Dysuria

Dysuria: Excerpt from In A Page: Pediatric Signs and Symptoms

Dysuria is defined as pain with urination and is a very common complaint in female children. It is commonly due to either urinary tract infection or perineal irritation from a variety of causes.

Differential Diagnosis

• Urinary tract infection (UTI)
  –Common cause of dysuria in children
  –Common pathogens: bacteria including E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa and other gram negatives

• Sexually transmitted disease (STD)
  –Gonorrhea, Chlamydia, Trichomonas
  –Very common in sexually active patients
  –More common in girls
• Bacterial vaginosis
  –Gardnerella or Mobiluncus spp, may be sexually or nonsexually transmitted
• Candidal vaginitis
  –Common after antibiotic treatment
• Local urethral irritation
  –Pinworms
  –Irritative dermatitis (e.g., bubble bath)
  –Diarrhea
• Hemorrhagic cystitis
  –Typically viral in origin
  –Sudden in onset
• Macroscopic blood in the urine from any cause, causing urethral irritation
• Periurethral herpes simplex
• Periurethral varicella
• Hypercalciuria
  –Dysuria and urinary frequency
• Kidney stone (within the urethra)
• Renal tuberculosis (rare)
  –Typically asymptomatic
  –Sterile pyuria
• Prostatitis (uncommon)
  –Can affect adolescent boys
  –Gonorrhea is the most common cause
• Trauma to the perineum
  –Sexual abuse
  –Masturbation
• Meatal ulceration
  –In boys, may occur from contact with diapers
• Pelvic abscess, including appendicitis
• Drugs
  –Amitriptyline hydrochloride (antidepressant)
• Reiter disease
  –Uncommon in children
  –Triad of arthritis, urethritis, and conjunctivitis

Workup and Diagnosis

• History
  –UTI, STD, sexual activity, recent antibiotic exposure
  –Instrumentation/irritation (urinary catheters, bubble baths, creams, masturbation)
  –Fever, abdominal pain, flank pain, vaginal discharge
  –Enuresis (especially new-onset), macroscopic hematuria, frequency, urgency
  –Family history of kidney stones (increased likelihood of hypercalciuria)

• Physical exam
  –Fever, CVA tenderness
  –Exam of the urethra/periurethral area for irritation
  –Pelvic exam (if done) for cervical motion tenderness, cervicitis, or vaginal discharge
• Labs
  –Urinalysis, urine culture
  –STD screening if sexually active
  –Urine spot calcium and creatinine if evidence of microscopic hematuria
• Additional studies based on clinical situation
  –Pelvic ultrasound if PID suspected
  –Renal ultrasound/voiding cystourethrogram if history of previous UTI (in girls <7 and boys of any age), or if macroscopic hematuria is present
  –High-resolution CT without contrast (kidney stones)
  –24-hour urine calcium (hypercalciuria, kidney stones)

Treatment

• UTI: Empiric antibiotics (e.g., co-trimoxazole) pending culture; adjust antibiotics based on bacterial sensitivities
• STD
  –Simple cervicitis: Treat with IM ceftriaxone and PO azithromycin, metronidazole if Trichomonas present
  –For an ill patient with signs of PID, consider hospital admission, give IV cefoxitin and PO doxycycline
• Candidal vaginitis: Topical antifungal agents or oral fluconazole

• Hypercalciuria/kidney stones
  –Increase fluid intake, decrease sodium intake (increases urinary calcium excretion), do not restrict calcium intake
  –Treat with thiazide diuretics (decrease urinary calcium excretion) if patient is persistently symptomatic and/or has urinary calculi

• Avoid instrumentation/local irritants (e.g., bubble baths)

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: DYSURIA (Differential Diagnosis in Primary Care)

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