Dysuria

Dysuria (pain on urination) is usually producedby inflammation of urethra or bladder or both.

Principal Causes of Dysuria

1. Urinarytract infection
   1. Urethritis
   2. Cystitis
   3. Pyelonephritis
2. Chemical irritation
3. Diaper dermatitis
4. Trauma
5. Psychogenic

Clinical Features and Diagnosis

Urinary Tract Infection (UTI)

UTI existswhen a significant number of bacteria are present in urine or whenthe urinary tract is infected with a virus. Infection can involveurethra, bladder, or renal parenchyma.

E. coli is most common pathogen inall age groups. Other pathogens include gram-negative enteric bacteria(Klebsiella, Proteus, Pseudomonas, and Enterobacter species) andgram-positive bacteria (Enterococcus species, coagulase-negativeStaphylococcus, group B Streptococcus, S. aureus).

Only virus likely to be encounteredas urinary tract pathogen is adenovirus, which causes acute hemorrhagiccystitis.

Manifestations vary with age. In neonatesclinical features include fever or temperature instability, poorfeeding, decreased activity, and vomiting. Fever, vomiting, anddecreased weight gain may occur in infants. In children and adolescents,common findings include fever, dysuria, frequency, urgency, vomiting,abdominal pain, and flank pain. In all age groups urine may be cloudyand foul smelling.

Pyuria and microscopic or gross hematuriamay be found. Positive urine culture is diagnostic.

Urethritis

In girlsvulvovaginitis is a common cause of urethritis. See Chap. 71, Vaginal Discharge.

Occasionally, dysuria occurs with labialadhesions, which are readily seen on physical exam. Proposed mechanismis pooling of urine behind adhesion and inadequate cleansing ofurethra.

In boys urethritis occurs most commonlyin adolescents. N. gonorrhoeae and C. trachomatis are the most commonpathogens in this age group.

Gonorrhea usually presents with creamyurethral discharge and dysuria 2–7 days after sexual contact.Gram-stained smear of discharge that shows gram-negative intracellulardiplococci is diagnostic, whereas positive culture of urethral dischargeis confirmatory.

Infection with C. trachomatis may ormay not produce mild mucoid discharge, and dysuria is usually mild.Positive urine culture is diagnostic.

When herpes simplex virus causes urethritis,vesicles are usually seen on genital exam.

Cystitis

Infectionof bladder with bacteria is common in girls but infrequent in boys.Long male urethra and bactericidal prostatic secretions may be responsiblefor lower incidence in boys.

Children with cystitis may have dysuria,urinary frequency, urgency, suprapubic tenderness, and occasionallyfever.

If dysuria persists in sexually activeindividuals and urine bacterial culture is negative, urine shouldbe cultured for C. trachomatis.

Adenovirus infection of bladder cancause severe dysuria and bloody urine (hemorrhagic cystitis). Usualurine culture for bacteria is sterile.

Pyelonephritis

Childrenwith acute pyelonephritis do not have dysuria unless cystitis isalso present. They are usually more ill and have higher fever thanthose with urethritis or cystitis.

Parenchymal infection should be suspectedin febrile child with flank pain and tenderness who may or may notbe toxic.

Renal scintigraphy using technetium99m–dimercaptosuccinic acid can show renal cortical involvementin most cases.

Chemical Irritation

Chemicalirritants, which include detergents, fabric softeners, perfumedsoaps, and bubble baths, are common causes of transient urethritis.

History and physical exam are diagnostic.

Diaper Dermatitis

Diaper dermatitiswith or without Candida infection can cause meatal inflammation withulcer formation in boys and urethral inflammation in girls.

History and physical exam are diagnostic.

Trauma

Any injuryto urethra (e.g., minor trauma, foreign body placed in urethra,or child abuse) can produce dysuria. Hematuria with or without bacteriuriaalso may occur.

History and physical exam are oftendiagnostic.

Urethrogram or cystogram may be necessaryif there is history of trauma and persistent hematuria. Pelvic radiographymay reveal radiopaque foreign body.

Psychogenic

Dysuria may occur for psychologic reasonswithout any pathologic process involving genitourinary tract.

Diagnostic Approach

History and physical exam are usually diagnosticof trauma, vulvovaginitis, labial adhesions, chemical irritation,and diaper dermatitis. Otherwise, suspect UTI and perform UA andurine culture.

