TUGAS BIKO DR.

SAA

 Kasus : Pasien Laki-laki usia 50 tahun dengan nyeri saat kencing dan riwayat pernah
tidak bisa kencing
 Solusi atas problem diatas:
1. ANAMNESIS : Onset, Lokasi, karakteristik- Nyeri(VAS : 1-10) & saat kencing
(sakit/tuntas atau tdk/ dll), yg memeperberat, yg meringankan, sudah diterapi belum.
Gejala lain (Demam, keluar darah/pus, dll), RPD (BSK, Pembesaran Prostat), RPK,
kebiasaan dan lingkungan (kebiasaan menahan kencing, kurang minum air putih dll).
2. PEMERIKSAAN FISIK : Keadaan Umum (tampak kesakitan), Vital Sign (Suhu,
Respi, Nadi, Tekanan Darah), Head to toe (Kepala, leher, thorax, abdomen,
ekstremitas). Px.Status lokalis (inspeksi,palpasi), Rectal to say (lihat BPH/Ca
Prostat).
3. PEMERIKSAAN PENUNJANG : Lab (Darah Rutin – ada infeksi atau tidak)
4. Terapi : Anti nyeri (relief seemntara pasien), obat kausatif tgt dari diagnosisnya

 DD : ISK, BSK, BPH

 DYSURIA

Dysuria is a symptom of pain and/or burning, stinging, or itching of the urethra or urethral
meatus with urination. It is among the most common symptoms experienced by most people
at least once over their lifetime. Dysuria usually happens due to bladder muscle contraction
and peristalsis of the urethra, which ends up causing the urine to come in contact with the
inflamed mucosal lining, which in turn stimulates pain receptors and causes one to feel pain
and/or burning. Other conditions can cause dysuria from different mechanisms. Also,
dysuria requires differentiation from other symptoms, which can also occur due to bladder
discomfort due to increased bladder volume, such as suprapubic or retropubic pain.[1]

ETIOLOGY

Primarily, causes of dysuria can be divided broadly into two categories, infectious and
non-infectious. Infectious causes include urinary tract infection or urethritis, kidney or
prostate infections, vaginal infections, and sexually transmitted diseases. Non-infectious
causes include skin conditions, foreign body or stone in the urinary tract, trauma, benign
prostatic hypertrophy, and tumors. Also, interstitial cystitis, certain medications, specific
anatomic abnormalities, menopause, atrophic vaginitis can cause dysuria.[2]

EPIDEMIOLOGY

Dysuria can happen in both males and females. One of the most common causes of
dysuria is urinary tract infection. Urinary tract infections are more common in females than
males due to female anatomy, having a shorter and straight urethra compared to males who
have longer and curved urethra due to male anatomy. In females, bacteria can reach the
bladder more easily due to shorter and straight urethra as they have less distance to travel.
Also, females who use the wrong wiping technique from back to front instead of front to back
can predispose themselves to more frequent urinary tract infections due to the opening of
the urethra being closer to the rectum. Because of these reasons, females tend to
experience dysuria more frequently compared to males. Also, most urinary tract infections
are uncomplicated. However, complicated urinary tract infections are also common in cases
of urinary tract infection happening in men, pregnancy, immunocompromised status,
anatomical or functional abnormalities of the urinary tract, and systemic spread.[3]

AX

Detailed history taking is essential when someone presents with dysuria. The clinician
must try to determine the timing, severity, duration, and persistence of the symptoms. Initial
history should include features of a possible local cause, which may be causing dysuria, like
vaginal or urethral irritation. Also, history regarding risk factors like pregnancy, the possibility
of stone, trauma, tumor, recent urologic procedure, and the possibility of urologic obstruction
merit consideration. Patient history should include information regarding associated
symptoms like fever, chills, flank pain, low back pain, nausea, vomiting, joint pains,
hematuria, nocturia, urgency, frequency, and incontinence. In elderly patients, history
regarding changes in mental status is necessary as many times the most common symptom
of urinary tract infection in older adults is confusion. History regarding recurrence of
symptoms is also necessary, and thorough physical examination should be carried out.

