Definition of Dysuria Our Symptoms article on Burning Urination provides a comprehensive look at the possible causes and treatments of Burning Urination. Definition of Dysuria Dysuria: Pain during urination, or difficulty urinating. Dysuria is usually caused by inflammation of the urethra, frequently as a result of infection. Last Editorial Review: 5/13/2016 Dysuria - Painful Urination Medical Information Attribution Overview, Causes, & Risk Factors Painful urination is any pain or discomfort that results when a person urinates. This pain can occur by itself or it can be associated with other symptoms. What is going on in the body? The urinary tract consists of several parts, each with a different function. The kidneys filter and remove waste products and water from the body and produce urine. Urine travels from the kidneys through two narrow tubes called ureters down to the bladder, where it is stored. When the bladder becomes full, it empties the urine through the urethra to the outside of the body. Painful urination can range from mild discomfort or a burning sensation in the urinary tract to severe, intense pain.

This pain may be acute, when it occurs suddenly, or chronic, when the pain lasts for a long period of time. Painful urination usually results from conditions that may be caused by infection, trauma, or something blocking the urinary tract. What are the causes and risks of the condition? There are many possible causes of painful urination. Some of these include: trauma to the urinary tract, such as genital injuries in males and females inflammation to any part of the urinary tract including the bladder, the kidney, or the urethra prostatitis, or inflammation or infection to the prostate gland in men vaginal infection, such a Candida albicans,\ \Candida tropicalis,\ \Candida glabrata,\ and \Candida parapsilosis.\ ',CAPTION,'Vaginal Yeast Infection');" onmouseout="return nd();">vaginal yeast infection sexually transmitted diseases, including Neisseria gonorrhoeae\ bacteria. These infections are usually acquired through sexual contact. A gonococcal infection may also be passed from mother to baby during childbirth.

',CAPTION,'Gonococcal Infections');" onmouseout="return nd();">gonorrhea, HIV, and genital herpes chemical irritation to the lining of the genitals and urethra, such as from soaps, bubble bath, or detergents used to wash undergarments conditions or diseases of the kidney, such as polycystic kidney disease or medullary cystic kidney disease sudden rupture of one of the small sacs, or cysts, in the kidney urinary obstruction, such as kidney stones autoimmune disorders, which are conditions in which a person's immune system attacks his or her own body for no apparent reason traumatic sexual experiences, including rape certain antidepressant medications tumors or cancer of any part of the urinary tract Symptoms & Signs What are the signs and symptoms of the condition? When a person has painful urination, the healthcare provider will want more information. Questions may include the following: When did the pain start? What type of pain is it? Mild, moderate, or severe? Is it a burning sensation? Does the pain occur each time the person urinates? Does the pain get worse before, during, at the end of, or after urinating? Does anything reduce the pain or make the pain worse?

Are there any other symptoms, such as fever, vomiting, headache, or itching? Is there pain in other areas, such as the back, pelvis, or to the side of the abdomen? Is there any blood in the urine, or any unusual color or smell to the urine? Is there any frequency or difficulty urinating? Is it difficult to start a stream when urinating? Or can the person only produce a small amount of urine at a time? Does bathing increase or decrease the pain? Has there been any change in the brand of soap, detergent, or fabric softener? What medications, drugs, or herbs does the person take, if any? Is there a history of any other medical problems or surgeries? Are there any symptoms of kidney failure, such as fatigue, nausea, vomiting, or loss of appetite? Is there any itching, shortness of breath, or loss of the sex drive? Are there any lesions, or sores, in the genital tract? Diagnosis & Tests How is the condition diagnosed? Diagnosing the cause of painful urination depends on the symptoms. A medical history and a history of activity, trauma, or illness may help in diagnosing the cause of the pain.

The healthcare provider will want to know when the pain occurs during urination. This may help pinpoint a diagnosis. A thorough physical exam may be necessary. Urine tests, such as a urinalysis and a urine culture, may be necessary to check for infection. Blood tests may be ordered if an infection is suspected throughout the body. Several other tests that may be done include the following: an ultrasound of the kidney and bladder, which uses sound waves to look for abnormalities a voiding cystourethrogram (VCUG), which shows the urethra and bladder while the bladder fills and empties. A liquid is put into the bladder through a catheter or tube inserted through the urethra. An x-ray shows the liquid traveling through the bladder and urethra. This test can reveal abnormalities of the inside of the urethra and bladder. It can also tell if any urine is traveling the wrong direction up the urinary tract. an intravenous pyelogram, which allows the doctor to examine the whole urinary tract. A liquid is injected through a tube inserted into a vein. Then x-rays are taken as the liquid flows through the urinary tract. This test may reveal obstructions. a nuclear scan, which uses radioactive materials injected into a vein.

