Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Dysuria

Dysuria - Key Features

1. In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated UTI.

Most common clinical triad for an acute uncomplicated cystitis is: dysuria, frequency, and urgency (in an immunocompetent woman of childbearing age who has no comorbidities or urologic abnormalities).

Negative macroscopic-screened urines (dipsticks) do not routinely require microscopic examination of urine, unless:
a) Dipstick analysis is positive for any of:
- leukocyte esterase or
- nitrite
- may be heme positive (blood)
- turbidity
- glucose >55mmol/l; protein (greater than trace)
- **Nitrites and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis in symptomatic woman. Mid-stream urine is best.

Urine culture:
- Urine culture only recommended for patients with suspected acute pyelonephritis; pts with symptoms that do not resolve or that recur within 2-4 weeks after completion of tx; and pts who present with atypical symptoms.
- A CFU >103/ml of a uropathogen is diagnostic

b) Special case: pts presenting with a condition where clinical record justifies further investigation such as:
- diabetes
- established kidney disease/transplant
- pregnancy
- recent urological sx/cystoscopy
- genitourinary problems
- neurogenic bladder
- requests by consultants for investigation of UT problems
- spinal cord injury or disease

2. When a dx of uncomplicated UTI is made, treat promptly without waiting for a culture result.

- Choose antibiotic based on agent’s effectiveness, risks of adverse effects, resistance rates, and propensity to cause collateral damage (ie. ecologic effects of AB therapy on normal body flora). Pts should notice relief within 36 hours.
- Commonly used are septra DS 1 tab bid x 3-5 days, nitrofurantoin 100 mg po bid 5-7 days; fluoroquinolones are reserved for exceptional cases (ie., allergies, etc) as there is a high rate of resistance

3. Consider non-UTI related etiologies of dysuria (e.g., prostatitis, vaginitis, STI, chemical irritation) and look for them when appropriate.

- If pts report vaginal discharge/irritation: vaginitis or cervicitis more likely
- Acute pyelonephritis should be suspected in ill-appearing pts, who are uncomfortable, and also have fever/tachycardia/CVA tenderness.

In Men consider:
- urethritis: commonly in young sexually active men
- UTI’s: commonly in older men with prostatic hypertrophy
- gonorrhea
- acute/chronic prostatitis: in young/middle age men
- epididymitis: irritative voiding symptoms (dysuria, frequency, urgency) and pain in one testicle. Often high fever and rigours.

In Women consider:
- urethritis: hx of unprotected sexual exposure
- gonorrhea/chlamydia
- Vaginitis: candidal, trichomonas, genital herpes
- Atrophic vaginitis: urine comes in contact with sensitive atrophied mucosal tissue
- Interstitial cystitis: often middle age, longstanding symptoms with negative cultures
- Pelvic Inflammatory Disease

4. When assessing patients with dysuria, identify those at higher risk of complicated UTI (e.g, pregnancy, children, diabetes, urolitiasis).

Characteristics of Pts with Uncomplicated and Complicated UTIs
Uncomplicated	Complicated
- Immunocompetent - no comorbidities - no known urologic abnormalities - non pregnant - premenopausal	- hx of childhood UTIs - immunocompromised - preadolescent or postmenopausal - pregnant - underlying metabolic disorder (ex. DM) - Urologic abnormalities (ex. stones, stents, indwelling catheters, neurogenic bladder, PCKD) - *UTIs in men are usually complicated

5. In patients with recurrent dysuria, look for a specific underlying cause (e.g., post-coital UTI, atrophic vaginitis, retention).

Recurrent UTI: >2 uncomplicated UTIs in 6 months, or commonly as >3 positive cultures within preceding 12 months. About 25% of women affected by this
Risk Factors:

Premen Women: inc. freq. of sex inter, use of spermicide, new sex partners, anatomical abnormalities

Postmen Women: Lactobacilli is natural pathogen against E.Coli. With vaginal atrophy, decreased lactobacilli. Incontinence, pelvic floor prolapse, and increased post-void residuals are at increased risk.

With recurrent infections, structural abnormalities should be considered. Especially if organisms such as Proteus, Pseudomonas, Enterobacter, and Klebsiella are found (associated with anatomy abnormalities or renal calculi).

Study Guide

Dysuria

References

SOGC Clinical Practice Guideline. “Recurrent Urinary Tract Infection”. No. 250, November 2010
Colgan, R. and Williams, M. Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician. 2011; 84(7):771-776