The clinician should also look for physical findings of fever, rash, direct tenderness over
the bladder area, and joint pain. Physical findings of increased temperature, increased
pulse, low blood pressure in the presence of dysuria can indicate systemic infection.
Urological obstruction due to stone or tumor can result in findings of hematuria, decreased
urination, and bladder spasms. All these physical findings should be looked for carefully
while obtaining history. History regarding recent sexual activity is crucial. In women, it is
essential to take history regarding complaints of vaginal discharge, history of menstruation,
and whether the patient is using contraception.[2][5] Males can present with different
symptoms than females and may have perineal pain or obstructive symptoms along with
dysuria, which could be caused by prostatitis.[6]

PHYSICAL EXAMINATION

Associated signs and symptoms of hematuria, suprapubic tenderness, urinary

frequency, urgency, fever, chills, nausea, vomiting, low back pain, joint pain, rash, etc.
require close followup. Urinalysis is the most useful test to start the work up in a patient of
dysuria. Urinalysis positive for nitrite carries a high predictive value of a positive urine
culture. Also, urine dipstick showing leukocytes as equal predictive value as the presence of
nitrites. When both are present, the predictive value goes even higher. If the patient only has
leukocyte esterase or bacteria in the urine, then dysuria may suggest that the patient
probably has urethritis.[7]

If the patient has risk factors for a complicated urinary tract infection and those who do
not respond to initial treatment, they should also have a urine culture and sensitivity
performed. Also, it is important to check complete blood count and a metabolic panel,
including serum creatinine if systemic infection is suspected, especially if the patient is
having nausea, vomiting, fever, or chills. Blood cultures need to be done if there is a
suspicion for systemic spread of infection. In severe cases, hospitalization requires
consideration, as well.[8]

Women who have vaginal symptoms, wet mount, or vaginal DNA probe is necessary. If
sexually-transmitted infections are suspected, then a urethral or vaginal probe should be
performed, and samples should be obtained to diagnose Neisseria gonorrhoeae and
Chlamydia trachomatis.[9] In male patients where chronic prostatitis is suspected, gentle
prostatic massage can be done to obtain a urine culture.[10] If the patient has hematuria
and if bladder cancer is suspected, then urine cytology can be helpful.[11] Imaging tests like
ultrasonography or CT scan may be in order in cases of dysuria where patients show signs
of having complicated urinary tract infection, obstruction, abscess, stones, or tumors.[12] In
certain cases, cystoscopy can be performed to evaluate for symptoms of chronic dysuria,
which could be associated with bladder cancer or hematuria. Sometimes patients who have
been having chronic dysuria may need a urology referral to rule out uncommon causes.[13]
[14]
DD

Differential diagnoses broadly divide into two categories. Inflammatory and

noninflammatory.[21][2]

Inflammatory 

1. Infectious causes - Cystitis, urethritis, pyelonephritis, sexually transmitted infections. In

females, vulvovaginitis, and cervicitis can be the causes of dysuria while in males,
prostatitis, and epididymo-orchitis.
2. Dermatologic - Contact dermatitis, psoriasis, Behcet syndrome, lichen sclerosus, lichen
planus, Stevens-Johnson syndrome
3. Noninfectious causes - Stone, a urethral or ureteral stent

Noninflammatory 

1. Trauma - Foreign body, surgery, urinary tract instrumentation, pelvic radiation.

2. Endocrine - Atrophic vaginitis, endometriosis
3. Drugs - Cyclophosphamide, Ketamine
4. Anatomic - Benign prostatic hypertrophy, urethral stricture.
5. Neoplastic - Renal cell cancer, bladder cancer, lymphoma, vaginal cancer, vulvar
cancer, prostate cancer, penile cancer, metastatic cancer. 
6. Idiopathic - Interstitial cystitis

TX

Treatment of dysuria depends on the cause of dysuria. The most common cause of
dysuria is urinary tract infection. Empiric antibiotic therapy based on a patient's history and
symptoms is usually the most cost-effective therapy. No further evaluation is necessary in
those cases where dysuria from uncomplicated urinary tract infection is suspected.[15]
Where the clinician suspects complicated urinary tract infections, in the presence of
associated symptoms like nausea, vomiting, fever, or chills, then along with starting
antibiotics, additional testing like blood cultures, metabolic panel, or complete blood count
are all viable options. In the case of suspected stones or obstruction, imaging with
ultrasonography or CT scan can be diagnostic.