An image is made that shows how well the kidneys work, how the kidneys are shaped, and how urine drains from the kidneys. Prevention & Expectations What can be done to prevent the condition? Preventing painful urination depends on the cause of the pain. Protecting the urinary tract from trauma may decrease the risk of pain. Seeking early care for possible infection may decrease the risk of further pain. Avoiding irritating bubble bath solutions, wearing cotton-lined underwear, and avoiding tight-fitting clothes may reduce the pain that goes along with allergic reactions or genital irritation. Limiting caffeine intake and practicing safer sex may also reduce a person's risk of having painful urination. Many causes cannot be prevented. What are the long-term effects of the condition? Long-term effects of painful urination will depend on the underlying cause of the pain. Pain caused by a genital injury may heal without any long-term effects. A person with a history of chronic urinary tract infections may need low-dose antibiotics for a long period of time. Some injuries or infections may lead to permanent urinary tract damage or pain. A person who has a tumor in the urinary tract may require surgery and medications over a long period of time.

A person with a cancerous tumor may be treated in some cases and may die in other cases. What are the risks to others? Painful urination is not necessarily contagious and poses no risk to others. However, if the cause is an infection, such as a sexually transmitted disease, the infection may be contagious. Treatment & Monitoring What are the treatments for the condition? Treatment of painful urination depends on the underlying cause of the pain. When an injury occurs, the person should apply an ice pack off and on for the first 24 hours to reduce pain and swelling. Heat, such as in a warm sitz bath, may be recommended for some causes of painful urination. Antibiotics may be prescribed for infections. Medications to stop the growth of kidney stones may be prescribed, as well as medications to stops spasms caused by kidney stones or infection. Other treatments will vary greatly depending on the cause of the pain. Those with cancer may need surgery, chemotherapy, or radiation therapy. Surgery may be needed for those who have kidney stones or damage to the urinary tract from an injury or recurrent infections. What are the side effects of the treatments? Side effects to treatment depend on the treatment used.

There are usually no side effects to ice packs or heat as long as they are not applied to the skin for long periods of time. There may be stomach upset, headache, or allergic reaction to antibiotics. Treatments that require surgery pose a risk of bleeding, infection, and allergic reaction to anesthesia. What happens after treatment for the condition? If painful urination was caused by a urinary tract infection, a urinalysis may be done after the person finishes the full course of antibiotics. A person with minor pain and no other conditions may heal fine and may not need any further treatment. If a person had surgery, he or she may need to take it easy for a few days to a few weeks and may need follow-up care. How is the condition monitored? Monitoring painful urination is important. If the pain worsens or any other symptoms are present, a healthcare provider may need to monitor the person carefully. Any new or worsening symptoms should be reported to the healthcare provider. Attribution Dysuria Causes, Symptoms, Treatment - How Is Dysuria Diagnosed? - eMedicineHealth How Is Dysuria Diagnosed? Dysuria Topic Guide How Is Dysuria Diagnosed?

Your health-care professional will first review your history, which will include questions about your overall health and previous episodes of dysuria. Information about the frequency of urination and sexual and social history will often be included. The extent of the physical examination will depend to some extent on the history information. The examination will usually include an abdominal examination and often an examination of the external genitalia and a gynecologic examination for women. A urine sample will be obtained. In the office, a dipstick test of the urine can often be done and give further clues to the cause of the dysuria. These dipstick tests can indicate the presence of bacteria and blood (both common in patients with an urinary tract infection ). The sample then is sent to the laboratory where it is examined under the microscope (to confirm the presence of blood or white blood cells). A culture of the urine is performed to see if bacteria grow (both confirming a bacterial infection as well as identifying the exact bacteria causing the infection). When Should I Call the Doctor About Dysuria? Any patient experiencing symptoms of dysuria should seek medical attention.

