass or tenderness on bimanual examination in women?
Endometriosis, pelvic inflammatory disease, gynaecological mass, or urethral diverticulum
High levels of excreted protein in the urine may indicate:
Kidney failure, diabetes mellitus, inflammation in the kidney, urinary tract infection, or renal carcinoma
Clinical presentation of interstitial cystitis (bladder pain syndrome):
Variable dysuria, frequency and urgency as primary symptoms, pain with bladder filling, and relief with emptying
Clinical presentation of overactive bladder:
Prominent urgency, frequency, and possible urge incontinence
Uncomplicated urinary tract infection:
Within the lower urinary tract, in the setting of a structurally and functionally normal urinary tract
Gonococcal urethritis presents with?
Yellow purulent discharge and irritative lower urinary tract symptoms
Non-gonococcal urethritis presents with?
Mucoid whitish purulent discharge, with or without irritative lower urinary tract symptoms
With urethritis you must rule out?
Reactive arthritis (Reiter's Syndrome)
Reactive arthritis clinical presentation?
Urethritis/cervicitis, uveitis/conjunctivitis, and arthritis
All patients with urethritis should be tested for?
N. gonorrheae and C. trachomatis
What is acute pyelonephritis?
Infection of renal parenchyma with local and systemic manifestation. It is potentially life-threatening and causes scarring of the kidneys.
Acute pyelonephritis is usually caused by?
An infection ascending from an UTI. It can also be caused by hematogenous spread and seeding.
Clinical presentation of acute pyelonephritis?
Rapid onset, CVA tenderness or exquisite flank pain, gross hematuria, lower urinary tract symptoms, fever, chills, nausea and vomiting, and possible confusion in the elderly.
What are the complications of pyelonephritis?
Permanent kidney scarring, which can predispose the patient to chronic kidney disease, hypertension, and renal failure. It can also cause sepsis.
Clinical presentation of acute bacterial prostatitis?
Acute onset, fever, chills, malaise, and vomiting. Pain in the rectal, lower back, and perineal areas. Irritative lower urinary tract symptoms (dysuria, frequency, and urgency) and hematuria. May also see painful ejaculation and hematospermia.
Clinical presentation of nephrolithiasis?
Flank pain (severe waxing and waning) which may radiate to the groin, testes, or tip of the penis (men). Nausea and vomiting, writhing, lower urinary tract symptoms, hematuria, diaphoresis, tachycardia, and tachypnea.
What is urethral stricture?
A decrease in the lumen of the urethra due to scar formation, injury, instrumentation, infection, and certain non-infectious forms of urethritis. Most commonly seen in men.
Some patients with severe urethral strictures are completely unable to urinate. This is referred to as ________ , and is a medical emergency. Hydronephrosis and renal failure may also occur.
Acute urinary retention
Interstitial cystitis symptoms can be defined as ________ .
Chronic urgency, frequency, with or without pain, and without any other reasonable causation. Can be ulcerative or non-ulcerative (more common).
What is interstitial cystitis?
A severely debilitating disease of the urinary bladder. Symptoms include excessive urgency and frequency of urination, suprapubic pain, dyspareunia and chronic pelvic pain. It can interfere with employment, social relationships, and sexual activity.
What are the symptoms of ulcerative interstitial cystitis?
Can result in fissures and cracks, inflammatory changes, mast cell infiltration, fibrosis, which can lead to reduced bladder capacity.
Non-ulcerative interstitial cystitis can present with?
Glomerulations, mucosal tears, and submucosal hemorrhages
__________________ refers to bladder hemorrhages which are thought to be associated with some types of interstitial cystitis (IC).
Clinical presentation of interstitial cystitis?
Acute onset with exacerbation and remission, frequency, urgency, pain, dysuria, pain with pressure in the pelvis, sense of incomplete bladder emptying, compulsion to void, and dyspareunia
What is renal carcinoma?
Deposition of malignant cells in the lining of the tubules of the kidney
Clinical presentation of renal cell carcinoma?
Hematuria, lower back pain specific to one side (not traumatic), a palpable mass on side with lower back pain, fatigue, loss of appetite, unintentional weight loss, elevated temperature, and/or anemia (low RBC) on CBC. Or can be completely asymptomatic.
Renal cell carcinoma can metastasize to?
Bone, brain, lung, and liver
Prognosis of renal cell carcinoma that is still within the renal structures and without metastasis?
73% of patients survive for 5 years
Renal failure findings?
High levels of urea, build-up of phosphates, build-up of potassium, failure to remove excess fluid, decreased EPO, and decreased circulating proteins
What is a sudden decrease in urinary output?
A sudden decrease in urinary output may result from _________ ?
Compromised renal blood supply (prerenal); damaged interstitia, glomeruli, or tubules (intrarenal); or obstructed urine flow (postrenal)
Patients at greater risk for renal failure are the ________ .
Elderly, diabetic, and those with history of renal, heart, or liver failure
Total hematuria is usually characteristic of lesions in the ________ .
Kidneys and ureters
Bladder lesions may produce bleeding independent of ________ .
_________ gross hematuria is consistent with upper or lower tract tumours, systemic coagulopathy, or excessive anticoagulant effect.
Less common causes of painless gross hematuria are ________
Acute necrosis or sloughing of papilla
In the elderly, painless hematuria may be a __________ of renal cancer.
