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Chapter 9. Dysuria

Kristen Feemster

Dysuria, defined as painful urination, indicates irritation of either the bladder, urethra, or prostate gland.1 It may be associated with urinary frequency and urgency or may be used to describe the discomfort associated with these symptoms. A complaint of dysuria can be difficult to elicit in younger children who may have difficulty distinguishing between dysuria and perineal or genital irritation.2

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.

Table 9–1. Infectious and Noninfectious Causes of Dysuria*
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Table 9–1. Infectious and Noninfectious Causes of Dysuria*

Infectious causes

Common

  • –Bacterial cystitis
  • –Pyelonephritis
  • –Urethritis
  • –N. gonorrhoeae
  • –C. trachomatis
  • –Herpes simplex virus
  • –Candida species

Less common

  • –Viral cystitis†
  • –Tuberculosis
  • –Prostatitis
  • –Schistosomiasis
  • —Bulbar urethritis (adolescent males)
  • —Balanitis (prepubertal males)

Noninfectious causes

Toxic/environmental

  • –Chemical irritation from bubble bath, detergents, or perfumed soaps
  • –Diaper dermatitis
  • –Systemic drugs (cytoxin)
  • –Contact dermatitis (poison ivy)

Trauma

  • –Masturbation/Sexual activity
  • –Local injury
  • –Irritation (tight clothing)
  • –Foreign body

Functional

  • –Dysfunctional elimination
  • –Syndrome/Constipation
  • –Attention-seeking behavior

Anatomic

  • –Labial adhesions
  • –Urolithiasis
  • –Nephrocalcinosis
  • –Uretheral stricture

Other

  • –Idiopathic urethritis
  • –Appendicitis
  • –Sarcoma botryoides
  • –Virginal vaginal ulcers

Systemic causes of urethritis

  • –Stevens–Johnson syndrome
  • –Reiter syndrome
  • –Behcet syndrome
  • –Varicella

*Conditions that predispose to infection, strictures, or urolithiasis include congenital and metabolic causes. Congenital causes include meatal stenosis, posterior urethral diverticula, ureterocele, ectopic ureter, posterior urethral valves, and vesicovaginal fistula. Metabolic causes include hypercalcuria and cystinuria.

†Adenovirus is the only viral pathogen likely to be found as a cause of urinary tract infection.6

Infection

Prepubertal Children

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....

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