Medically Reviewed by a Doctor on 10/28/2016 Medical Author: Burning with urination | definition of Burning with urination by Medical dictionary Burning with urination | definition of Burning with urination by Medical dictionary Related to Burning with urination: dysuria dysuria painful or difficult urination. adj., adj dysu´ric. dys·u·ri·a /dys·uria/ (dis-u´re-ah) painful or difficult urination.dysu´ric dysuria dys·u′ric (-yo͝or′ĭk) adj. dysuria [disyoo͡r′ē·ə] Etymology: Gk, dys + ouron, urine painful, burning urination, often caused by a bacterial infection, inflammation, or obstruction of the urinary tract. Laboratory examination of the urine may reveal the presence of blood, bacteria, or white blood cells. Dysuria is a symptom of cystitis, urethritis, prostatitis, urinary tract tumors, and some gynecological disorders and of the use of certain medications, such as opiates. Compare hematuria, pyuria .

dysuria Painful or difficult urination, which may be linked to a sexually transmitted infection. dysuria Pain on urination, difficulty urinating Urology A common Sx of bladder infection, which also occurs in prostate lesions, eg, BPH, accompanied by sensation of pressure and tenderness around the bladder, pelvis, and perineum, which may ↑ as the bladder fills and ↓ as it empties; ↓ bladder capacity; an urgent need to urinate; painful sexual intercourse; in ♂, hyperpain in the penis and scrotum. See Cystitis . dys·u·ri·a Difficulty or pain in urination. [dys- + G. ouron, urine] dysuria Pain on passing urine. This is most commonly due to a urinary infection and is usually associated with undue frequency in the desire to urinate. Dysuria Dysuria - Symptoms & Information - Patient Education Center Tweet What Is It? Dysuria is the medical term for pain or discomfort when urinating. Often described as a burning sensation, dysuria most commonly is caused by bacterial infections of the urinary tract.

Lower urinary tract infection (cystitis or bladder infection) — Dysuria is a common symptom of a bladder infection (cystitis). Cystitis is very common in women aged 20 to 50. An infection often starts when bacteria enter the opening where urine comes out (urethra) during sexual intercourse. Bacteria also can enter the urethra in women and girls who wipe with toilet tissue from back to front. Once bacteria enter a woman’s urethra, it only has to travel a short distance to the bladder. In men over age 50, a bladder infection usually is associated with an enlarged prostate or prostate infection. Upper urinary tract infection (pyelonephritis or kidney infection) — A kidney usually becomes infected because bacteria have traveled to the kidney from an infection in the bladder. Kidney infections occur more commonly: During pregnancy In people with abnormal bladder function In people with persistent kidney stones In children with an abnormal backflow of urine from the bladder to the kidneys (called vesicoureteral reflux) or an obstruction related to abnormal development of the urinary tract. Pyelonephritis is more common in women than in men. Urethritis — Urethritis is an inflammation of the urethra.

It is usually caused by sexually transmitted diseases (such as chlamydia and gonorrhea). Urethritis also can be caused by contact with an irritating chemical (such as antiseptics, bubble bath or some spermicides) or by irritation from an object, such as a tube (catheter) inserted to drain urine. Vaginitis — Vaginitis is an inflammation of the vagina. It can be caused by an allergic reaction to an irritating chemical (spermicide, douche, bath soap), a low level of estrogen after menopause, or an object such as a tampon that was not removed. It can also be caused by infection. Common infections include: Bacterial vaginosis, a condition linked to changes in the normal bacteria that live in the vagina Candidiasis, also called a yeast infection Trichomoniasis, a sexually transmitted disease caused by the microscopic one-celled organism Trichomonas vaginalis Symptoms Depending on the cause of dysuria, there may be other symptoms in addition to pain when urinating.

Symptoms can include: Lower urinary tract infection (cystitis) — Frequent urination, an intense urge to urinate, loss of bladder control, pain in the lower front portion of the abdomen (near the bladder), cloudy urine that may have a strong odor, bloody urine Upper urinary tract infection (pyelonephritis) — Pain in the upper back, high fever with shaking chills, nausea and vomiting, cloudy urine, frequent urination, an intense urge to urinate Urethritis — A discharge from the urethra, redness around the opening of the urethra, frequent urination, vaginal discharge. Partners of people with urethritis that comes from a sexually transmitted disease often will not have any symptoms. Vaginitis — Pain, soreness or itching in the vagina, an abnormal or foul-smelling vaginal discharge or odor, pain or discomfort during sexual intercourse Diagnosis Many people have occasional episodes of brief discomfort when they start urinating. Usually this is caused by irritation, and does not need to be treated. However, you should see your health care professional if pain while urinating lasts longer, is severe or if it continues to happen. Your doctor will ask about your symptoms and personal and sexual habits.

