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Vanderbilt Core Clinical Curriculum

Dysuria and Incontinence

Dysuria is a very common symptom that is associated with significant morbidity and is sometimes associated with serious medical disorders. Diagnosing the etiology of dysuria is an important training problem for medical students because accurate diagnosis requires prudent selection and interpretation of common diagnostic studies. Learning the proper use of antibiotic therapy for in patients with dysuria is important because of its impact on health care cost, on selection pressure for antimicrobial resistance in the community, and on patient morbidity. Likewise, incontinence is a symptom associated with multiple etiologies including serious medical disorders.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with DYSURIA AND INCONTINENCE can include:

Medical Knowledge Learning Topics related to DYSURIA AND INCONTINENCE:

1. Signs and symptoms in women with cystitis, urethral syndromes, and estrogen deficiency changes
2. Signs and symptoms in men with cystitis and urethritis
3. Signs and symptoms of:

  • urinary tract infection associated with dysuria
  • pyelonephritis
  • prostatitis
  • asymptomatic bacteriuria

4. Clinical features that typically help to differentiate between cystitis, urethritis, and urethral syndrome
5. Factors that may predispose a patient to cystitis, pyelonephritis, urethritis, and asymptomatic bacteriuria
6. Signs that differentiate the causes of urinary tract infection, such as:

  • flank tenderness
  • enlarged kidney
  • palpable bladder
  • post-void residual urine
  • urethral discharge

9. Indications for diagnostic tests for urinary tract infection, such as:

  • intravenous pyelogram
  • urodynamic determination
  • renal ultrasound
  • CT scan

10. Rationale for different durations of antimicrobial therapy for cystitis and pyelonephritis
11. Commonly used antimicrobial drugs used for urinary tract infections, including:

  • names and classes of common antimicrobial drugs and the class to which each belongs
  • description of the antimicrobial spectrum and effectiveness for each agent
  • identification of the cost of each agent
  • identification of the toxicity and side effect profile of each agent

Diagnostic Evaluation Learning Topics related to DYSURIA AND INCONTINENCE

1. Age-appropriate medical history taking, documentation and presentation that differentiate among etiologies of disease, including:

  • full description of symptoms which may distinguish cystitis (e.g., frequency, dysuria) from other causes (e.g., vaginal discharge, genital lesion)
  • determination if dysuria is associated with sexual activity, menstruation, or pregnancy
  • determination of the patient’s risk for sexually transmitted infection
  • description of prior episodes of dysuria and how they were treated
  • determination of the presence or absence of predisposing causes, such as prior instrumentation, catheterization, and anatomic abnormalities

2. Physical examination to establish the diagnosis and severity of disease, including:

  • palpation of the bladder for distention and tenderness
  • recognition of atrophic perineal changes, perineal inflammation, and balanitis
  • determination the presence or absence of flank tenderness

3. Sexual history taking and genitourinary physical examination
4. Differential diagnosis generation recognizing specific history and physical exam findings that suggest a specific etiology
5. The use and timing of diagnostic and laboratory testing, both prior to and after initiating treatment, in consideration of the differential diagnosis, test performance, cost, and patient preferences, such as:

  • urinalysis, with recognition of pyuria, bacteria, white cell casts, hematuria, renal tubular epithelial cells, and transitional cells in the urine sediment
  • gram stain of urethral discharge
  • urethral swab sampling for culture or polymerase chain reaction testing
  • vaginal/cervical swab sampling for culture or polymerase chain reaction testing
  • KOH preparation of genital mucosal scrapings
  • urinary catheterization to assess for post-void residual
  • urine culture

6. Basic procedural skills, including:

  • urinalysis
  • gram stain of urethral discharge
  • urethral swab sampling for culture or polymerase chain reaction testing
  • vaginal/cervical swab sampling for culture or polymerase chain reaction testing
  • KOH preps
  • urinary catheterization

Management Plan Learning Topics related to DYSURIA AND INCONTINENCE

1. Description of preventive measures, including counseling and education about sexual activity
2. Identification of treatment options, such as the appropriate prescribing of antibiotics (i.e., choice of medication, length of therapy) as well as appropriate use of consultants and referral to specialists
3. Psychological support if indicated
4. Use of appropriate information systems to ascertain information about health system and community resources
5. Follow-up planning
6. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle
7. Consideration of the cost and cost-effectiveness of the management plan

Potential Differential Diagnosis Topics Include:

In women

  • cystitis
  • pyelonephritis
  • urethral syndrome
  • genital herpes
  • vaginitis
  • estrogen deficiency atrophic changes in the older adult
  • labial adhesions in the prepubertal female

In men

  • urethritis
  • cystitis
  • pyelonephritis
  • anatomic abnormality such as urethral stricture in the prepubertal male