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Infectious Diseases and Microbiology: Dysuria and Fever
Basics
Description
Dysuria refers to painful urination. Acute urethral syndrome describes dysuria with urgency and frequency in the absence of significant bacteriuria.
Approach to the Patient
Irritation of urethral and bladder mucosa typically causes frequent, painful voiding of small urine volumes. Dysuria is often assumed to be a urinary tract infection and treated empirically, which can miss important diagnoses in some patients and lead to unnecessary antibiotics in others, so targeted evaluation is preferred. A focused history and examination, including pelvic and rectal examination when indicated, often clarifies the cause and enables directed therapy. Sexually transmitted infections including Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex virus can cause dysuria in any sex. Prostatitis is a key diagnosis in men because it is harder to eradicate and can recur. Fever is uncommon in cystitis but may occur with acute prostatitis; dysuria with fever should also raise concern for upper-tract infection such as pyelonephritis. Primary genital herpes can cause dysuria with fever, while chlamydia, gonorrhea, and nonspecific urethritis rarely cause fever unless complicated by pelvic inflammatory disease or Fitz-Hugh–Curtis syndrome. Dysuria with hematuria suggests infectious or noninfectious cystitis and also warrants consideration of tuberculous cystitis, bladder cancer, trauma, renal stones, and schistosomiasis. Dysuria with urethral or vaginal discharge suggests gonorrhea or chlamydia, nonspecific urethritis (with or without conjunctivitis and arthritis consistent with reactive arthritis), and prostatitis. Urinalysis and urine culture are standard initial tests, though young women with classic uncomplicated symptoms and no risk factors for complicated or recurrent infection may be treated empirically.
Epidemiology
Incidence
UTIs are among the most common infectious syndromes and carry substantial costs, including antibiotic expenditures exceeding one billion dollars annually in the United States. Most patients with primary symptomatic genital herpes experience dysuria, though dysuria is typically absent with recurrences. Sexual intercourse is linked to several dysuria etiologies, with symptom timing differing by syndrome: postcoital cystitis often appears within days, urethritis tends to appear after one to two weeks, and vaginitis may present weeks to months later. Pyelonephritis is a frequent cause of hospitalization, and UTIs account for over 100,000 U.S. admissions annually. Healthcare-associated infections are often UTIs, commonly catheter-related; bacteriuria develops in a substantial proportion of patients with prolonged catheterization with a daily incremental risk of infection, and even single catheterization can cause UTI. Escherichia coli causes most uncomplicated UTIs. In pregnancy, asymptomatic bacteriuria can progress to pyelonephritis and is associated with adverse obstetric outcomes including premature labor
.
Etiology
Beyond bacterial cystitis and pyelonephritis and sexually transmitted causes, dysuria may result from atrophic vaginitis, Candida-associated vaginitis, irritation from a distal urethral stone, chemical exposures, compression from an adnexal mass, radiation injury, and vaginal or urethral trauma including sexual abuse or foreign body insertion. Among women with acute dysuria and frequency, most have significant bacteriuria, and many without significant bacteriuria still have infections of the bladder, kidneys, or urethra. Ureaplasma urealyticum is often detected in symptomatic patients but is also found in asymptomatic individuals, and both U. urealyticum and Mycoplasma hominis have been identified in prostatic and renal tissues in patients with dysuria. Adenovirus can cause acute hemorrhagic cystitis in children and some young adults, sometimes in outbreaks, while other urinary viral isolates are generally not considered causes of infection in immunocompetent hosts.
Diagnosis
History
Dysuria with frequency, urgency, and suprapubic discomfort commonly reflects bladder or urethral inflammation. Prostatitis typically causes dysuria, frequency, and urgency and may be suggested by a boggy, tender prostate on rectal examination. Acute pyelonephritis usually evolves over hours to a day with fever, rigors, nausea, vomiting, and sometimes diarrhea; cystitis symptoms may be absent or present. Examination in pyelonephritis often shows fever, tachycardia, diffuse myalgias, and marked costovertebral angle tenderness. Evaluate predisposing factors for UTI or pyelonephritis, including atrophic vaginitis, which may present with reduced discharge, vaginal tenderness, postcoital spotting, and dyspareunia.