During a physical examination, the doctor will check for tenderness over the kidneys and examine your genitals. For women, this may include a pelvic exam. Men with suspected prostate problems may have a digital rectal exam. If your doctor thinks you have a simple bladder infection, he or she usually can confirm this with a urine test in the doctor’s office. To diagnose urethritis and vaginitis, a swab of the infected area may need to be taken and sent for testing. If your doctor suspects you have a kidney infection, a urine sample will be sent to a laboratory to identify the species of bacteria. If you have a fever or appear ill, a blood sample may be tested in a laboratory to check for bacteria in the blood. If you have dysuria and a have had unprotected sex with multiple partners, your doctor may order tests to look for various types of sexually transmitted diseases, including gonorrhea, chlamydia, trichomoniasis, syphilis and HIV. Expected Duration How long dysuria lasts depends on its cause. Most people with infections of the urinary tract respond well to treatment within a few days. When the cause is more difficult to determine, symptoms may last longer.

Prevention To help prevent dysuria caused by cystitis or pyelonephritis, you can drink several glasses of water each day to flush out your urinary tract. Women should wipe from front to back after having a bowel movement. Also they should urinate soon after sexual intercourse to flush bacteria away from the urethra. This helps prevent the bacteria from moving into the bladder. To prevent dysuria caused by irritation, women should keep the genital area clean and dry, change tampons and sanitary napkins frequently, and avoid using irritating soaps, vaginal sprays and douches. To avoid irritation in female children, limit bubble baths, wash girls thoroughly but gently after playing in sand and be wary of extended play in wet swimsuits, all of which can lead to irritation and redness of the vulva (vulvitis). To help prevent dysuria caused by sexually transmitted diseases, practice safe sex. This includes always using a condom unless you have only one steady sexual partner. Treatment Treatment of dysuria depends on its cause: Cystitis and pyelonephritis — These infections, usually caused by bacteria, can be cured with antibiotics taken by mouth.

Antibiotics may be given into a vein (intravenously) for severe pyelonephritis with high fever, shaking chills and vomiting. Urethritis — Urethritis is treated with antibiotics. The type of antibiotic used depends on which infection causes the urethritis. Vaginitis — Trichomoniasis and bacterial vaginosis are treated with antibiotics. Yeast infections are treated with antifungal drugs, either as a pill by mouth or as a suppository or cream inserted into the vagina. If you are sexually active and are being treated for dysuria caused by a sexually transmitted disease, your sex partners must be treated, too. When To Call A Professional Call your doctor or seek urgent care if you have painful urination or blood in the urine and any these other symptoms: Fever Frequent urination and an urgent need to urinate Abdominal pain Dysuria (General Information) Dysuria GENERAL INFORMATION: What is dysuria? Dysuria is difficulty urinating, or pain, burning, or discomfort when you urinate. Dysuria is usually a symptom of another problem. What causes dysuria?

The following are the most common causes of dysuria: Infections, such as urinary tract infections and sexually transmitted infections Trauma, such as bicycle injury or sexual abuse Abnormal structure, such as narrowing of the urethra Blockage, such as kidney stones Medical conditions, such as constipation, enlarged prostate, and reactive arthritis Chemicals, such as douches, spermicides, and bubble bath Medicines, such as chemotherapy What increases my risk for dysuria? Dehydration Loss of bladder muscle strength due to older age Holding urine in your bladder for a long period of time Caffeine, soda, alcohol, and citrus drinks What other symptoms may I have with dysuria? Fever Urge to urinate often but urinating little Back, side, or abdominal pain Blood in your urine Swelling of your genitals Pain with ejaculation or bowel movement (for males) How is dysuria diagnosed? Your caregiver will examine you and ask about your symptoms. Tell your caregiver about any medicines you are taking. You may need any of the following to find the cause of your dysuria: Urine test: Your urine is tested for bacteria, blood, or pus. Blood test: Your blood may be tested for infection.

Cystoscopy: A cystoscopy allows caregivers to look for problems inside your bladder. A scope is put into your bladder through your urethra. The scope is a flexible tube with a light and camera on the end. Ultrasound: An ultrasound uses sound waves to show pictures on a monitor. An ultrasound may be done to show problems in your bladder. How is dysuria treated? Treatment will depend on what is causing your dysuria. Your caregiver may refer you to a specialist, such as a urologist or a nephrologist. You may need any of the following: Antibiotics: This medicine will help fight or prevent an infection. Take your antibiotics until they are gone, even if you feel better. Pyridium: This medicine will stop bladder spasms. What are the risks of dysuria? You may develop a urinary tract infection. You may develop cystitis. This is when your bladder becomes inflamed and irritated. This can lead to scarring or stiffening of your bladder. You may develop kidney stones. You may develop prostatitis or hyperplasia. This is when your prostate becomes inflamed or enlarged. A life-threatening condition, such as kidney failure, may develop. How can I manage my dysuria?