Urinalysis

Presenceof WBCs (>10/high-power field) in sediment ofcentrifuged specimen of urine suggests but is not diagnostic ofUTI. Neither is positive leukocyte esterase test (urine dipstick), whichindicates presence of WBCs in urine.

Positive nitrite test using nitritestrip (Griess test) on urine dipstick is highly sensitive and specificfor detection of gram-negative bacteria (e.g., E. coli, Klebsiella,and Proteus species). Positive reaction usually indicates 10⁵ CFUs/mL.False-positive reactions are uncommon if urine is fresh; however,if urine is not examined immediately, test result may be positivebecause of bacteria growing at room temperature. False-negativereactions may occur when there has been inadequate time for bacterialproliferation (random collection rather than first morning specimen)or when infection is due to Enterococcal species and some Staphylococcaland Pseudomonas species that do not convert nitrate to nitrite.

Presence of ≥1 bacteria/oilimmersion field of unspun urine (unstained or Gram stain) from clean-catchmidstream specimen correlates with urine colony count of >10⁵ CFUs/mL80–95% of the time.

Urine Culture

Quantitative culture of properly collectedurine specimen establishes diagnosis of UTI, and susceptibilitytesting can be performed. Table15.1, based on data from many studies, is useful guidefor diagnosis of UTI.

Table 15.1. Criteria for Diagnosis of Urinary Tract Infections

Method of Collection	Colony Counta (Pure Culture)	Probability of Infection (%)
Suprapubic aspiration	Gram-negative bacilli: any number	>99
	Gram-positive cocci: > a few thousand
Catheterization	>105	95
	104–105	Infection likely
	103–104	Suspicious; repeat
	<103	Infection unlikely
Clean-voided (male)	>104	Infection likely
Clean-voided (female)	3 specimens: >105	95
	2 specimens: >105	90
	1 specimen: >105	80
	5 × 104–105	Suspicious; repeat
	104 to 5 × 104	Symptomatic; suspicious; repeat
	104 to 5 ×104	Asymptomatic; infection unlikely
	<104	Infection unlikely

^aCFUs/mL of single isolate.

From Hellerstein S. Recurrent urinary tract infections inchildren. Pediatr Infect Dis 1982;1:275, with permission.

Radiologic Imaging

Differencesof opinion exist concerning usefulness of radiologic studies inevaluation of children with UTI. Studies are performed to searchfor anatomic abnormalities that may predispose to infection andalso to identify presence of vesicoureteral reflux.

In our hospital when infant or childhas first UTI, initial studies include renal U/S in both girlsand boys followed by a radionuclide voiding cystourethrogram ingirls and contrast voiding cystourethrogram in boys.

Use of renal cortical scintigraphyis controversial, but it can help diagnose acute pyelonephritisand identify renal scarring.

References

1. Baker RB. Dysuria: presenting complaintin labial fusion. Am J Dis Child 1986;140:1100–1101.
2. Demetriou E, et al. Dysuria in adolescent girls: urinarytract infection or vaginitis. Pediatrics 1982;70:299–301.
3. Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
4. Fleisher GR. Dysuria. In: Fleisher G, Ludwig S, eds.Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:449–452.
5. Hellerstein S. Recurrent urinary tract infections inchildren. Pediatr Infect Dis 1982;1:271–281.
6. Hellerstein S. Urinary tract infections: old and newconcepts. Pediatr Clin North Am 1995;42:1433–1457.
7. Lohr JA, et al. Urinary tract infection. In: Long SS,et al., eds. Principles and practices of pediatric infectious diseases.New York: Churchill Livingstone, 1997:370–377.

>>

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Urination pain

Read excerpts from these other book chapters related to Urination pain:

Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

More About Causes of Urination pain

• Back to symptom: Urination pain: Introduction (review 154 causes)
• Next Book Extract About Urination pain: Dysuria (Nursing: Interpreting Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Urination pain

---

More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

 » Next page: Dysuria (Nursing: Interpreting Signs and Symptoms)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Dysuria (Nursing: Interpreting Signs and Symptoms)
• Oliguria (Nursing: Interpreting Signs and Symptoms)
• Urinary hesitancy (Nursing: Interpreting Signs and Symptoms)
• Urine cloudiness (Nursing: Interpreting Signs and Symptoms)
• DYSURIA (Differential Diagnosis in Primary Care)

Tools & Services:

• Bookmark this page
• Take a survey relating to Urination pain
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com