Physical Examination
Check vital signs and hydration, especially when pyelonephritis is possible. Suprapubic tenderness supports lower-tract infection, while flank tenderness suggests upper-tract involvement. Perform a genital examination when sexually transmitted infection is suspected, and perform a prostate examination in all men.
Diagnostic Tests and Interpretation
Laboratory Studies
Pyuria is the most sensitive indicator of UTI, and leukocyte esterase testing is highly sensitive for detecting infection-associated pyuria. Urine colony counts of 10^5 CFU/mL generally indicate infection, while lower thresholds (≥10^2 CFU/mL) can be diagnostic in symptomatic patients and in specimens obtained by suprapubic aspiration or catheterization. Most uropathogens convert nitrate to nitrite; nitrite positivity is highly specific but has low sensitivity. Rapid bacteriuria detection methods using techniques such as photometry or bioluminescence can yield results in one to two hours but may miss infections when lower colony counts are used as the comparison standard. Sterile pyuria suggests atypical infections such as chlamydia, ureaplasma, tuberculosis, or fungal infection and can also occur with prostatitis and noninfectious urologic conditions including stones, structural abnormalities, nephrocalcinosis, vesicoureteral reflux, interstitial nephritis, polycystic kidney disease, and related disorders.
Treatment
Therapy for acute urethritis depends on cause. Uncomplicated lower-tract infection in women is treated with short-course antibiotics (about 3–5 days), while men or those with upper-tract disease generally require longer courses (10–14 days). Suspected or confirmed prostatitis requires prolonged therapy, typically at least four weeks. Patients with acute dysuria and frequency who have negative urine cultures and no pyuria generally do not improve with antibiotics.
Ongoing Care and Follow-Up
Many women experience cystitis during their lifetime, and recurrent episodes are common. Most recurrent UTIs represent reinfections after at least one month without symptoms and are often related to vaginal and rectal colonization with uropathogens; anatomic abnormalities are uncommon in young women with recurrent cystitis.
Complications
Lower-tract infection can ascend and cause upper-tract disease.
Basics
Description
Dysuria refers to painful urination. Acute urethral syndrome describes dysuria with urgency and frequency in the absence of significant bacteriuria.
Approach to the Patient
Irritation of urethral and bladder mucosa typically causes frequent, painful voiding of small urine volumes. Dysuria is often assumed to be a urinary tract infection and treated empirically, which can miss important diagnoses in some patients and lead to unnecessary antibiotics in others, so targeted evaluation is preferred. A focused history and examination, including pelvic and rectal examination when indicated, often clarifies the cause and enables directed therapy. Sexually transmitted infections including Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex virus can cause dysuria in any sex. Prostatitis is a key diagnosis in men because it is harder to eradicate and can recur. Fever is uncommon in cystitis but may occur with acute prostatitis; dysuria with fever should also raise concern for upper-tract infection such as pyelonephritis. Primary genital herpes can cause dysuria with fever, while chlamydia, gonorrhea, and nonspecific urethritis rarely cause fever unless complicated by pelvic inflammatory disease or Fitz-Hugh–Curtis syndrome. Dysuria with hematuria suggests infectious or noninfectious cystitis and also warrants consideration of tuberculous cystitis, bladder cancer, trauma, renal stones, and schistosomiasis. Dysuria with urethral or vaginal discharge suggests gonorrhea or chlamydia, nonspecific urethritis (with or without conjunctivitis and arthritis consistent with reactive arthritis), and prostatitis. Urinalysis and urine culture are standard initial tests, though young women with classic uncomplicated symptoms and no risk factors for complicated or recurrent infection may be treated empirically.