Depending on the risk factors, the clinician should be mindful of the possibility of anti-
microbial resistance, and optimal antibiotics should start based on likely pathogens. The
choice of antibiotics should be made based on local resistance patterns and costs
associated with the treatment.[16] When dysuria is occurring due to chronic prostatitis in
males, oral antibiotics merit consideration after obtaining urine culture.[17] If the cause of
dysuria is renal stones, then various treatment options can be considered depending on the
size and location of stones. Stones smaller than 5 mm typically pass on their own, and
patients should be asked to hydrate themselves and strain the urine to document the
evidence of a passed stone. The stones that are bigger than 5 mm are treatable through
various modalities, including extracorporeal shock wave lithotripsy (ESWL) or percutaneous
nephrolithotomy (PCNL) or open surgery.[18]

When the patient presents with dysuria and a perinephric abscess is suspected, then it
should be first evaluated with an imaging study like an ultrasonography or CT scan. Once it
is confirmed to be an abscess, the patient should be hospitalized, and intravenous
antibiotics should be initiated, which can be followed by open surgical drainage or
percutaneous catheter drainage or both. [19] If the cause of dysuria is benign prostatic
hypertrophy, then medical treatment with alpha-blockers or 5-alpha reductase inhibitors
should be considered. If the patient has no symptomatic improvement after trying the
medical therapy, then the surgical option of transurethral resection of the prostate should be
considered.[20]

PROGNOSIS

The prognosis for dysuria depends upon the cause of dysuria. Most of the etiologies of
dysuria, including inflammatory and noninflammatory, demonstrate a good long term
prognosis, but early detection of causes of dysuria is essential. However, systemic infections
occurring due to urinary tract infections can cause lead to higher morbidity or mortality
compared to systemic infections of other organs or systems; sepsis from urinary tract
infections still has a better prognosis.[22] Long term complications can occur due to stones,
chronic infections, or benign prostatic hypertrophy, which can lead to renal failure and in
severe cases, end-stage renal disease. During pregnancy, complications can arise in both
mother and fetus if urinary tract infections do not receive treatment timely and adequately.[4]
Prognosis of dysuria occurring from neoplastic causes like renal cancers or bladder cancers
depends upon the stage and type of cancer when it gets diagnosed. Early diagnosis and
quick follow-up with adequate treatment carries a good prognosis, while a delayed diagnosis
is associated with higher recurrence and poor prognosis.[23]

COMPLICATION

Depending on the cause of dysuria, short term complications can include acute renal
failure, development of systemic infection and sepsis, acute anemia from hematuria,
emergent hospitalization while long term complications can consist of the development of
end-stage renal disease, infertility, long term disability from recurrent infections or urinary
tract cancers and even death from severe systemic infections or advanced urinary tract
cancers. Patients who have complicated urinary tract infections can end up having recurrent
infections and higher antibiotic resistance, which may lead to higher rates of
hospitalizations, and higher morbidity and mortality.[24]

PATIENT EDUCATION

Patient education is crucial in preventing recurrent cases of dysuria. If women have

dysuria due to recurrent urinary tract infections or vaginal infections, they should be
educated about not using douches, maintain perineal hygiene, and use correct wiping
techniques. For patients who are experiencing recurrent sexually transmitted infections, they
should be educated about safe sex practices, using condoms, urinating right after sex. For
patients who get recurrent urinary tract infections due to uncontrolled diabetes should be
educated about the importance of controlling their blood sugars. Patients who have dysuria
from atrophic vaginitis can benefit from the education of hormone replacement therapy.
Male patients suspected of having dysuria from benign prostatic hypertrophy should be
educated about routine prostate exams and taking medications to control the symptoms.
Patients who are high risk or are suspected of having cancer of the urinary tract should
receive education about early detection and intervention with specialty referral. All patients
should understand the importance of early detection of infections, which can present as
dysuria as the earliest sign and should be encouraged to seek proper follow-up and
treatment.

REFERENCES

[1] Dysuria: What You Should Know About Burning or Stinging with Urination. Am Fam
Physician. 2015 Nov 01;92(9):Online. [PubMed]

[2] Michels TC, Sands JE. Dysuria: Evaluation and Differential Diagnosis in Adults. Am Fam
Physician. 2015 Nov 01;92(9):778-86. [PubMed]

[3] Geerlings SE. Clinical Presentations and Epidemiology of Urinary Tract Infections.
Microbiol Spectr. 2016 Oct;4(5) [PubMed]

[4] Wrenn K. Dysuria, Frequency, and Urgency. In: Walker HK, Hall WD, Hurst JW, editors.
Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths;
Boston: 1990. [PubMed]

