PAIN: DYSURIA

JACQUELINE B. CORBOY, MD AND PATRICIA LOPEZ, MSN, CRNP

Many conditions of the genitourinary tract produce symptoms of pain or burning associated with urination, or dysuria. The sensation is produced by the muscular contraction of the bladder and the peristaltic activity of the urethra, both of which stimulate the pain fibers in the edematous and inflamed mucosa. Young children may complain of painful urination when they are instead experiencing related symptoms, such as pruritus. When a child is too young to verbalize his or her symptoms, parents may interpret various nonspecific statements or behaviors by their child as indicative of painful urination.

Dysuria is a commonly reported symptom associated with a number of infectious and noninfectious causes, but it usually stems from one of several common disorders of childhood and adolescence. Most children with dysuria as a chief complaint will have primary disorders of the genitourinary tract, and although patients with urethritis secondary to systemic illnesses may have dysuria as one of their many symptoms, it is only occasionally the principal reason for a visit to an emergency department (ED).

Most diseases causing dysuria are self-limited or easily treated; however, the rarely seen systemic causes of urethritis or the spread of some bacterial pathogens beyond the genitourinary tract may be life-threatening. A differential diagnosis of the many systemic, infectious, and noninfectious causes most commonly presenting as dysuria may be found in Table 52.1–52.4.

EVALUATION AND DECISION

The approach to the child with dysuria must be broad, and history will help determine the direction of the workup. A thorough investigation of possible causes should be conducted, including questions about trauma (both accidental and nonaccidental), and exposure to chemicals such as detergents, fabric softeners, perfumed soaps, bubble baths, and medications that have been reported to irritate the mucosal lining of the urethra or bladder. A negative history for injury may not be accurate, however, because most traumas are not recalled by young patients or, in the case of masturbation or abuse, may be denied. The detection of sexually transmitted infections (STIs), a common cause of dysuria in adolescents, may in turn be facilitated by obtaining a history about the nature and extent of sexual activity (Figs. 52.1 and 52.2).

A urethral or vaginal discharge suggests an infection of the genitalia: urethritis in the boy and urethritis or vulvovaginitis in the girl (see Table 52.3). Neisseria gonorrhoeae is an organism that commonly causes disease in this area. A Gram stain can be a helpful adjunct in determining the nature of the discharge. In prepubertal girls or boys of any age, the finding of gram-negative intracellular diplococci points to the diagnosis of gonorrhea. However, because nonpathogenic organisms that colonize the vagina after puberty have the same appearance as N. gonorrhoeae on Gram stain, additional testing is needed. The development of nucleic acid amplification tests (NAATs), which use ligase chain reaction (LCR) or polymerase chain reaction (PCR) technologies, allows first-catch urine (not clean-catch) to be tested for the presence of Chlamydia trachomatis and N. gonorrhoeae in a noninvasive manner. Where available, these provide an accurate screening tool for STIs without performing a cervical or male urethral swab culture. Self-collected vaginal swabs from adolescent female patients can also be used for testing and offer similar accuracy when compared with provider-obtained cervical specimens. In prepubertal patients, a urethral or vaginal culture may be required by local law enforcement agencies however NAAT results are accepted in most states. Postpubertal patients may be treated in the ED; treatment in young children should be based on symptoms and clinical findings after all needed testing has been collected for medical–legal documentation.

TABLE 52.1

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