Drink more liquids: Liquids help flush out bacteria that may be causing an infection. Ask your caregiver how much liquid to drink each day and which liquids are best for you. Sitz baths: A sitz bath may decrease your pain. Caregivers may give you a portable sitz bath. This is a small tub that fits in the toilet. Fill the sitz bath or a bathtub with 4 to 6 inches of warm water. Sit in the warm water for 20 minutes 2 to 3 times a day. For more information: National Kidney and Urologic Diseases Information Clearinghouse 3 Information Way Difficulty urinating (dysuria) - PatientsLikeMe Difficulty urinating (dysuria) Watch member Ed share how PatientsLikeMe has helped him manage his condition. Your data has a heartbeat that gives new life to medical research. Donate your data for you, for others, for good. Evaluation of Dysuria in Men - American Family Physician Evaluation of Dysuria in Men RICHARD G. ROBERTS, M.D., J.D., and PAUL P. HARTLAUB, M.D., M.S.P.H., University of Wisconsin Medical School, Madison, Wisconsin Am Fam Physician.

1999 Sep 1;60(3):865-872. References Men with pain or a burning sensation on urination should be evaluated with a thorough history, a focused physical examination and urinalysis (both urine dipstick and microscopic examination of the urine specimen). Although dysuria may be caused by anything that leads to inflammation of the urethal mucosa, it is most often the result of urinary tract infection. In younger patients, the infectious agent is usually a sexually transmitted organism such as Chlamydia trachomatis. In patients over 35 years of age, coliform bacteria predominate. Infection in older men most often occurs as a result of urinary stasis secondary to benign prostatic hyperplasia. Other conditions that may cause dysuria include renal calculus, genitourinary malignancy, spondyloarthropathy and medications. Successful treatment of dysuria depends on correct identification of its cause. Dysuria is the sensation of pain or burning on urination. In males, this sensation is usually felt in the distal urethra during voiding and resolves shortly after micturition. The timing of the discomfort can often predict its location in the urinary tract.

1 Pain at the start of urination usually indicates a urethral source of inflammation. More severe pain occurring over the suprapubic area on completion of urination suggests inflammation of the bladder. 2 Urinary symptoms are far more common in women than in men and in older men than in younger men. 3 Population-based surveys suggest that urinary tract symptoms significant enough to cause persons to seek medical attention occur in about 0.6 percent of women per year and about 0.1 percent of men each year. 4 Voiding symptoms in men increase significantly between the ages of 40 and 60 years, reflecting the rising prevalence of benign prostatic hyperplasia (BPH) in aging men. 5 Nearly one half of men over 55 years of age report some urinary symptoms, and about 25 percent of these men see a physician about their symptoms. 6 Among men of all ages who complain of urinary symptoms occurring more than rarely, dysuria is mentioned as one of the symptoms about 5 percent of the time. 7 Common Causes of Dysuria In Men Jump to section + References Any source of irritation or inflammation of the urinary tract, especially the bladder, prostate or urethra, can cause dysuria ( Table 1 ).

Dysuria is often associated with other irritative voiding symptoms, such as urgency, frequency and nocturia, but its most common cause is urinary tract infection. Urinary stasis resulting from urethral obstruction makes BPH a very common predisposing factor for urinary tract infection. The most common cause of recurring urinary tract infection in men is chronic bacterial prostatitis. 8 Furthermore, as men age, urinary obstruction can induce changes in bladder compliance that result in both obstructive symptoms and increased irritative symptoms, including dysuria.

9 , 10 Common Causes of Dysuria in Men Type of problem Quinolones; aminoglycosides plus ampicillin (Principen); third-generation cephalosporins; piperacillin (Pipracil) Cystitis Trimethoprim-sulfamethoxazole (Bactrim), quinolones, cephalosporins, nitrofurantoin (Furadantin), amoxicillin (Amoxil) Urethritis Ceftriaxone (Rocephin) plus doxycycline (Vibramycin); macrolides; quinolones Prostatitis Coliform organisms, viruses (e.g., mumps virus) Quinolones, doxycycline, trimethoprim-sulfamethoxazole Acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex) Obstruction Alpha blockers, finasteride (Proscar), hyperthermia therapy, surgery Urethral stricture Stone disease Metabolic disorders, infection Hydration, pain management, antibiotics (if infection is present), correction of metabolic defects (e.g., allop

urinol [Zyloprim] for hyperuricemia) Spondyloarthropathy Toxicity or drug side effects Dopamine, cantharidin and others *—Exact treatment varies, depending on patient and antibiotic sensitivities.

