Urethral Discharge and Dysuria

32 Urethral Discharge and Dysuria


About 2 million cases of urethritis (men and women) occur annually in the United States; more than 60% of these cases are nongonorrheal. Nongonococcal urethritis occurs five times more frequently than gonococcal urethritis, largely because of a decline in gonococcal urethritis. Chlamydia, which causes nongonorrheal urethritis, is a major cause of sexually transmitted disease (STD) and infertility in the United States. Because of the frequency of complaints of dysuria and urethral discharge, the associated public health problem, and the ease of treatment, it is essential that physicians be expert in recognizing the causes of these symptoms.


Dysuria denotes burning or pain associated with urination and can have several causes. Frequency, hesitancy, urgency, and strangury (slow, painful urination) are other symptoms typically associated with micturition disorders. Urinary urgency occurs as a result of trigonal or posterior urethral irritation produced by inflammation, stones, or tumor; it most often occurs with cystitis. Acute inflammatory processes of the bladder cause pain or urgency when only a small quantity of urine is present in the bladder.


When it is due to bladder problems, frequency of urination occurs either with decreased bladder capacity or with pain on bladder distention. Frequency is caused most often by lesions of the bladder or urethra, although diseases of the nervous system involving the bladder’s nerve supply (either centrally as in tabes and multiple sclerosis or peripherally as in diabetic neuropathy) may produce bladder decompensation with voiding abnormalities. Urinary frequency may also be a manifestation of overflow incontinence, which can occur with either prostatic hypertrophy or neurologic bladder disorders.


Inflammatory lesions of the prostate, bladder, and urethra are the most common cause of dysuria and frequency and include prostatitis in men, urethrotrigonitis in women, and bladder and urethral infections in men and women. Both men and women may have chronic inflammation of the posterior urethra. In the United States, dysuria accounts for 5% to 15% of visits to family physicians; however, only 50% of women with dysuria have classic cystitis with urine culture bacteria concentrations greater than 105 organisms per milliliter. Several studies indicate that symptomatic women with urinary bacteria counts of fewer than 105 organisms/mL (female urethral syndrome) should be considered to have an infectious cause and should be treated accordingly.



Nature of Patient


In children, meatal stenosis may cause recurrent lower urinary tract infections (UTIs). Up to 20% of children with urinary complaints may have some degree of meatal stenosis. Dysuria and urethral discharge are uncommon in children. When these symptoms occur in young girls, they are frequently caused by chemical vaginitis or mechanical urethritis. When these findings are seen in young boys, they are often secondary to mechanical urethritis, which can result from continued jarring of the perineum from bicycle riding, horseback riding, a foreign body, or masturbation. Sexually transmitted diseases (STDs) must be considered in cases of urethritis or vaginitis that occur in boys or girls. If STDs are discovered in young children, child abuse is usually the cause.


A UTI should be considered in infants and children (2 months to 2 years of age) with an unexplained fever for 2 or more days.


Bacteriuria is rare in school-age boys and occurs in only 0.1% of men. The incidence of bacteriuria increases in men at age 50 years and rises to about 1% at age 60 and to 4% to 15% in later years, coinciding with the onset of prostatic disease. Women younger than 18 years have a 5% incidence of asymptomatic bacteriuria. Having multiple sexual partners increases the likelihood of STDs such as Chlamydia, gonorrhea, and herpes.


Women between ages 15 and 34 years account for the majority who present with symptoms of UTIs. A study in Great Britain showed that 20% of women in this age group experienced dysuria and frequency. Dysuria in women is most frequently caused by cystitis, interstitial cystitis, vaginitis, female urethral syndrome, and mechanical irritation of the urethra. Dysuria in young men is most often caused by Chlamydia urethritis. In men older than 35 years, UTI is caused by coliform bacteria; in older men, prostatitis and cystitis resulting in urinary stasis are usually caused by prostatic hypertrophy. Dysuria can also be caused by stones, mechanical urethritis, and medications. Urethral discharge, which is essentially limited to men, is usually caused by gonorrheal or nongonorrheal urethritis (Chlamydia or Trichomonas). A male smoker who has culture-negative hematuria and dysuria should be examined for a bladder tumor.



Nature of Symptoms



Cystitis


In women who complain of frequency, urgency, and dysuria without clinical evidence of an upper UTI, bacterial cystitis is usually suspected. However, several studies have shown that 30% to 50% of women complaining of these symptoms do not have a positive urine culture according to traditional criteria (isolation of a pathogen in concentrations greater than 105 bacteria per milliliter of urine in a clean-voided specimen). There are several possible reasons for this.


First, dysuria often represents a vaginal infection rather than a UTI. When carefully questioned, women with dysuria due to cystitis usually describe internal discomfort, whereas women with dysuria due to vaginitis usually describe more external discomfort; their burning sensation appears to be in the vagina or the labia and is caused by urine flow over an inflamed vaginal mucosa. All women with dysuria should be questioned about an associated vaginal discharge or irritation.


Second, many women who present with symptoms due to bacterial cystitis (dysuria, frequency) have colony counts of fewer than 105 bacteria/mL. Various studies have shown that if pathogens are found in a concentration of fewer than 105/mL in a symptomatic woman, there is probably a significant bacterial infection.


Third, Chlamydia trachomatis is frequently the causative agent. Patients who are infected with this organism have symptoms and pyuria but a negative routine urine culture result. Chlamydial infection of the bladder and urethra in a woman is somewhat analogous to nongonorrheal urethritis in a man; in both, there is pyuria but no growth on routine culture. Although it is rare, urinary tract tuberculosis may also manifest as pyuria and a negative routine culture result.


The physician must inquire about the duration and onset of symptoms. Longer duration and gradual onset of symptoms suggest a chlamydial infection, whereas a history of hematuria and sudden onset of symptoms indicate a bacterial infection. Dysuria that is more severe at the end of the stream, particularly if associated with hematuria, suggests cystitis; dysuria that is worse at the beginning of the stream is a sign of urethritis. Patients with the female urethral syndrome often have dysuria, frequency, suprapubic pain, onset of symptoms over 2 to 7 days, and some pyuria. Besides having dysuria, frequency, and suprapubic pain, patients with cystitis demonstrate symptoms that develop quickly—pyuria, bacteriuria, and positive urine culture results (Table 32-1). Fever, nausea, back pain, and leukocytosis are uncommon findings in both female urethral syndrome and cystitis. Dysuria at the end of urination, with or without suprapubic pain, suggests cystitis.


TABLE 32-1 Clinical Features of Female Urethral Syndrome and Cystitis



















































CLINICAL FEATURES FEMALE URETHRAL SYNDROME CYSTITIS
Dysuria, frequency, suprapubic pain + –
Fever, nausea, back pain, other systemic signs – –
Duration of symptoms (days) 2-7 1-2
Leukocytosis – –
Urinalysis:    
Pyuria + or – +
Bacteriuria – +
Hematuria – + or –
White blood cell casts – –
Urine cultures – +
Blood cultures – –

From Meadows JC: The acute urethral syndrome: diagnosis, management, and prophylaxis. Contin Educ Dec:112-120, 1983.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Urethral Discharge and Dysuria

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