1. Assist Prof Microbiology Dr. Syed Yousaf Kazmi
DYSURIA
Assist Prof Microbiology
Dr. Syed Yousaf Kazmi

2. LEARNING OBJECTIVES Define dysuria
Enumerate the major causes of dysuria
Discuss common microbiological agents responsible for dysuria
Explain the patho- physiological changes
Describe the symptoms and signs of presentation
Discuss the investigations and principles of management

3. DYSURIA-DEFINITION
‘Painful or difficult urination’ ‘Pain during urination, or difficulty urinating’ ‘Dysuria is the feeling of pain, burning, or discomfort upon urination’

4. DYSURIA- MAJOR CAUSES CAUSES IN MALE CAUSES IN FEMALE
CAUSES IN CHILDREN
NON GENDER SPECIFIC CAUSES

5. CAUSES IN MALE URINARY TRACT INFECTION
Pyelonephritis (Enterobacteriaceae)
Acute Cystitis (Enterobacteriaceae)
URETHRITIS (Gonorrhea and Chlamydia)
PROSTATITIS (Enterobacteriaceae)
EPIDIDYMITIS AND ORCHITIS (Enterobacteriaceae, Mumps)
MEATITIS and URETHRITIS (HSV II infection)
BALANITIS
OBSTRUCTIVE UROPATHY (Nodular hyperplasia prostate)
URETHRAL STRICTURE
Urethral instrumentation
Prior Gonorrhea infection
MISCELLANEOUS CAUSES Prostatitis

6. CAUSES IN FEMALE URINARY TRACT INFECTION GENITAL HERPES (HSV II)
Acute Cystitis
Pyelonephritis
GENITAL HERPES (HSV II)
URETHRITIS (Gonorrhea ,Chlamydia )
VULVO-VAGINITIS ( Candida, Trichomonas, Atrophic Vaginitis)
URETHRAL SYNDROME (Acute Cystitis symptoms & normal urine)
CONTACT DERMATITIS
Vaginal Douche, Vaginal lubricant, Spermicidal gel, Contraceptive foams or sponges, Tampons, Perfumed soap, Toilet paper

7. CAUSES IN CHILDREN URINARY TRACT INFECTION
CHEMICAL IRRITANTS (e.g. bubble bath)
PHYSICAL IRRITANTS
Self exploration
Self-infusion of water into urethra (common in boys)
LOCAL INFECTION (e.g. Pinworms)

8. NON GENDER SPECIFIC CAUSES
URINARY TRACT INFECTION
NEPHROLITHIASIS
BLADDER CANCER
LOCAL URETHRAL TRAUMA (e.g. Bicycling, catheter)
MEDICATION ADVERSE EFFECTS
Dopamine, Ticarcillin, Penicillin G, Cyclophosphamide
FOOD AND HERBAL SUPPLEMENT ADVERSE EFFECTS
Saw Palmetto
Pumpkin seeds
PSYCHOGENIC CAUSES
Somatization, Chronic Pain Syndrome , Major Depression
Sexual abuse

9. MICROBIOLOGICAL CAUSES OF DYSURIA
URINARY TRACT INFECTION
Mainly cystitis
Major pathogens usually intestinal flora
Most common in women in pregnancy
Community acquired:
E coli (75%), Klebsiella, Proteus, Staph saphrophyticus, other Enterobacteriaceae
Hospital acquired:
Enterococcus, Pseudomonas aeruginosa., E coli, Staphylococcus sp., Candida spp
Mostly multidrug resistant, catheter related

10. MICROBIOLOGICAL CAUSES OF DYSURIA
URETHRITIS
90% symptomatic in male than female
Ns. gonorrhea, Chlamydia trachomatis, Ureaplasma urealyticum
Trichomonas vaginalis

11. MICROBIOLOGICAL CAUSES OF DYSURIA
GENITAL SKIN LESIONS
Genital herpes (HSV 2)
Chancre ( Syphilis)
Candida infection

12. MICROBIOLOGICAL CAUSES OF DYSURIA
EPIDIDYMITIS & ORCHITIS
Enterobacteriaceae (E. coli, Proteus, Klebsiella etc.)
Mumps virus infection
Mycobacterium tuberculosis
Ns. gonorrhea, Chlamydia trachomatis

13. PATHO-PHYSIOLOGICAL CHANGES
Depends upon causative agent
Gonorrhea e.g. causes necrosis of urethral epithelium and inflammation
Syphilis causes chancre formation and dissemination to other organs
HSV infection causes recurrent sores by causing skin blisters and ulcers
TB produces granulomatous reaction in tissue infected

14. SIGNS & SYMPTOMS LOWER URINARY TRACT INFECTION (CYSTITIS)
Frequent urination
An intense urge to urinate
Loss of bladder control
Pain in the lower front portion of the abdomen
Cloudy urine that may have a strong odor,
Blood in urine

15. SIGNS & SYMPTOMS UPPER URINARY TRACT INFECTION (PYELONEPHRITIS)
Pain in the upper back
High fever with shaking chills
Nausea and vomiting
Cloudy urine
Frequent micturition
An intense urge to urinate

16. SIGNS & SYMPTOMS URETHRITIS Discharge from the urethra
Redness at urethral meatus
Frequent urination
Vaginal discharge
Fever
Nausea & vomiting

17. SIGNS & SYMPTOMS VAGINITIS Pain, soreness or itching in the vagina
An abnormal or foul-smelling vaginal discharge or odor
Pain or discomfort during sexual intercourse

18. INVESTIGATIONS URINE ROUTINE EXAMINATION
Color: May be normal, or reddish color (hematuria)
Smell: Normal to offensive in certain infections
Turbidity: In UTI, usually turbid urine
Protein: usually present in UTIs
RBCs: May be present in UTIs, other infections,
WBCs: Usually >10-20/HPF

19. URINE ROUTINE EXAMINATION
MICROSCOPY
WBCs, RBCs, in UTIs
Can visualize bacteria, yeast cells in UTIs and other infections
Trichomonas vaginalis motility
RBCs
WBCs
Trichomonas vaginalis in urine

20. CULTURE OF SPECIMENS URINE CULTURE DISCHARGE FOR C/S
Easy way of diagnosing UTI
Antimicrobial sensitivity helpful in treatment
Helpful in cystitis and pyelonephritis
Negative cultures do not rule out UTIs(Fastidious org, etc.)
DISCHARGE FOR C/S
Urethral discharge, vaginal discharge
Helpful in diagnosing gonorrhea, and vaginitis

21. LAB INVESTIGATION OF STIs
DARK FIELD MICROSCOPY
For motility of Spirochetes e.g. Treponema pallidum
IMMUNOFLOURESENSCE TEST
For Chlamydia trachomatis from urethral discharge
SEROLOGICAL TESTS FOR SYPHILIS
RPR test, FTA Adsorbed test, TP PA test etc.

22. MANAGEMENT PROTOCOLS Each disease merits its specific treatment
UTI must be diagnosed by C/S and given antimicrobial course
Empiric therapy may be instituted in severe conditions and amended on report of C/S
Local antimicrobial susceptibility pattern must be known to the physicians
Syphilis, Gonorrhea, Chlamydia etc. needs protocols like, Penicillin G, Ceftriaxone, oral doxycyclin respectively
For Candida vaginitis, local & systemic antifungal treatment reqd