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Dysuria, Pediatric


Basics


Description


Painful urination  

Diagnosis


Differential Diagnosis


  • Infectious
    • Cystitis
    • Viral infection
    • Gonorrhea
    • Chlamydia
    • Herpes simplex
    • Varicella
    • Tuberculosis
    • Candidiasis
    • Urethritis
    • Pinworms
    • Prostatitis
    • Balanitis
  • Congenital/anatomic
    • Meatal stenosis
    • Urethral stricture
    • Posterior urethral diverticula
    • Urethral stones
    • Vesicovaginal fistula
    • Labial adhesions
  • Toxic/environmental/drugs
    • Bubble bath urethritis
    • Spermicides, douches
    • Cytoxan
  • Trauma
    • Diaper dermatitis
    • Foreign body
    • Bicycle injury
    • Masturbation
    • Sexual abuse
    • Irritation (e.g., from sand, tight pants)
  • Tumor
    • Sarcoma botryoides
  • Genetic/metabolic
    • Cystinuria
  • Allergic/inflammatory
    • Food allergy
    • Stevens-Johnson syndrome
    • Contact dermatitis (e.g., poison ivy)
  • Functional
    • Attention mechanism
    • Dysfunctional voiding
  • Miscellaneous
    • Appendicitis
    • Hypercalciuria

Approach to the Patient


  • General goal: Determine the cause and begin treatment.
    • Phase 1: Rule out common causes such as trauma, infection, chemical irritant, constipation, and masturbation.
    • Phase 2: Continue investigation-look for congenital or acquired problems that cause infection, strictures, or calculi.
    • Phase 3: Begin treatment.
  • Hints for screening problems:
    • Ask about medications and food allergies.
    • Ask about special situations (e.g., travel, sand in bathing suit causing irritation).

History


  • Question: Do the symptoms occur any special time of day?
  • Significance: May indicate an attention mechanism if occurs before school
  • Question: What kinds of medication do you take?
  • Significance: Some medications (e.g., Cytoxan) may cause irritation of the urethra.
  • Question: Have there been any new foods or known food allergens?
  • Significance: Milk is a possible food allergen that may cause dysuria. Citrus fruits may increase the acidity of the urine and cause dysuria in some patients. Best to determine whether symptoms regress on elimination of possible offending food.
  • Question: Do you use bubble bath?
  • Significance: Bubble bath may deplete the protective lipids in the urethra.
  • Question: Any signs of bleeding?
  • Significance: May indicate trauma, infection, or congenital anomalies. Calcium excretion may cause dysuria as well as hematuria.
  • Question: Fever?
  • Significance: Fever is a common sign of urinary tract infection (UTI).
  • Question: Frequency?
  • Significance: Both frequency and dysuria are common findings in UTIs.
  • Question: Past history of urologic operations?
  • Significance: Antireflux surgery may have a side effect of dysuria.
  • Question: What have you taken for discomfort?
  • Significance: Although cranberry juice is used for many urinary problems, the volume needed is usually more than what can be easily ingested.
  • Question: Quality and strength of the urinary stream?
  • Significance: Patients with posterior urethral valves may have urinary dribbling, poor urinary stream, difficulty potty training, or diurnal enuresis.
  • Question: Sexual activity?
  • Significance: Urethritis from gonorrhea or chlamydia
  • Question: Frequency?
  • Significance: It can sometimes be difficult to differentiate dysuria from frequency, which may cause an uncomfortable feeling or pressure that is described by the child as pain with urination.
  • Question: Vaginal discharge?
  • Significance: Vaginal discharge with dysuria suggests gonococcal or chlamydial infection.

