Dysuria

Rationale

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. Also, 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.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

1. Anatomy and physiology of the male and female urinary tract
2. Pathophysiology of ureteral reflux, urethral obstruction, hydronephrosis, bladder dysfunction, prostatic hypotrophy, and cast formation
3. Microbial pathogens associated with urinary tract infections
4. Ability to perform a complete medical history and physical exam

Specific Learning Objectives

1. Knowledge: Student should be able to define and describe:
   1. the signs and symptoms, in women, of the following:
      1. cystitis
      2. urethral syndrome
      3. estrogen deficiency changes
      4. genital herpes
      5. vaginitis
   2. the signs and symptoms, in men, of the following:
      1. urethritis
      2. cystitis
      3. genital herpes
      4. balanitis
   3. the signs and symptoms of the following:
      1. urinary tract infection associated with dysuria
      2. pyelonephritis
      3. prostatitis
      4. asymptomatic bacteruria
   4. the signs and symptoms of the following:
      1. cystitis
      2. urethritis
      3. urethral syndrome
   5. the typical presenting features that distinguish cystitis, pyelonephritis, and urethritis from each other
   6. the signs and symptoms of bacteremia and sepsis
   7. factors that may predispose a patient to cystitis, pyelonephritis, urethritis, and asymptomatic bacteruria including:
      1. sexual activity
      2. pregnancy
      3. barrier contraceptives (diaphragm)
      4. prior urinary tract instrumentation
      5. urinary catheterization (in-dwelling and intermittent)
      6. anatomic anomalies (congenital and acquired)
      7. bladder dysfunction
   8. reasons why the following signs differentiate the causes of urinary tract infection:
      1. flank tenderness
      2. enlarged kidney
      3. palpable bladder
      4. post-void residual urine
      5. urethral discharge
   9. the indications for the diagnostic tests for urinary tract infection including:
      1. intravenous pyelogram
      2. voiding cystourethrogram
      3. urodynamic determination
      4. renal ultrasound
   10. the rationale for different durations of antimicrobial therapy for cystitis and pyelonephritis
   11. the commonly used antimicrobial drugs used for urinary tract infections by:
       1. naming six drugs and the class to which each belongs
       2. describing the antimicrobial spectrum for each, and their effectiveness
       3. designating the cost of each
       4. toxicity/side effects of each
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiology of disease including:
      1. eliciting a full description of symptoms which considers both cystitis and non-cystitis causes of dysuria
      2. determining if dysuria is associated with sexual activity, menstruation, or pregnancy
      3. determining the patient’s risk for venereal disease.
      4. obtaining a description of all prior episodes of dysuria and how they were treated
      5. determining the presence or absence of predisposing causes, such as prior instrumentation, catheterization, and anatomic anomalies
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
      1. palpating the bladder for distention and tenderness
      2. palpating and massaging the urethra to express a discharge
      3. recognizing atrophic perineal changes, perineal inflammation, balanitis
      4. determining the presence or absence of flank tenderness
      5. performing prostatic massage
   3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology:
      1. In women:
         • cystitis
         • urethral syndrome
         • estrogen deficiency atrophic changes
         • genital herpes
         • vaginitis
      2. In men:
         • urethritis
         • cystitis
         • genital herpes
         • balanitis
   4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
         • 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 assess for post-void residual
   5. communication skills: Students should be able to:
      1. counsel and educate patients about sexual activity.
      2. communicate the diagnosis, treatment plan and subsequent follow-up to patients.
   6. basic procedural skills: Students should be able to perform:
      1. urinalysis
      2. gram stain of urethral discharge
      3. urethal swab culture
      4. KOH preps
      5. urinary catheterization
   7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patient including:
      1. select appropriate antibiotic therapy prior to culture results
      2. select the appropriate duration of therapy for cystitis and pyelonephritis
      3. identify information about costs of alternative treatment regimens
      4. access and utilize appropriate information systems and resources to help delineate issues related to dysuria
3. Attitudes and Professional Behaviors: Each student should be able to:
   1. appreciate the discomfort and concern associated with dysuria