Dysuria is defined as painful or difficult urination, often accompanied by urinary frequency, urgency, or hesitancy. It typically reflects lower urinary tract irritation or inflammation, most commonly due to urinary tract infection (UTI), particularly in women. Dysuria may arise from irritation of the bladder, urethra, or adjacent structures. The timing of pain during urination provides diagnostic clues: pain just before voiding often indicates bladder irritation or distention, pain at the start of urination suggests bladder outlet or urethral irritation, and pain at the end of voiding may indicate bladder spasms or, in women, vaginal candidiasis.

Pathophysiology

Dysuria results from stimulation of sensory nerve endings in the bladder and urethra due to inflammation, infection, obstruction, or chemical irritation. Specific mechanisms include:

• Infection: Bacterial, viral, or fungal pathogens trigger inflammation and pain.

• Obstruction: Urethral strictures or calculi increase bladder pressure, causing painful voiding.

• Chemical irritants: Substances such as bubble bath salts, feminine deodorants, and spermicides cause local irritation.

• Inflammatory disorders: Conditions like prostatitis, paraurethral gland inflammation, or vaginitis cause tissue irritation.

The onset and nature of pain often correlate with the underlying cause, guiding clinical evaluation.

Signs and Symptoms

• Painful or difficult urination

• Urinary frequency and urgency

• Hesitancy or diminished urine stream

• Suprapubic discomfort, perineal pain, or lower back pain

• Hematuria in some cases

• Systemic symptoms (e.g., fever, fatigue, nausea) depending on etiology

• Vaginal or urethral discharge in women and men, respectively

Clinical Assessment

History

• Onset, severity, duration, and pattern of dysuria

• Associated urinary symptoms (frequency, urgency, nocturia, hematuria)

• Previous urinary or genital infections

• Recent invasive procedures (cystoscopy, urethral dilatation, catheterization)

• Medications (including chemical irritants and drugs like MAO inhibitors)

• Female-specific factors: menstrual disorders, vaginal discharge, use of irritant products

Physical Examination

• Inspect urethral meatus for discharge, erythema, or lesions

• Pelvic or rectal examination if indicated

• Assess bladder tenderness, suprapubic or flank pain

• Check for systemic signs (fever, tachycardia)

Medical causes of dysuria

Special considerations

• Monitor vital signs, intake/output

• Perform diagnostic tests as indicated: urinalysis, urine culture, cystoscopy

• Educate about increased fluid intake, frequent voiding, proper perineal hygiene

• Advise avoidance of irritant products (bubble baths, vaginal deodorants)

• Emphasize adherence to prescribed medications

Geriatric considerations

• Elderly patients may underreport symptoms

• Older men: increased incidence of non-sexually related UTIs

• Postmenopausal women: higher incidence of noninfectious dysuria

Patient counseling

• Explain the importance of hydration and frequent urination

• Teach proper perineal care

• Advise avoiding chemical irritants

• Reinforce adherence to prescribed medications and follow-up care

References

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