Overall, the most common conditions associated with dysuria are urinary tract infections (UTIs), urethritis, and local irritation. However, there are many other causes to consider (Table 9–1).2–4 The patient's age and the presence of specific clinical or laboratory findings can help focus the differential diagnosis. Additionally, sexual abuse and pruritis associated with pinworm infestation can mimic dysuria.
A complaint of dysuria can be difficult to ascertain in younger children, but the presence of fever, increased fussiness, decreased appetite, lower abdominal pain, or suprapubic or flank tenderness may signal the presence of a UTI. Among febrile infants and children of age 2 months to 2 years with no other source of fever, the prevalence of a UTI is about 5% with an overall predominance of girls. Male neonates are five to eight times more likely to have a UTI than girls during the neonatal period but after 3 months of age, female infants are two times more likely to be infected and 1–5-year-old girls are 10–20 times more likely to be compared with boys.5
A UTI can affect either the upper or lower genitourinary tract. The presence of fever and other signs such as flank pain point to pyelonephritis rather than cystitis. These signs, however, are more reliable in older children. The most common organisms associated with UTI are enterobacteria. Escherichia coli is associated with 70–90% of infections.5,6 Other organisms include Pseudomonas aeruginosa, Proteus mirabalis, and Enterococcus spp. Viruses, though less common, can also cause cystitis. Adenovirus in particular is a well-described cause of acute hemorrhagic cystitis. Uncommon organisms that cause UTI include Staphylococcus aureus, Schistosomae (associated with acute hemorrhagic cystitis), and Mycobacterium tuberculosis.1,5,6S. aureus most commonly causes infection when there is a predisposing condition such as an indwelling catheter or concurrent infection such as a renal abscess.
Other causes of dysuria in the prepubertal child include vaginitis in girls and balanitis in boys. Vaginitis can be caused by group A Streptococcus, Shigella spp., or Candida spp. Varicella lesions involving the perineum and vagina may also cause dysuria.4 If there are signs of vaginitis or urethritis and the source is found to be a sexually transmitted organism such as Chlamydia trachomatis or Neisseria gonorrhoeae, an evaluation for sexual abuse should be initiated.
Among adolescents, UTI remains the most common cause of dysuria, particularly in girls. UTIs occur less commonly in postpubertal boys in the absence of an anatomic urinary tract abnormality. Beyond UTI, the most important consideration is sexually transmitted infection causing urethritis, cervicitis, or vaginitis. The symptoms for both urinary tract and sexually transmitted infections overlap such that evaluation for both etiologies is often required in adolescents. One prospective study of adolescent females with dysuria showed that only 17% had a UTI, while 15% had C. trachomatis and 29% had urethritis and vaginitis caused by a variety of sexually and nonsexually transmitted agents.7 UTIs are caused by many of the same pathogens that cause infection in younger children, with the exception of Staphylococcus saprophyticus,7 which occurs more commonly in adolescent girls.
The burden of sexually transmitted infection among adolescents is high. According to the Centers for Disease Control and Prevention (CDC), 40% of all cases of C. trachomatis are diagnosed in 15–19-year-old females.7 Since a history of sexual activity is not always reliable, screening for N. gonorrhoeae and C. trachomatis should be a routine part of the evaluation of an adolescent with dysuria, particularly if no other cause has been identified. Also, among boys, a complaint of dysuria is much more likely to be due to urethritis rather than UTI.8 The presence of urethral or vaginal discharge strongly suggests urethritis, most commonly caused by either N. gonorrhoeae or C. trachomatis. Dysuria can also be associated with genital herpes simplex virus infection or with vaginitis caused by other sexually or nonsexually transmitted agents such as Candida albicans, Trichomonas vaginalis, and Gardnerella vaginalis.7,9
In an adolescent with dysuria, fever, and abdominal or flank pain, an upper genitourinary tract infection such as pyelonephritis or pelvic inflammatory disease (PID) should be considered. However, these symptoms can overlap with a wide range of other intra-abdominal conditions such as appendicitis, gastroenteritis, and nephrolithiasis.7 The presence of flank pain and pyuria helps to distinguish pyelonephritis. Among sexually active adolescent females, assessing for PID is extremely important given the potential long-term sequelae of untreated infection. In addition to dysuria, patients may complain of lower abdominal or pelvic pain, fever, dyspareunia, vaginal discharge, and vaginal bleeding.9 However, symptoms for PID can be very mild and only include one or two of these findings. In these cases, PID may not be considered in the differential diagnosis and infection can be missed. Minimal criteria defined by the CDC for the diagnosis of PID include cervical motion, uterine, or adnexal tenderness with or without other signs of of lower genitourinary tract infection. These criteria, while not very specific, minimize the frequency of missed infection.
Noninfectious Causes of Dysuria
In younger children, particularly those who present with isolated dysuria, local irritation is a common etiology. Local irritation can be induced by exposure to a variety of products including bubble bath, perfumed soap, or detergents. There may be no apparent signs of irritation on physical examination but symptom resolution will coincide with removal of the offending exposure. Dysuria is also caused by local trauma associated with genital self-exploration, masturbation, or by direct trauma caused by events such as straddle injuries.2–4 It is often difficult to elicit a history of trauma. Younger children may not remember an injury event and older children may be reluctant to disclose self-exploration or masturbation.2–4
Anatomic abnormalities can also cause dysuria. In young girls, labial adhesions are relatively common. While they are usually asymptomatic, there can be associated dysuria, especially if the urethral meatus is involved. Urinary strictures have also been found to cause dysuria in both younger children and adolescents.4 Additionally, genitourinary abnormalities can predispose children to infection that results in dysuria. For infants and young children with a first UTI or older children with recurrent infection, evaluation for these abnormalities should be considered.10
Dysfunctional elimination syndrome (DES) with associated idiopathic urethritis is a relatively common cause of dysuria in younger children.11,12 This diagnosis should be strongly considered if there is (1) no evidence of infection, (2) no history of exposure to irritants or trauma, and (3) no anatomic abnormality. Here, dysuria occurs in conjunction with constipation, which causes inadequate bladder emptying and chronic uretheral irritation. Bladder and bowel retraining programs effectively treat the urethritis.11,12
If dysuria is accompanied by hematuria and flank or lower abdominal pain with no fever or other signs of infection, urolithiasis should be considered. This is relatively uncommon among children and adolescents unless there is a history of a predisposing metabolic disorder such as hypercalciuria.13
When no cause for dysuria is identified, the complaint is isolated or is associated with times of stress, psychogenic dysuria should be considered. It is also important to seek other causes of perineal irritation such as pinworm infestation, which causes discomfort that is misidentified as dysuria.2,3 If dysuria is associated with multiple symptoms such as rash, fever, conjunctivitis, the systemic causes of dysuria must be ruled out.2 However, in these cases, dysuria is not usually the presenting complaint.