As men draw near the common goal,
Can anything be sadder
Than he who, master of his soul,
Is servant to his bladder? Anonymous Speculum, 1938
Disturbances of micturition are a common problem in general practice, with an annual incidence of about 20 per 1000 patients at risk.1 Such disturbances include dysuria, frequency of micturition, difficulty or inability to initiate micturition, stress incontinence and haematuria. These symptoms are three times as common in women as in men.1 The combination of dysuria and frequency is the most common of the symptoms with an incidence of about 14 per 1000 patients and a female:male ratio of 5:1.1
Among children and the elderly, the patient may complain of urinary incontinence unassociated with stress. However, with the exception of enuresis (CHAPTER 91), disturbances of micturition are uncommon in children.
Dysuria, or difficult and/or painful micturition, which is characterised mainly by urethral and suprapubic discomfort, indicates mucosal inflammation of the lower genitourinary tract (i.e. the urethra, bladder or prostate). The passage of urine across inflamed mucosa causes pain. Frequency can vary from being negligible to extreme. It can be ‘habit frequency’ or associated with anxiety, which is typically long term and worse with stress and cold weather. In these conditions urinalysis is normal. Sometimes haematuria and systemic symptoms can accompany dysuria and frequency.
A summary of the diagnostic strategy model for dysuria is presented in Table 76.1.
Dysuria: diagnostic strategy model
|Favorite Table|Download (.pdf) Table 76.1
Dysuria: diagnostic strategy model
|Q. ||Probability diagnosis |
|A. ||UTI esp. cystitis (female) |
Urethral syndrome (female)
|Q. ||Serious disorders not to be missed |
|A. ||Neoplasia: |
• genital herpes
Calculi (e.g. bladder)
|Q. ||Pitfalls (often missed) |
|A. ||Menopause syndrome |
Foreign bodies in lower urinary tract (LUT)
• benign prostatic hyperplasia
• urethral stricture
• meatal stenosis
|Q. ||Seven masquerades checklist |
|A. ||Depression |
|Q. ||Is the patient trying to tell me something? |
|A. ||Consider psychosexual problems, anxiety and hypochondriasis. |
Key facts and checkpoints1,2
Strangury = difficult and painful micturition with associated spasm.
Inflammation usually results in the frequent passage of small amounts of urine and a sense of urgency.
Urethritis usually causes pain at the onset of micturition.
Cystitis usually causes pain at the end of micturition.
Suprapubic discomfort is a feature of bladder infection (cystitis).
Vesicocolonic fistulas (e.g. prostatic cancer) cause severe dysuria, pneumaturia and foul-smelling urine.
Dysuria and frequency are most common in women aged 15 to 44 years.
They are four times more common in sexually active women.
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