Dysuria

Published on 06/06/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2398 times

Chapter 22 Dysuria

INTRODUCTION

Description: Dysuria is the painful passage of urine (symptom, not diagnosis).
Prevalence: Common in women, 10% to 20% per year. One third of women during their lifetime.
Predominant Age: Any.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection and inflammation in the urethra and suburethral tissues. Most urinary tract infections in women ascend from contamination of the vulva and meatus acquired via instrumentation, trauma, or sexual intercourse. (A history of intercourse within the proceeding 24 to 48 hours is present in up to 75% of patients with acute urinary tract infection.) Coliform organisms, especially Escherichia coli, are the most common organisms responsible for asymptomatic bacteriuria, cystitis, and pyelonephritis. Ninety percent of first infections and 80% of recurrent infections are caused by E. coli, with between 10% and 20% resulting from Staphylococcus saprophyticus. Infection with other pathogens such as Klebsiella species (5%) and Proteus species (2%) account for most of the remaining infections. Infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma, and Ureaplasma should all be considered when urethritis is suspected. Chemical irritation, allergic reactions, or vulvitis may all produce symptoms of dysuria.
Risk Factors: Sexual activity, instrumentation, more virulent pathogens, altered host defenses, infrequent or incomplete voiding, foreign body or stone, obstruction, or biochemical changes in the urine (diabetes, hemoglobinopathies, pregnancy) estrogen deficiency, diaphragm use, spermicides.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Painful urination
• Frequency, urgency, nocturia (commonly associated, indicate irritation of the bladder wall)
• Pelvic pressure (if cystitis is present)
• Pyuria (more than five white blood cells per high-power field in a centrifuged specimen, most prominent in first one third of voided specimen)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Cystitis
• Traumatic trigonitis
• Urethral syndrome
• Interstitial cystitis
• Bladder tumors or stones
• Vulvitis and vaginitis (may give rise to external dysuria as in herpetic vulvitis)
• Urethral diverticulum
• Infection in the Skene’s glands
• Detrusor instability

Associated Conditions: Dyspareunia, cystitis.

Workup and Evaluation

Laboratory: Nonpregnant women with a first episode of dysuria suggestive of urinary tract infection do not need laboratory confirmation of the diagnosis; they may be treated empirically. (Recent data suggest that this may be an acceptable strategy for women with fewer than three episodes per year, who lack fever or flank pain, and have not been treated recently for the same symptoms.) For others, urinalysis and culture should be performed. For uncentrifuged urine samples, the presence of more than one white blood cell per high-power field is 90% accurate for detecting infection. Gram stain of urine samples or sediments may help to establish the diagnosis or suggest a possible pathogen.
Imaging: No imaging indicated.
Special Tests: A sterile swab inserted into the urethra may be used to obtain material for culture and Gram stain to establish the diagnosis.
Diagnostic Procedures: History and physical examination, urinalysis. (Gentle pressure beneath the urethra or bladder trigone will often reproduce the patient’s symptoms when significant urethritis is present.)

Pathologic Findings

Pyuria (hematuria may be present as well).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Fluids, frequent voiding, and antipyretics. Urinary acidification (with ascorbic acid, ammonium chloride, or acidic fruit juices) and urinary analgesics (phenazopyridine [Pyridium]) may also be added based on the needs of the individual patient.
Specific Measures: Antibiotic therapy when infection is suspected.
Diet: Increased fluids and reduction of caffeine.
Activity: No restriction.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP050 (Urinary Tract Infections).

Drug(s) of Choice (Nonpregnant Patients)

Single-dose therapy: amoxicillin 3 g, ampicillin 3.5 g, a first-generation cephalosporin 2 g, nitrofurantoin 200 mg, sulfisoxazole 2 g, trimethoprim 400 mg, trimethoprim/sulfamethoxazole (320/1600 mg).
Three- to seven-day therapy: amoxicillin 500 mg every 8 hours, a first-generation cephalosporin 500 mg every 8 hours, ciprofloxacin 250 mg every 12 hours, nitrofurantoin 100 mg every 12 hours, norfloxacin 400 mg every 12 hours, ofloxacin 200 mg every 12 hours, sulfisoxazole 500 mg every 6 hours, tetracycline 500 mg every 6 hours, trimethoprim/sulfamethoxazole 160/800 mg every 12 hours, trimethoprim 100 (200) mg every 12 hours.

image image

Contraindications: Known or suspected hypersensitivity.
Precautions: Urinary analgesics (phenazopyridine [Pyridium]) should be used for no longer than 48 hours and may stain some types of contact lenses.
Interactions: See individual medications.

Alternative Drugs (Pregnant Patients)

Seven-day therapy: amoxicillin 500 mg every 8 hours, a first-generation cephalosporin 500 mg every 6 hours, nitrofurantoin 100 mg every 12 hours.

FOLLOW-UP

Patient Monitoring: No follow-up is necessary after single-dose treatment or after multiday treatment for nonpregnant women who experience resolution of their symptoms. Cure for all other patients should be confirmed by urinalysis and culture. Recurrent lower tract infections require prompt evaluation. Possible causes include incorrect or incomplete (e.g., noncompliant) therapy, mechanical factors (such as obstruction or stone), or compromised host defenses.
Prevention/Avoidance: Frequent voiding, adequate fluid intake, voiding after intercourse.
Possible Complications: Urethral syndrome and interstitial cystitis. Bacteremia, septic shock, adult respiratory distress syndrome, and other serious sequelae are associated with pyelonephritis.
Expected Outcome: For most patients, symptoms (when resulting from infection) should resolve within 2 to 3 days after the initiation of therapy.

MISCELLANEOUS

Pregnancy Considerations: Those at high risk (e.g., patients with diabetes) should be monitored carefully to avoid urethritis, cystitis, and ascending infection.
ICD-9-CM Codes: 788.1 (Urinary tract infection).

REFERENCES

Level I

Greenberg RN, Reilly PM, Luppen KL, et al. Randomized study of single-dose, three-day, and seven-day treatment of cystitis in women. J Infect Dis. 1986;153:277.

Level III

Car J. Urinary tract infections in women: diagnosis and management in primary care. BMJ. 2006;332(7533):94.

Franco AV. Recurrent urinary tract infections. Best Pract Res Clin Obstet Gynaecol. 2005;19:861. Epub 2005 Nov 17

Mittal P, Wing DA. Urinary tract infections in pregnancy. Clin Perinatol. 2005;32:749.

Nicolle L, Anderson PA, Conly J, et al. Uncomplicated urinary tract infection in women. Current practice and the effect of antibiotic resistance on empiric treatment. Can Fam Physician. 2006;52:612.

Pappas P. Laboratory in the diagnosis and management of urinary tract infections. Med Clin North Am. 1991;75:313.

Sheffield JS, Cunningham FG. Urinary tract infection in women. Obstet Gynecol. 2005;106:1085.

Stamm W. Criteria for the diagnosis of urinary tract infection and for the assessment of therapeutic effectiveness. Infection. 1992;20(Suppl 3):S151. S160.

Stamm W. Controversies in single dose therapy of acute uncomplicated urinary tract infections in women. Infection. 1992;20:S272.

Stamm W, Hooton T. Management of urinary tract infections in adults. N Engl J Med. 1993;329:1328.

Whelan P. Manage urinary tract infections. Practitioner. 2006;250:38. 41, 43 passim.

Related posts:

Cervical Incompetence Forceps-Aided Delivery Anorectal Fistula Vaginitis: Bacterial (Nonspecific) and Bacterial Vaginosis Rh Incompatibility Breast: Galactocele