TABLE 1 Common Causes of Dysuria in Men Type of problem Quinolones; aminoglycosides plus ampicillin (Principen); third-generation cephalosporins; piperacillin (Pipracil) Cystitis Trimethoprim-sulfamethoxazole (Bactrim), quinolones, cephalosporins, nitrofurantoin (Furadantin), amoxicillin (Amoxil) Urethritis Ceftriaxone (Rocephin) plus doxycycline (Vibramycin); macrolides; quinolones Prostatitis Coliform organisms, viruses (e.g., mumps virus) Quinolones, doxycycline, trimethoprim-sulfamethoxazole Acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex) Obstruction Alpha blockers, finasteride (Proscar), hyperthermia therapy, surgery Urethral stricture Stone disease Metabolic disorders, infection Hydration, pain management, antibiotics (if infection is present), correction of metabolic defects (e.g., allopurin

ol [Zyloprim] for hyperuricemia) Spondyloarthropathy Toxicity or drug side effects Dopamine, cantharidin and others Avoidance *—Exact treatment varies, depending on patient and antibiotic sensitivities.

Dysuria also has other causes, such as malignancies of the urinary system, especially the bladder. Urinary calculi can damage urothelium, causing inflammation and urinary discomfort. Inflammation of mucosal surfaces, including the urethra, may occur with spondyloarthropathies and other autoimmune disorders. Certain toxins and numerous pharmaceutical agents, such as cantharidin 11 and dopamine, 12 can be uncommon sources of dysuria. (Of note, dysuria is mentioned as a side effect of approximately 200 medications in the Physicians' Desk Reference. 13 ) INFECTION Dysuria is due to infection about 60 percent of the time. All portions of the urinary tract are susceptible to infection, although the causative organisms vary by site. Hollow, or tubular, structures in the urinary system, such as the kidney, renal pelvis, bladder, prostate and epididymis, are most vulnerable to infection by coliform bacteria. These bacteria are believed to gain access at the urethral meatus (through intercourse or local contamination) and then ascend to the affected organ.

A study of community-based practices found that about two thirds of culture-proven infections were caused by Escherichia coli. 3 About 15 percent were due to Staphylococcus epidermidis, 10 percent to Proteus mirabilis, 5 percent to Staphylococcus aureus, 3 percent to Enterococcus species and 3 percent to Klebsiella species. 3 Most community-acquired urinary tract infections can be managed with amoxicillin (Amoxil), trimethoprim-sulfamethoxazole (Bactrim) or nitrofurantoin (Furadantin). 14 , 15 Men with abnormalities in urinary anatomy or function are likely to have more unusual, recurrent or persistent infections with organisms such as Proteus, Klebsiella or Enterobacter species. Examples of urinary tract abnormalities include bladder diverticula, renal cysts, urethral stricture, BPH and neurogenic bladder resulting from multiple sclerosis, diabetes, stroke or spinal cord injury. Rarely, hematogenous spread of bacteria to the kidneys may cause pyelonephritis and subsequent dysuria.

Organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis preferentially infect the urethra. 16 Urethral discharge is the most frequent manifestation of infection with these organisms. Discharge that is thick and discolored (yellow to gray) typifies gonococcal urethritis, whereas watery, scant or mucoid discharge is most common with nonspecific (nongonococcal) urethritis caused by infection with C. trachomatis or Ureaplasma urealyticum. 17 , 18 However, up to 18 percent of men with gonococcal infection do not have discharge, and up to 47 percent do not have dysuria. 19 Note that a bloody discharge, as distinct from hematuria or hematospermia, raises concern about urethral carcinoma, an uncommon condition. Bacterial venereal infections are commonly treated with doxycycline (Vibramycin), erythromycin, quinolones or ceftriaxone (Rocephin). Viruses such as adenovirus, herpesvirus or mumps virus can also cause dysuria.

