Andrew Siegel MD 6/5/2020
“Doc, it feels like there is a hot poker iron inside me when I pee.”
Image by Jennifer Beebe from Pixabay
DYSURIA: DEFINITION AND CAUSES
Dysuria is medical-speak for uncomfortable, burning quality and/or painful urination. It is a common symptom and a frequent reason for a consultation with a urologist. Underlying causes are many and varied including infections, inflammatory conditions, trauma and injury, pelvic floor dysfunction, and local processes and conditions of the urethra (the channel that leads out from the urinary bladder).
Dysuria is often caused by infections of the lower urinary tract or genital structures (urethra, bladder, prostate and vagina). The most common reason for painful urination is a bladder infection, a.k.a. cystitis, prevalent in females although occurring occasionally in males. Prostatitis, an infection of the prostate gland can be a cause of painful urination in males and the parallel process in females, para-urethral gland infection (a.k.a. Skenitis, an infection of the Skene’s gland—the female homologue of the prostate) can also give rise to dysuria. Because of the close geographical proximity of the female urethra to the vagina, yeast infections, a.k.a. candida vulvovaginitis, as well as other forms of bacterial vaginitis can secondarily involve the urethra and cause dysuria. Urethritis, an infection of the urethra, is another frequent cause of dysuria, most often on the basis of sexual transmitted infections (STI), particularly those caused by chlamydia, gonorrhea, and herpes. Urethritis is often but not always accompanied by a urethral discharge.
Dysuria has non-infectious causes as well. Urine contains the nitrogenous breakdown product of protein metabolism– urea–and if the urine concentration becomes too high because of insufficient fluid intake or other reasons for dehydration, one may experience burning with urination. This happens particularly with the first urination of the day, when the urine is most concentrated because of the relative dehydration from the hours spent sleeping without consuming liquids. During the course of and immediately following prostate radiation therapy for treatment for prostate cancer, dysuria is a common issue due to radiation-induced inflammatory changes that generally improve over time. Radiation therapy literally burns the prostatic urethra, with resulting swelling, inflammation, redness and weeping (as you would see if you burned your skin). On occasion, a long-term consequence of radiation to the prostate, bladder, uterus, colon or any pelvic organ is radiation cystitis, manifested with dysuria, bleeding and other urinary symptoms. Interstitial cystitis, a painful inflammatory condition of the bladder that may severely impact one’s quality of life, causes dysuria, pelvic pain and urinary frequency, typical symptoms of a urinary infection, yet with normal urine cultures.
Any condition that directly impacts urethral anatomy or function can give rise to painful and difficult urination. A urethral stricture is scar tissue within the urethra that impedes urinary flow and can cause dysuria. A stone lodged within the urethral channel that originated in the kidney or bladder in the process of passage can do the same. A urethral diverticulum is an out-pouching from the urethra, much more common in females than males, that typically presents with painful urination, painful sex and dribbling of urine after completing the act of urination. Another not infrequent cause of dysuria is atrophic urethritis, the term applied to changes of the urethra that accompany menopause due to cessation of estrogen production. Urethral trauma is an obvious source of dysuria. This can happen to females after vigorous sexual intercourse and after vaginal delivery, particularly with large babies and prolonged labor. Urethral trauma can occur from straddle injuries that occur when the perineum (area between anus and scrotum in a male, anus and vagina in a female) strikes a hard object such as the crossbar of a bicycle or the top rail of a fence. A common cause of temporary urethral trauma is from a catheter placed in the urethra or from transurethral surgery, operations performed via the urethra that require instrumentation of the urethra.
Pelvic floor dysfunction can cause dysuria as well as a myriad of other urinary, bowel, sexual and pelvic symptoms. Pelvic floor tension myalgia occurs when stress becomes internalized within the pelvic floor creating “knots” within the pelvic muscles–discrete areas of hyper-tensioned muscle–that cause pelvic pain. Many patients thought to have other medical conditions that give rise to pelvic pain including interstitial cystitis/chronic pelvic pain syndrome, irritable bowel syndrome, chronic prostatitis, vulvodynia and fibromyalgia in actuality have pelvic floor tension myalgia.
PATIENT HISTORY
A few basic questions, a tailored physical exam and some lab tests can help pinpoint the underlying cause of the dysuria and formulate a treatment plan. Relevant questions include the following: Where precisely is the pain perceived? What is the pain’s quality and severity, when does it occur, and how long has it been present? Is it constant or intermittent? Does it occur only with urination or at all times? Are there other urinary symptoms that accompany the pain: bleeding, urgency, frequency, weak stream, etc.? Is there a discharge from the urethra or vagina? Are there systemic symptoms such as fever, chills and malaise? Did any event seem to precipitate the onset of the pain? Is there a relationship of the pain to sexual activity? Is there a history of kidney stones, recent procedures that required a catheter or urethral instrumentation, radiation therapy, recent treatment with antibiotics, redness, swelling or other physical changes noted, urinary infection that was not cured with antibiotics, trauma/injuries, recent stressful life events?
PHYSICAL EXAM AND FURTHER TESTING
Examination of the urethra, penis, testes and prostate in males and a pelvic exam in females will help diagnose the underlying cause of the dysuria. Urinalysis and urine culture with sensitivity (to seek the best antibiotic to treat the infection) are imperative since urinary infections are the leading cause of dysuria. If there is urethral discharge accompanying the dysuria and/or a history of unprotected sex, a STI screen is appropriate. Depending on associated urinary symptoms, a possible uroflowmetry test (urinating into a machine to gauge if there might be a urinary blockage) and cystoscopy (visual inspection of the urethra and bladder with a tiny fiberoptic telescope) are indicated. If a urethral diverticulum is recognized or suspected, MRI is a helpful test to precisely discern the anatomy before considering surgical repair.
TREATMENT
After history, physical, lab and possible additional testing, the underlying cause of the dysuria will be defined and treatment directed appropriately. Urinary infections are usually easily managed with a course of antibiotics. If urine is hyper-concentrated, increasing fluid intake generally will improve the situation. Prostatitis and Skenitis commonly require a prolonged course of antibiotics. STIs are typically easily managed with the appropriate antibiotic or antiviral. Yeast infections are readily treated with anti-fungals. Urinary tract analgesics/antispasmodics are helpful for temporary relief of dysuria associated with infections. At times, a prostate relaxant medication can be helpful for the urinary difficulties associated with prostatitis, whether infectious or radiation induced. Anti-inflammatories are often useful as well. Interstitial cystitis is a complex situation with multiple potential treatment options, beyond the scope of this discussion. Atrophic urethritis can be addressed with topical estrogen. If a stone, stricture, diverticulum, or traumatic injury is the underlying cause, surgical correction is often indicated. Pelvic floor physical therapy can be extremely helpful and is often the key treatment for pelvic floor dysfunction to foster relaxation and “down-training” of the spastic pelvic muscles in order to untie the “knot(s)” of over-tensioned muscle within the pelvis.
At times, despite substantial effort and testing, no source for the dysuria is found, a frustrating situation for patient and physician alike. This is oftentimes labeled chronic urethritis and management may include local therapy including hot baths and the application of topical lidocaine jelly. The good news, however, is that in the vast majority of cases the diagnosis and treatment of dysuria are straightforward.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States. His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Our Greatest Wealth Is Health 