Physical Exam


  • Finding: Any signs of redness or ecchymoses?
  • Significance: May indicate trauma from masturbation or abuse
  • Finding: Any bleeding?
  • Significance: Seen in trauma, tumors, and infection
  • Finding: Any change in behavior?
  • Significance: May be an attention-seeking device
  • Finding: Abnormal swelling?
  • Significance: May occur in trauma or rare tumors
  • Finding: Abnormal urethra?
  • Significance: Prolapsed urethra or diverticula
  • Finding: Grapelike structures in vagina?
  • Significance: Sarcoma botryoides
  • Finding: Abdominal pain?
  • Significance: Intra-abdominal abscess or low-lying inflamed appendix may cause dysuria. A low-lying inflamed appendix may also cause bladder irritation and dysuria.

Diagnostic Tests & Interpretation


Lab
  • Test: Urinalysis
  • Significance: In most UTIs, there are WBCs in the urine.
  • Test: Urine culture
  • Significance: Check for infection.
  • Test: Metabolic screens
  • Significance: If sediment shows crystals or if familial history of metabolic disease
  • Test: Urinary screen for gonorrhea and chlamydia
  • Significance: DNA amplification by polymerase or ligase chain reaction on freshly voided urine has 95% sensitivity and 100% specificity.

Imaging
Ultrasound: not routinely requested unless a congenital anomaly is suspected  

Treatment


Additional Treatment


General Measures
  • See treatment of UTI, vaginitis, urethritis
  • Phenazopyridine (Pyridium) may be used for symptomatic relief while documenting cause of dysuria.
  • Warm water sitz baths may be helpful for symptomatic treatment.

Issues for Referral


  • Evidence of congenital anomaly
  • Increasing severity of symptoms
  • Failure to respond to symptomatic or specific treatment

Additional Reading


  • Claudius  H. Dysuria in adolescents. West J Med.  2000;172(3):201-205.  [View Abstract]
  • Hellerstein  S, Linebarger  JS. Voiding dysfunction in pediatric patients. Clin Pediatr (Phila).  2003;42(1):43-49.  [View Abstract]
  • Lee  HJ, Pyo  JW, Choi  EH, et al. Isolation of adenovirus type from the urine of children with acute hemorrhagic cystitis. Pediatr Infect Dis J.  1996;15(7):633-634.  [View Abstract]
  • Rushton  HG. Urinary tract infections in children: epidemiology, evaluation, and management. Pediatr Clin North Am.  1997;44(5):1133-1169.  [View Abstract]

Codes


ICD09


  • 788.1 Dysuria
  • 599 Urinary tract infection, site not specified
  • 597.8 Urethritis, unspecified
  • 753.6 Atresia and stenosis of urethra and bladder neck
  • 753.8 Other specified anomalies of bladder and urethra
  • 752.49 Other anomalies of cervix, vagina, and external female genitalia

ICD10


  • R30.0 Dysuria
  • N39.0 Urinary tract infection, site not specified
  • N34.2 Other urethritis
  • Q64.33 Congenital stricture of urinary meatus
  • Q52.5 Fusion of labia
  • Q64.79 Other congenital malformations of bladder and urethra

SNOMED


  • 49650001 Dysuria (finding)
  • 431309003 acute urinary tract infection (disorder)
  • 31822004 Urethritis (disorder)
  • 48337000 Congenital stricture of urinary meatus (disorder)
  • 1.1410001191e+012 Congenital labial adhesion (disorder)
  • 253907008 Congenital anterior urethral valve (disorder)

FAQ


  • Q: How does bubble bath cause dysuria?
  • A: The bubble bath depletes lipids that protect the urethra, causing the tissue to swell and become inflamed.
  • Q: Can allergies cause dysuria?
  • A: It is difficult to directly prove allergies as a cause of dysuria; however, in some cases, elimination of certain foods such as spices, citrus fruits, or known skin allergens has improved symptoms.
  • Q: How do children get infected with gonorrhea?
  • A: This is a red flag for sexual abuse, which must be investigated.
  • Q: Which viruses cause dysuria?
  • A: Adenovirus has been associated with dysuria.
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