Late presenting sign
In men older that 50, the presence of slow urinary stream, hesitancy, intermittency, and dribbling of urine with a gradual onset over time indicates _________ .
Obstructive problems from benign prostatic hypertrophy
Renal tract pain may present with a constant dull ache in the __________ area.
Costovertebral angle (CVA)
Dislodged kidney stones will produce an acute ureteral pain that is ________ .
Colicky and cyclic in nature
In men, pain from a dislodged kidney stone may _________ .
Radiate to the abdomen, testes, and penis
Other than a kidney stone, _________ do not frequently cause pain.
True renal pain can originate from the ________.
Calyces or renal pelvis
Other than a kidney stone, renal pain can result from _________ , but this is a seldom occurrence.
Stretching of the kidney capsule, interstitial edema, or inflammation of the capsule
Primary bladder disease from infection, stones, or tumours can produce __________ .
Prostate __________ characteristically produces nocturia.
_________ is defined as a volume greater than 3L of urine/day, and depends on the fluid intake and the patient's state of hydration.
Polyuria may be an early indication of ________ because of the kidney's inability to concentrate urine.
Renal disease progression
What is glycosuria?
The excretion of glucose into the urine. Ordinarily, urine contains no glucose because the kidneys are able to reabsorb all of the filtered glucose from the tubular fluid back into the bloodstream. Glycosuria is nearly always caused by elevated blood glucose levels, most commonly due to untreated diabetes mellitus.
Rarely, _______ is due to an intrinsic problem with glucose reabsorption within the kidneys (such as Fanconi syndrome), producing a condition termed renal glycosuria.
________ intake inhibits antidiuretic hormone; ________ promotes excess solute excretion, and resulting water loss.
Nocturia can also occur with the __________ of fluid during sleep, secondary to __________ .
Mobilization; congested heart failure
A patient who appears ill or who is in pain, is likely to have an __________ urinary tract problem such as pyelonephritis, urolithiasis, or acute prostatitis.
Patients with ________ urinary tract problems usually do not present with signs of systemic involvement, are fever free, and generally appear well.
________ is seen in patients with nephritis.
A pale skin colour may suggest anemia caused by _________ .
Poor nutrition or chronic renal failure
What is termed a toxic condition resulting from kidney disease in which there is retention in the bloodstream of waste products normally excreted in the urine?
Yellow-coloured to brown-coloured skin without _________ may indicate severe chronic uremia.
If the patient is hypertensive, auscultate the abdominal aorta, renal, and iliac arteries for bruits, which could indicate a _________ cause of the hypertension.
On urine dipstick, a positive ________ result is indicative of urethritis.
Leukocyte esterase or nitrite test
________ may indicate kidney involvement.
Suspect proximal renal tubular damage if urine __________ is elevated while ________ glucose levels are normal.
Serum ________ and blood ________ levels are used to indicate kidney function.
Creatinine; urea nitrogen
Dysuria usually reflects irritation or inflammation of the ________ (urethral meatus, labia majora/minora) or _________ (urethra, bladder), or ________ (ureters, kidneys).
External genitalia; lower; upper
In women with dysuria and vaginal discharge ________ is much more common than a urinary tract infection (UTI).
In women with dysuria but no vaginal symptoms ________ is more common.
Urinary tract infection (UTI)
Symptoms that support an urinary tract infection (UTI) are ________ .
Recent-onset dysuria, urinary urgency, frequency, nocturia, suprapubic pain, and cloudy urine
When symptoms recur in a women who has previously had cystitis, her pretest probability of an urinary tract infection (UTI) is ________ .
In older individuals, what are the risk factors that may increase the risk of an urinary tract infection (UTI)?
Atrophic vaginitis, benign prostatic hyperplasia, chronic prostatic, and urinary tract instrumentation
Infection or inflammation of the bladder may _________ , resulting in urinary frequency, nocturia, incontinence, and discomfort with holding even small amounts of urine leading to urinary urgency.
Decreases its capacity
Dysuria with insidious onset raises the possibility of ________ .
Rare neoplastic etiologies
Dysuria in the presence of systemic symptoms (e.g., fever, chills, abdominal or flank pain, nausea and vomiting) should prompt the consideration of other acute bacterial causes such as _________ .
Pyelonephritis, acute prostatitis, epididymitis, or pelvic inflammatory disease
What is the major structural abnormality associated with UTI and renal damage?
Nausea and vomiting often accompany an ________ .
Upper UTI, pyelonephritis, or lithiasis
Strenuous exercise can cause ________ often caused by trauma to the kidney and bladder.
Infants with a UTI may present with ________ and continuous damp diapers.
Strong foul smelling urine
Young children with pinworms may present with dysuria and vaginitis because of the ________ .
Abrasions that result from scratching
Women who use a ________ may experience mechanical compression of the urethra, with subsequent urine retention that predisposes them to the development of cystitis.
Foods that can cause dysuria without pyuria are ________ .
Spicy foods, caffeine, carbonated beverages, and alcohol
Mechanical factors related to compression of the bladder and bladder neck by a ________ may cause an UTI.
Hard mass of stool from constipation
In women, vulvovaginitis is a common cause of dysuria. The patient often describes the dysuria as ________ , which is a burning sensation as the urine passes inflamed labia.
In older women, ________ may present with vaginal dryness or discomfort during sexual intercourse. On physical examination, the vaginal mucosa is thin, pale, and dry with fewer rugae.