Dysuria là gì

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Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.


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Definition

Dysuria is any discomfort associated with urination. Abnormally frequent urination (e.g., once every hour or two) is termed urinary frequency. Urgency is an abrupt, strong, often overwhelming, need to urinate.


Technique

The term dysuria is used to describe painful urination, which often signifies an infection of the lower urinary tract. The discomfort is usually described by the patient as burning, stinging, or itching. Pain occurring at the beginning of or during urination suggests a urethral site of disease, whereas pain after voiding implies pathology within the bladder or prostate area. Sometimes a patient will relate a history of pain in the suprapubic area.

In men, pain on urination is often referred most intensely to the glans penis regardless of whether the location of the disorder is in the urethra or in the bladder; the pain may persist between voiding. Specific questioning about a discharge from the penis should be undertaken, especially in younger men. Inquiries as to the character and volume of discharge are important. Gonococcal urethritis usually presents with a copious purulent discharge, whereas nongonococcal urethritis commonly is mucoid and of small quantity. In older men, specific questions should be asked about associated hesitancy, intermittency, or straining. Ask the patient about standing closer to the toilet or taking longer to start than previously. These symptoms suggest obstruction, a common harbinger of infection, usually occurring either from prostatic enlargement or a urethral stricture.

In women with dysuria, the first question should be whether the discomfort is internal or external; in addition to urinary tract inflammation or infection, vaginal inflammation can cause dysuria as urine passes by the inflamed labia. If the sensation is internal or suprapubic, a urinary tract source is more likely; questions about associated fever, chills, back pain, nausea, vomiting, and prior urinary tract infections should be asked in an attempt to differentiate upper from lower urinary tract infection. If the sensation is "outside," then a vaginal etiology should be suspected. Questions about a vaginal discharge or itching should always be asked. Vaginitis and a urinary tract infection often coexist, and vaginal infections in some populations are seen almost six times more frequently than urinary tract infections. Remember that women often do not spontaneously volunteer information about a vaginal discharge or vaginal itching. To help delineate the etiology of dysuria in the individual patient, both a urinalysis and a pelvic examination will often be necessary.

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Ascertain the acuteness of onset of symptoms as well as whether there is associated hematuria or suprapubic pain. Coliform or staphylococcal urinary tract infections are typically more acute in onset (less than 4 days) and more often associated with suprapubic pain and hematuria than are chlamydial infections. Women with chlamydial infections are more likely to use oral contraceptives and less likely to have a history of a urinary tract infection within the preceding 2 years. One should also inquire about the sexual history because chlamydial infections are more likely in women with a new sex partner. In addition, a history of a sex partner with recent urethritis or discharge might direct attention toward chlamydia or gonorrhea, which tends to be less symptomatic in the early stages of infection in women.

Historic information such as immunosuppression (diabetes mellitus, sickle cell disease, steroids, etc.), childhood infections, previous acute pyelonephritis, prior relapses or recurrences of urinary tract infections (especially if greater than three), underlying urinary tract disease (stones, prior instrumentation, congenital anomalies), or presence of symptoms for greater than 7 days define a population of women at risk for subclinical pyelonephritis. This clinical entity of an upper tract infection without the usual accompanying symptoms or signs of fever, chills, back pain, nausea, and vomiting is less amenable to short courses of therapy and more likely to relapse. Subclinical pyelonephritis occurs in up to 30% of women in typical primary care settings and in up to 80% of indigent women presenting with dysuria.

Urinary frequency should be differentiated from polyuria, which specifically relates to the passage of an abnormally large volume of urine in a relatively short period of time. Frequency of normal urination may vary considerably from individual to individual depending on personality traits, bladder capacity, or drinking habits. Because of this fact, a history of frequency is sometimes difficult to obtain. Changes in the pattern of frequency or a history of voiding more than once at night after retiring, however, are clues to urinary pathology. Ask about volume and voiding times, since a large bladder capacity may conceal an increase in urine production. Frequency commonly accompanies the dysuria associated with urinary tract infections but less commonly with vaginitis. Ask also about periodicity of symptoms because day frequency without nocturia, or frequency lasting only a few hours at a time, suggests nervous tension or a psychiatric cause.

Urgency may occur with or without voiding and frequently culminates in incontinence. With severe lower urinary tract inflammation, the desire to urinate may be constant with only a few milliliters of urine eliminated with each voiding. Urge incontinence must be differentiated from the other types of incontinence, especially stress incontinence. Urgency also more commonly accompanies the dysuria associated with urinary tract infections than that associated with vaginitis.