The woman with dysuria - includes patient information

Author: Kurt Kurowski
Date: May 1, 1998

An appropriate starting point in identifying the cause of dysuria is to attempt to classify the woman's symptoms by the specific anatomic site thought to be responsible. Table 1 lists disorders associated with symptoms of dysuria and their characteristic laboratory and physical findings.

[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]

Historical Differentiation

Dysuria with frequency and urgency suggests cystitis.[1] Women usually sense internal discomfort (located in the urethra and bladder) as opposed to external discomfort such as the labial irritation associated with vaginitis. Hematuria is common with urinary tract infections and is unlikely to occur with other potential etiologies.[1] Sexual intercourse is associated with many causes of dysuria, but women with postcoital cystitis typically develop symptoms within a few days of intercourse, whereas women with urethritis develop symptoms one to two weeks later and women with vaginitis develop symptoms from weeks to months later. A history of recurrent urinary tract infections, use of a spermicide and diaphragm, and a higher frequency of intercourse within the previous week increases the risk for a urinary tract infection.[2] Only about 15 to 20 percent of women with acute cystitis have suprapubic pain.[1] Rarely, women with cystitis mention lower back pain or have a low-grade fever.

Associated vaginal discharge suggests some type of vaginitis, although patients with urethritis can atypically have a discharge as well. Perimenstrual exacerbation of symptoms points to candidal or Trichomonas vaginitis. Dyspareunia and the sensation of the dysuria being external are typical of vaginitis. Dysuria associated with symptoms of pelvic inflammatory disease, occurring about one to two weeks after intercourse or noted just at the start of urination, suggests urethritis.[3]

Associated fever, myalgia and headache suggest acute pyelonephritis or primary genital herpes as the cause of dysuria. Nausea and emesis also typically accompany acute pyelonephritis. Bladder irritation from a distal urethral stone, compression from an adnexal mass, and radiation or chemical exposure can also produce dysuria.

Examination Differentiation

The physical examination is unremarkable in patients with cystitis, except in the 15 to 20 percent of patients who have suprapubic tenderness. Fever (greater than 38.5 [degrees] C [101.3 [degrees] F]), costovertebral angle tenderness or upper abdominal tenderness to deep palpation suggest acute pyelonephritis. Women with candidal or Trichomonas vaginitis may have vaginal discharge. Satellite vaginal pustules are sometimes present in patients with vaginal candidiasis, and grouped painful vesicles and tender inguinal adenopathy may be present in patients with genital herpes.

Laboratory Differentiation

Urine Analysis

The most sensitive laboratory indicator for urinary tract infections is pyuria. A positive leukocyte esterase dipstick test is 75 to 95 percent sensitive in detecting pyuria secondary to infection.[4] If no vaginal contamination occurs during collection, vaginitis does not produce pyuria. The presence of white blood cell casts suggests acute pyelonephritis. Bacteriuria and urine nitrite are also frequently present but are less sensitive indicators of urinary tract infection. Most of the subtypes of the known bacterial pathogens (with the exception of Staphylococcus saprophyticus and Enterococcus) can convert urinary nitrate to nitrite. Positive nitrite is over 90 percent specific for urinary tract infections, but sensitivity is usually only about 30 percent.[5] This is secondary to the six-hour incubation time needed. Sensitivity increases to 60 percent with first-voided morning urine samples.

Urine Culture

Women with uncomplicated cystitis who are not pregnant do not usually require a urine culture. However, if a culture is performed and symptoms of cystitis are present, the finding of greater than [10.sup.2] colony-forming units per mL of urine in a promptly cultured specimen is significant.

Vaginal Smears/pH Testing

Increased vaginal PH is characteristic of trichomoniasis and bacterial vaginosis; however, bacterial vaginosis does not typically produce dysuria. The replacement of vaginal lactobacillus with coliform bacteria also increases pH. This may occur in women with recurrent urinary tract infections. Potassium hydroxide and normal saline vaginal smears may reveal mycelia and motile trichomonads in patients with suspected vaginitis. Most women with urethritis are found to have greater than five white blood cells per high-power field on urethral smear.

Cystitis

Acute cystitis is the most common bacterial infection occurring in women. Of the more than 30 percent of women who will experience at least one episode of cystitis in their lifetime, 20 percent will have recurrent cystitis.[3]

Pathogenesis. The shorter urethra in women makes the ascension of bacteria more likely, especially during sexual intercourse. Urine is a natural bactericide with a low pH and a high osmolarity and urea content. Normal urine flow and voiding physically expel bacteria from the urinary tract. A protective mucin coating also inhibits the adherence of bacteria. Women normally have lactobacillus colonization of the vaginal mucosa. Vaginal secretions have a lower pH that inhibits coliform bacteria.

Some patients experience the disruption of some of these defense mechanisms. The conditions that increase the incidence of disruptions are listed in Table 2. Some women have genetically determined receptors on their uroepithelial cells that allow attachment by the glycolipid fimbriae of many fimbriated subtypes of bacteria. Women with these receptors who do not have mucosal secretion of a fucosyltransferase enzyme (which helps to block bacterial adherence) are more likely to have the lactobacillus in their vaginal mucosa replaced with Escherichia coli and other coliforms from their rectum and to have more frequent episodes of cystitis. Since these uroepithelial receptors are also found in the upper urinary tract, these women are also more prone to pyelonephritis.[6,7] Table 3 lists the likely bacterial pathogens in uncomplicated and complicated urinary tract infections.

