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Dysuria is the medical term for uncomfortable, burning, or painful quality urination that occurs in both women and men. It is a common symptom and a frequent reason for a consultation with a urologist. There are many underlying causes including infections, inflammatory conditions, trauma, injury, and pelvic floor dysfunction.
Causes
Painful urination often occurs due to infections of the urogenital tract (urethra, bladder, prostate, and vagina). The most common reason for painful urination is a bladder infection, cystitis. Because of the close proximity of the female urethra to the vagina, yeast infections and other forms of bacterial vaginitis can secondarily involve the urethra and give rise to painful urination. Urethritis, an infection of the urethra, is a frequent cause of painful urination, most often on the basis of sexual transmitted infections (STI), particularly those caused by chlamydia, gonorrhea, and herpes. Prostatitis, an infection of the prostate gland may cause dysuria in males and the parallel process in females is para-urethral gland infection (Skenitis).
There are also numerous non-infectious causes of painful urination. Urine contains waste products and if the urine concentration is too high because of insufficient hydration, one may experience a burning sensation. This happens particularly with the first void of the day, when the urine is most concentrated because of the relative dehydration from the hours spent sleeping without consuming liquids. During radiation therapy as treatment for prostate cancer, radiation-induced inflammatory changes of the prostate may occur, resulting in irritative lower urinary tract symptoms and painful urination. A potential long-term consequence of pelvic radiation therapy is radiation cystitis, which can manifest with bleeding, irritative lower urinary tract symptoms and painful urination. Interstitial cystitis, a painful inflammatory condition of the bladder that may severely impact one’s quality of life, causes painful urination, pelvic pain, and urinary frequency.
Conditions that directly impact the anatomy or function of the urethra can cause painful and difficult urination. These include the following: urethral stricture (scar tissue within the urethra), a urethral stone (lodged within the urethral channel), urethral diverticulum (an out-pouching of the urethra), atrophic urethritis (changes of the urethra that accompany menopause), and urethral trauma (following sexual intercourse, childbirth, straddle injuries, and commonly from urinary catheters and following transurethral surgery). Pelvic floor dysfunction with excess tension of the pelvic floor muscles can cause painful urination as well as give rise to urinary, bowel, sexual and pelvic symptoms.
Diagnosis
It is imperative to examine the urethra, penis, testes, and prostate in males and perform a pelvic exam in females, along with urinalysis and urine culture. Urinalysis and culture will rule out urinary infection. Depending on associated urinary symptoms, cystoscopy (visual inspection of the urethra and bladder with a tiny fiberoptic telescope) and imaging tests may be indicated. If there is urethral discharge accompanying the painful urination and/or a history of unprotected sex, a STI screen is appropriate.
Treatment
If the urine is hyper-concentrated, increasing fluid intake will improve the situation. Urinary infections are usually easily managed with a course of antibiotics that are based upon the culture and sensitivity results. Urinary tract analgesics/antispasmodics are helpful for temporary relief of painful urination associated with infections. Prostatitis and Skenitis will generally require a more prolonged course of antibiotics. STIs are typically easily treated with the appropriate antibiotic or antiviral. Yeast infections are readily treated with anti-fungal medications. At times, a prostate relaxant medication can be helpful for the urinary difficulties associated with prostatitis, whether infectious or radiation induced. Anti-inflammatories are often useful as well. Interstitial cystitis is a complex situation with multiple potential treatment options. Atrophic urethritis can be addressed with topical estrogen. If a stone, stricture, or diverticulum is found within the urethra, surgery is often indicated. For pelvic floor dysfunction, pelvic floor physical therapy can be extremely helpful to foster relaxation and “down-training” of the spastic pelvic muscles.
In the vast majority of cases of painful urination, the diagnosis and treatment is straightforward. However, on occasion, despite substantial effort and testing, no source for the burning urination is found, a frustrating situation for patient and physician alike. This is oftentimes labeled chronic urethritis and management may include including hot baths, anti-inflammatory analgesics, and the application of topical lidocaine jelly.