Epidemiology
Incidence
UTIs are among the most common infectious syndromes and carry substantial costs, including antibiotic expenditures exceeding one billion dollars annually in the United States. Most patients with primary symptomatic genital herpes experience dysuria, though dysuria is typically absent with recurrences. Sexual intercourse is linked to several dysuria etiologies, with symptom timing differing by syndrome: postcoital cystitis often appears within days, urethritis tends to appear after one to two weeks, and vaginitis may present weeks to months later. Pyelonephritis is a frequent cause of hospitalization, and UTIs account for over 100,000 U.S. admissions annually. Healthcare-associated infections are often UTIs, commonly catheter-related; bacteriuria develops in a substantial proportion of patients with prolonged catheterization with a daily incremental risk of infection, and even single catheterization can cause UTI. Escherichia coli causes most uncomplicated UTIs. In pregnancy, asymptomatic bacteriuria can progress to pyelonephritis and is associated with adverse obstetric outcomes including premature labor
.
Etiology
Beyond bacterial cystitis and pyelonephritis and sexually transmitted causes, dysuria may result from atrophic vaginitis, Candida-associated vaginitis, irritation from a distal urethral stone, chemical exposures, compression from an adnexal mass, radiation injury, and vaginal or urethral trauma including sexual abuse or foreign body insertion. Among women with acute dysuria and frequency, most have significant bacteriuria, and many without significant bacteriuria still have infections of the bladder, kidneys, or urethra. Ureaplasma urealyticum is often detected in symptomatic patients but is also found in asymptomatic individuals, and both U. urealyticum and Mycoplasma hominis have been identified in prostatic and renal tissues in patients with dysuria. Adenovirus can cause acute hemorrhagic cystitis in children and some young adults, sometimes in outbreaks, while other urinary viral isolates are generally not considered causes of infection in immunocompetent hosts.
Diagnosis
History
Dysuria with frequency, urgency, and suprapubic discomfort commonly reflects bladder or urethral inflammation. Prostatitis typically causes dysuria, frequency, and urgency and may be suggested by a boggy, tender prostate on rectal examination. Acute pyelonephritis usually evolves over hours to a day with fever, rigors, nausea, vomiting, and sometimes diarrhea; cystitis symptoms may be absent or present. Examination in pyelonephritis often shows fever, tachycardia, diffuse myalgias, and marked costovertebral angle tenderness. Evaluate predisposing factors for UTI or pyelonephritis, including atrophic vaginitis, which may present with reduced discharge, vaginal tenderness, postcoital spotting, and dyspareunia.
Physical Examination
Check vital signs and hydration, especially when pyelonephritis is possible. Suprapubic tenderness supports lower-tract infection, while flank tenderness suggests upper-tract involvement. Perform a genital examination when sexually transmitted infection is suspected, and perform a prostate examination in all men.
Diagnostic Tests and Interpretation
Laboratory Studies
Pyuria is the most sensitive indicator of UTI, and leukocyte esterase testing is highly sensitive for detecting infection-associated pyuria. Urine colony counts of 10^5 CFU/mL generally indicate infection, while lower thresholds (≥10^2 CFU/mL) can be diagnostic in symptomatic patients and in specimens obtained by suprapubic aspiration or catheterization. Most uropathogens convert nitrate to nitrite; nitrite positivity is highly specific but has low sensitivity. Rapid bacteriuria detection methods using techniques such as photometry or bioluminescence can yield results in one to two hours but may miss infections when lower colony counts are used as the comparison standard. Sterile pyuria suggests atypical infections such as chlamydia, ureaplasma, tuberculosis, or fungal infection and can also occur with prostatitis and noninfectious urologic conditions including stones, structural abnormalities, nephrocalcinosis, vesicoureteral reflux, interstitial nephritis, polycystic kidney disease, and related disorders.
Treatment
Therapy for acute urethritis depends on cause. Uncomplicated lower-tract infection in women is treated with short-course antibiotics (about 3–5 days), while men or those with upper-tract disease generally require longer courses (10–14 days). Suspected or confirmed prostatitis requires prolonged therapy, typically at least four weeks. Patients with acute dysuria and frequency who have negative urine cultures and no pyuria generally do not improve with antibiotics.
Ongoing Care and Follow-Up
Many women experience cystitis during their lifetime, and recurrent episodes are common. Most recurrent UTIs represent reinfections after at least one month without symptoms and are often related to vaginal and rectal colonization with uropathogens; anatomic abnormalities are uncommon in young women with recurrent cystitis.
Complications
Lower-tract infection can ascend and cause upper-tract disease.
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