Hemorrhagic cystitis may result from adenovirus infection of the bladder. Herpesvirus infection may disrupt meatal integrity, causing dysuria. 20 Acyclovir (Zovirax) or valacyclovir (Valtrex) can decrease symptom duration and viral shedding with herpesvirus infections. Mumps infection of the epididymis and testicles can produce urethral inflammation and dysuria, although these complications have become infrequent since the introduction of the mumps vaccine. In developing countries, a common cause of bladder infection and dysuria is the parasite Schistosoma haematobium. 21 OBSTRUCTION In aging men, BPH is the most common cause of urinary complaints, including dysuria and obstruction. More than 50 percent of men over 70 years of age have the clinical syndrome of BPH, and nearly 90 percent have microscopic evidence of prostatic hyperplasia. 22 BPH-induced dysuria may be caused by urinary infection resulting from obstruction and stasis. It may also be caused by inflammation of the distended urethral mucosa.

Over time, chronic obstruction of urinary outflow as a result of BPH can cause bladder hyperplasia, trabeculation and, eventually, decompensation. 23 The syndrome of BPH is thought to be the manifestation of a static component, a dynamic component, or both. The static component results from hyperplastic enlargement of the gland, which occludes the prostatic urethra. Blocking the conversion of testosterone to dihydrotestosterone using a 5-alpha reductase inhibitor such as finasteride (Proscar) can shrink the gland. The dynamic component is due to increased tone of the fibromuscular stroma of the prostate, resulting in compression of the urethra. This increased tone is modulated primarily by α1-adrenoreceptors and can be reduced by alpha-blocker medications. Alpha blockers have been shown to improve BPH-related dysuria. 24 Nearly one half of men with mild BPH symptoms, however, stay the same or improve with expectant management. 9 Surgery, most often transurethral resection of the prostate, continues to represent the most definitive and enduring treatment for BPH. 25 Seminal vesicle congestion following prostatectomy has been described as a cause of dysuria.

26 Decreased symptoms and improved urine flow have also been demonstrated with microwave hyperthermia therapy. 27 Urethral obstruction may be the result of a stricture. Strictures usually occur because of prior instrumentation or surgery affecting the urethra. MALIGNANCY Dysuria may be the earliest symptom of the irritative changes caused by carcinoma in situ of the bladder. In particular, bladder cancer should be considered when a male smoker presents with dysuria and culture-negative microhematuria. Urethral carcinoma is rare and is an uncommon cause of dysuria. Other malignancies, such as renal cell cancer (hypernephroma), may provoke sufficient urothelial inflammation to induce dysuria. Surgical excision is usually used to treat urothelial cancers (i.e., cancers arising from the lining of the ureters, bladder or urethra), either by fulguration via a transurethral approach or by more extensive surgery such as cystectomy. Radiation is often used as augmentative therapy. STONE DISEASE As renal calculi descend from the kidney or develop in the bladder, they can injure the urothelium, resulting in inflammation and dysuria.

Relative dehydration superimposed on various metabolic states (e.g., hyperoxaluria, hyperuricemia and hypercalciuria) is the most common precipitant of a stone attack. Depending on the frequency of attacks, treatment may range from adequate hydration to more definitive therapy such as diuretics or allopurinol (Zyloprim). SPONDYLOARTHROPATHIES The constellation of dysuria, oligoarthralgia, low back or heel pain, and ocular symptoms (e.g., uveitis) are typical in spondyloarthropathies such as Reiter's syndrome. 28 The additional finding of oral ulcers is consistent with Behçet's syndrome. Treatment has included anti-inflammatory agents such as prednisone, immunosuppressants such as azathioprine (Imuran) and antibiotics such as doxycycline. Other autoimmune processes, such as systemic vasculitis or necrotizing glomerulonephritis, have also been associated with dysuria.

29 Diagnosis of Dysuria In Men Jump to section + Hematuria (more than 3 to 5 red blood cells per high-power field Infection, malignancy (bladder cancer), stone disease Other tests Gram stain of urine, DNA probe test, rapid antigen test, culture of expressed prostatic secretions, ultrasonography, cystography or urodynamic studies Used when the findings of the history, physical examination and urinalysis do not yield a cause of dysuria HISTORY The physician should ask the patient about the timing, frequency, severity and location of the dysuria, as well as the presence of other irritative symptoms such as urgency, frequency or nocturia. It is also important to inquire about obstructive symptoms such as weak stream, hesitancy, intermittency and dribbling. The American Urological Association (AUA) has developed a survey to more precisely define the nature and severity of prostate-related symptoms ( Figure 1 ). 30 The family physician can use this survey or the International Prostate Symptom Score 31 to track the progress of prostate symptoms. AUA Symptom Index FIGURE 1. American Urological Association (AUA) Symptom Index.