[5] Sinnott JD, Howlett DC. Urinary frequency and dysuria in an older woman. BMJ. 2016
Sep 13;354:i4587. [PubMed]

[6] Rees J, Abrahams M, Doble A, Cooper A., Prostatitis Expert Reference Group (PERG).
Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic
pain syndrome: a consensus guideline. BJU Int. 2015 Oct;116(4):509-25. [PMC free article]
[PubMed]

[7] Bellazreg F, Abid M, Lasfar NB, Hattab Z, Hachfi W, Letaief A. Diagnostic value of
dipstick test in adult symptomatic urinary tract infections: results of a cross-sectional
Tunisian study. Pan Afr Med J. 2019;33:131. [PMC free article] [PubMed]

[8] Artero A, Esparcia A, Eiros JM, Madrazo M, Alberola J, Nogueira JM. Effect of
Bacteremia in Elderly Patients With Urinary Tract Infection. Am. J. Med. Sci. 2016
Sep;352(3):267-71. [PubMed]

[9] Wagenlehner FM, Brockmeyer NH, Discher T, Friese K, Wichelhaus TA. The
Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections. Dtsch Arztebl
Int. 2016 Jan 11;113(1-02):11-22. [PMC free article] [PubMed]

[10] Ateya A, Fayez A, Hani R, Zohdy W, Gabbar MA, Shamloul R. Evaluation of prostatic
massage in treatment of chronic prostatitis. Urology. 2006 Apr;67(4):674-8. [PubMed]
[11] Comploj E, Trenti E, Palermo S, Pycha A, Mian C. Urinary cytology in bladder cancer:
why is it still relevant? Urologia. 2015 Oct-Dec;82(4):203-5. [PubMed]

[12] Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging
techniques. Nat Rev Urol. 2016 Nov;13(11):654-662. [PMC free article] [PubMed]

[13] DeGeorge KC, Holt HR, Hodges SC. Bladder Cancer: Diagnosis and Treatment. Am
Fam Physician. 2017 Oct 15;96(8):507-514. [PubMed]

[14] Bremnor JD, Sadovsky R. Evaluation of dysuria in adults. Am Fam Physician. 2002 Apr
15;65(8):1589-96. [PubMed]

[15] Barry HC, Ebell MH, Hickner J. Evaluation of suspected urinary tract infection in
ambulatory women: a cost-utility analysis of office-based strategies. J Fam Pract. 1997
Jan;44(1):49-60. [PubMed]

[16] Bader MS, Hawboldt J, Brooks A. Management of complicated urinary tract infections in
the era of antimicrobial resistance. Postgrad Med. 2010 Nov;122(6):7-15. [PubMed]

[17] Coker TJ, Dierfeldt DM. Acute Bacterial Prostatitis: Diagnosis and Management. Am
Fam Physician. 2016 Jan 15;93(2):114-20. [PubMed]

[18] Shafi H, Moazzami B, Pourghasem M, Kasaeian A. An overview of treatment options for

urinary stones. Caspian J Intern Med. 2016 Winter;7(1):1-6. [PMC free article] [PubMed]

[19] Edelstein H, McCabe RE. Perinephric abscess. Modern diagnosis and treatment in 47
cases. Medicine (Baltimore). 1988 Mar;67(2):118-31. [PubMed]

[20] Tanguay S, Awde M, Brock G, Casey R, Kozak J, Lee J, Nickel JC, Saad F. Diagnosis
and management of benign prostatic hyperplasia in primary care. Can Urol Assoc J. 2009
Jun;3(3 Suppl 2):S92-S100. [PMC free article] [PubMed]

[21] FERGUSON JD. The differential diagnosis of dysuria. Practitioner. 1952

Oct;169(1012):458-61. [PubMed]

[22] Qiang XH, Yu TO, Li YN, Zhou LX. Prognosis Risk of Urosepsis in Critical Care
Medicine: A Prospective Observational Study. Biomed Res Int. 2016;2016:9028924. [PMC
free article] [PubMed]

[23] Yaxley JP. Urinary tract cancers: An overview for general practice. J Family Med Prim
Care. 2016 Jul-Sep;5(3):533-538. [PMC free article] [PubMed]

[24] Bleidorn J, Hummers-Pradier E, Schmiemann G, Wiese B, Gágyor I. Recurrent urinary

tract infections and complications after symptomatic versus antibiotic treatment: follow-up of
a randomised controlled trial. Ger Med Sci. 2016;14:Doc01. [PMC free article] [PubMed]