TABLE 2Conditions That Cause an Increased Incidenceof Urinary in WomenCondition CauseObstruction or alterations Tumors or stones in ureter or at in urine flow ureterovesical junction; anomalies of tract anatomy/function such as cystocele, cystic kidneys, pregnancyAlterations in normal vaginal Nonoxynol-9 in spermatocidal lactobacillus colonization jellies selectively kills lactobacillus but not Escherichia coli[2]; certain antibiotics (especially betalactam-based) alter vaginal flora; ostmenopausal status is associated with a decrease in vaginal lactobacillus colonization'Disruption of mucin layer Urinary tract instrumentation, including insertion of Foley catheterTABLE 3Incidence of Bacterial Pathogensin Lower Urinary Tract InfectionsPathogen Incidence (%)Uncomplicated infectionsEscherichia coli 80Staphylococcus saprophyticus 10Proteus mirabilis 5Klebsiella pneumoniae 4Enterobacter species 1Beta-hemolytic streptococci <1Complicated infectionsE. coli 35Enterococcus faecalis 16P. mirabilis 13Staphylococcus epidermidis 12K. pneumoniae 7Pseudomonas aeruginosa 5Staphylococcus aureus 4Enterobacter species 3Others(*) 5

(*)--Includes Serratia, Streptococcus, Acinetobacter and Citrobacter species.

Adapted with permission from Sweet RL, Gibbs RS. Infectious diseases of the female genital tract. 3d ed. Baltimore: Williams & Wilkins, 1995.

Trichomonas vaginalis infection may be asymptomatic but usually causes an inflammatory vaginitis. There is a three-day to three-week incubation period. Trichomonads reproduce better at the higher vaginal pH in menstrual blood; consequently, a woman with Trichomonas vaginitis will usually note that her symptoms increase during and immediately following menstruation.

Genital Herpes

Eighty percent of patients with primary symptomatic genital herpes will have dysuria; however, dysuria is usually not present if the infection recurs.[26] Most new cases of genital herpes are acquired from sexual contact with asymptomatic viral shedders. Primary herpetic infections typically produce dysuria, associated fever, headache, neck pain, photo-phobia and tender inguinal adenopathy. Seventy-five percent of patients with genital herpes will have vaginal discharge.

Atrophic Vaginitis

Dysuria occurs in women with atrophic vaginitis because of urine contact with the inflamed atrophic tissues themselves or because of the increased incidence of urinary tract infections in these women. Atrophic vaginitis is a common disorder, affecting from 20 to 30 percent of postmenopausal women. Decreased vaginal discharge, vaginal tenderness and dyspareunia are common in women with atrophic vaginitis. Women may also have bloody vaginal spotting, especially after intercourse.

Atrophic vaginitis also increases the risk for urinary tract infections. Approximately 10 to 15 percent of women over 60 years of age have frequent urinary tract infections. Postmenopausal status is associated with a higher vaginal pH, a decrease in vaginal lactobacillus colonization and increased colonization with E. coli. Topical estriol vaginal cream is an effective treatment in postmenopausal women with recurrent infections. In one study,[27] patients treated with the estriol cream averaged 0.5 infections per year, compared with about 6.0 infections per year in women who were not treated.

Infectious Urethritis

Infectious urethritis has not been studied as extensively in women as it has been in men. Chlamydia infection has long been thought to be responsible for many cases of dysuria in women with negative urine cultures.[28] However, some authorities have been unable to show an association between dysuria and Chlamydia in women.[29] A correlation between greater than five white blood cells per high-power field on a urethral swab and the presence of Chlamydia has been identified.[29] A gonococcus may, less commonly, be asymptomatically present in the female urethra as well. About 75 percent of women with Chlamydia identified on urethral swabs have simultaneously had the organism isolated from their cervixes. The finding of intracellular, gram-negative diplococci on Gram's stain is 50 percent sensitive for gonorrhea infection in women.[30] If either organism is suspected, the patient should undergo further testing such as a DNA probe to confirm the diagnosis.

Miscellaneous

Vaginal and urethral trauma, including sexual abuse and the insertion of a foreign body, can cause dysuria, as can irritant or topical allergic responses to soaps, douches, vaginal lubricants, spermicidal jellies, contraceptive foams and sponges, and tampons and sanitary napkins. Perfumed soaps and toilet paper are also common causes of dysuria. Avoidance of the irritative agent generally leads to the resolution of symptoms.

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KURT KUROWSKI, M.D., is an assistant professor and predoctoral director in the Department of Family Medicine at the Finch University of Health Sciences/Chicago Medical School, North Chicago. He received a medical degree from the University of Wisconsin Medical School, Madison, and completed a family practice residency at Resurrection Hospital, Chicago.

Address correspondence to Kurt Kurowski, M.D., Finch University of Health Sciences/Chicago Medical School, 3333 Green Bay Rd., Bldg. 50, Room 115, North Chicago, IL 60064-3095. Reprints are not available from the author.

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