This survey can be used in patients with dysuria to more precisely define the nature and severity of symptoms related to benign prostatic hyperplasia and to track the progress of symptoms. Adapted with permission from Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 1992;148:1549–55. Permission is also granted to physicians who wish to reproduce this figure for use in their practices. AUA Symptom Index FIGURE 1. American Urological Association (AUA) Symptom Index. This survey can be used in patients with dysuria to more precisely define the nature and severity of symptoms related to benign prostatic hyperplasia and to track the progress of symptoms. Adapted with permission from Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, et al. The American Urological Association symptom index for benign prostatic hyperplasia.

J Urol 1992;148:1549–55. Permission is also granted to physicians who wish to reproduce this figure for use in their practices. Prostatitis can cause a sensation of rectal pain or perineal aching (prostalgia or prostadynia). A urethral discharge may indicate a sexually transmitted disease (STD), and the color, type and amount of discharge should be determined. Bladder cancer can cause dysuria and hematuria. Prostate cancer rarely results in dysuria or other urinary symptoms. Various systemic symptoms can help identify the cause of the dysuria. Fever, chills, nausea and emesis suggest infection. Associated arthralgias, oral mucosal symptoms or ocular symptoms may indicate a spondyloarthropathy such as Reiter's syndrome or other autoimmune condition. It is also important to ask about toxins and medications that might cause dysuria (e.g., dopamine and cantharidin) as well as herbal remedies that may have been taken for genitourinary problems (e.g., saw palmetto for BPH or pumpkin seeds for prostatitis).

PHYSICAL EXAMINATION Palpation and percussion of the abdomen can provide information about possible enlargement of the kidneys (suggesting renal cell tumor) or bladder (suggesting distention and possible retention). Tenderness to palpation or percussion over the costovertebral angle can be consistent with pyelonephritis. Examination of the penis may reveal a urethral discharge indicative of an STD or meatal lesions consistent with a viral infection or other dermatologic condition. Testicular swelling and tenderness (arthritis) are most often caused by a viral infection. Pain along the epididymis is usually due to inflammation resulting from a bacterial infection. However, it may be difficult to clinically distinguish isolated swelling of the epididymis from orchitis. A digital rectal examination should also be performed. A tender, boggy prostate is consistent with prostatitis, whereas an enlarged prostate suggests BPH. A hard, nodular prostate is typical of prostate cancer. When prostatitis is suspected, gentle digital rectal examination is advised, because an overly vigorous examination may precipitate bacteremia with subsequent sepsis.

It is important to remember that a man can have significant symptoms of BPH without the finding of obvious enlargement of the prostate on rectal examination. Most of the prostate is anterior to the examining finger, and significant symptoms can result from increased muscular tone without much enlargement of the gland. URINALYSIS The sensitivity of the urine dipstick test makes it a useful tool for identifying blood or infection. However, certain bacteria (e.g., Enterococcus species 32 ) may be nitrate negative. Thus, the gold standard remains clean-catch, midstream urine that is spun and examined under a microscope. The presence of any white or red blood cells in the urine specimen of a circumcised man is not normal, but the finding of more than 3 to 5 cells per high-power field is typically used for the diagnosis of pyuria or hematuria. Some clinicians and investigators also advocate routine Gram staining of unspun urine to identify potential organisms. Although colony counts greater than 10 5 per mL are frequently used to diagnose asymptomatic infection, a pure colony count of 10 2 per mL in the presence of symptoms is considered sufficient to conclude that an infection is present.

Hematuria without pyuria should raise the question of stone disease or a urinary tract malignancy such as bladder cancer. OTHER TESTS Urethral discharge should be Gram stained and tested for N. gonorrhoeae and C. trachomatis. 33 More commonly, however, DNA probe testing or rapid antigen testing is being used. In men with chronic prostalgia, the precise diagnosis of dysuria can be elusive. Determining whether a patient has nonbacterial prostadynia or true infection may require microscopic evaluation or culture of expressed prostatic secretions. Concerns about upper urinary tract pathology (e.g., abscess, hydroureter or hydronephrosis) may warrant ultrasound examination of the kidneys and ureters. Ultrasound examination can also be helpful in evaluating the prostate for biopsy needle placement and assessing the bladder for stones (a sign of urinary stasis) or diverticula (a sign of bladder compensation). Excretion urography (intravenous pyelography) is often used to localize ureteral calculi. Cystoscopy must be considered in the evaluation of noninfectious hematuria to rule out bladder or urethral cancer.

Men with more complicated BPH findings, such as incomplete emptying, may require urodynamic studies to determine bladder decompensation. Final Comment

Question: In medicine, dysuria is pain or difficulty in doing what?
Answer: Urinating