Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Dysuria

 

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 third year medical students because accurate diagnosis requires prudent selection and interpretation of common diagnostic studies. Learning the proper use of antibiotic therapy for dysuria is important because of its impact on health care cost, on selection pressure for antimicrobial resistance in the microbial pool of the community, and on patient morbidity. 

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Prerequisites

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Describe and discuss:

  • anatomy, physiology of the male, and female urinary tract
  • pathophysiology of urethral reflux, urethral obstruction, hydronephrosis, bladder dysfunction, prostatic hypotrophy, and cyst formation
  • microbial pathogens associated with urinary tract infections

Demonstrate:

  • ability to complete medical history
  • ability to perform basic physical examination
  • basic communication skills       

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe signs and symptoms in women of:

  • cystitis
  • urethral syndrome
  • estrogen deficiency changes
  • genital herpes
  • vaginitis

2.     Describe the signs and symptoms in men of:

  • urethritis
  • cystitis
  • genital herpes
  • balanitis

3.     Describe the signs and symptoms of:

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

4.     Describe the signs and symptoms of cystitis, urethritis, and urethral syndrome.

5.     Describe the typical clinical features that help to differentiate among cystitis, urethritis, and urethral syndrome.

6.     Describe the signs and symptoms of bacteremia and sepsis.

7.     Describe the factors that may predispose a patient to cystitis, pyelonephritis, urethritis, and asymptomatic bacteruria.

8.     Describe reasons why the following signs differentiate the causes of urinary tract infection:   

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

9.     Describe indications for diagnostic tests for urinary tract infection:

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

10.  Describe rationale for different durations of antimicrobial therapy for cystitis and pyelonephritis.

11.  Describe commonly used antimicrobial drugs used for urinary tract infections by:

  • naming six drugs and the class to which each belongs
  • describing the antimicrobial spectrum for each, and their effectiveness
  • designating the cost of each
  • toxicity/side effects of each

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including: 

  • eliciting a full description of symptoms which considers both cystitis (frequency, dysuria) from other causes (example: vaginal discharge, genital lesion)
  • determining if dysuria is associated with sexual activity, menstruation, or pregnancy
  • determining the patient’s risk for venereal disease
  • obtaining a description of all prior episodes of dysuria and how they were treated
  • determining the presence or absence of predisposing causes, such as prior instrumentation, catheterization, and anatomic

2.     Perform a physical exam to establish the diagnosis and severity of disease, including;

  • palpating the bladder for distention and tenderness
  • palpating and massaging the urethra to express a discharge
  • recognizing atrophic perineal changes, perineal inflammation, balanitis
  • determining the presence or absence of flank tenderness
  • performing prostatic massage

3.     Demonstrate confidence and comfort in obtaining an adequate sexual history and performing genitor-urinary exams.

4.     Generate a differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology.

5.     Recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and interpret the results (with consultation), including the following tests:

  •  three glass urinalysis test
  • 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 culture
  • vaginal/cervical swab culture
  •  KOH preparation of genital mucosal scrapings
  •  urinary catheterization to asses for post-void residual
  • urine culture

6.     Perform basic procedural skills:

  • urinalysis
  • gram stain of urethral discharge
  • urethral swab culture
  • KOH preps
  • urinary catheterization

7.     Communicate the diagnosis to the patient.

8.     Record, present, research, critique, and manage clinical information.

 

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Develop a Management Plan

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Make a decision about what to include from the following items, and explain why each item selected should be included.

1.     Describing preventive measures, including counseling and educating patients about sexual activity.

2.     Identifying treatment measures such as the appropriate prescribing of antibiotics (choice of medication, length of therapy) as well as appropriate use of consultants and referral to specialists.

3.     Providing psychological support if indicated.

4.     Accessing and utilizing appropriate information systems to ascertain information about health system and community resources.

5.     Plan for follow-up.

6.     Formulate a prognosis and communicate it to the patient in a caring and compassionate manner.

7.     Communicate the treatment plan and follow up plan to patient.

8.     Consider the cost-effectiveness of the management plan.

 

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Differential Diagnosis

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In women

  • cystitis
  • pyelonephritis
  • urethral syndrome
  • genital herpes
  • vaginitis
  • elderly: also consider estrogen deficiency atrophic changes
  • prepubertal female: also consider labial adhesions

In men

  • urethritis
  • cystitis
  • genital herpes
  • balanitis
  • prepubertal male: anatomic abnormality such as urethral stricture