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Dysuria: History Taking and Differential Diagnoses for OSCEs

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Overview

When taking a history regarding the genitourinary system, many personal and potentially awkward questions need to be asked including regarding sexual activity. Care should be taken to ensure the privacy and comfort of assessing patients.

A helpful way to alleviate the awkwardness and avoid the patient feeling like they have been singled out or judged is by normalising questions and prefacing them with something such as “This is something we ask all patients”. This allows for sensitive and non-judgmental discussion of these topics and is likely to help get better answers from the patient.

Causes

Urologic causes of dysuria include:

Non-urologic causes include:

History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Dysuria

Use SOCRATEs to assess pain:

  • Site:
    • Where is the pain?
    • If abdominal pain is present, consider causes of abdominal pain
  • Onset:
    • Did it come on suddenly or gradually?
    • When does it start?
      • Pain when starting urination suggests urethral disorders, whereas suprapubic pain suggests bladder disorders
  • Character:
    • How would they describe the pain? (e.g. stinging, burning, sharp, stabbing)
  • Radiation:
    • Does the pain spread anywhere?
    • Loin-to-groin pain suggests upper urinary tract disorders (e.g. pyelonephritis or renal stones)
  • Associated symptoms:
    • See review of symptoms
  • Timeline:
    • Is it getting better, worse, or staying the same?
  • Exacerbating/relieving symptoms:
    • Does anything make it better or worse?
  • Severity/scale:
    • On a scale of 0-10, where would they put the pain?

Screen for urologic features:

  • Urine characteristics:
  • Urinary frequency, nocturia, urethral discharge?
  • Is there any abdominal, pelvic, or groin pain or discomfort?
  • Are there any abdominal, pelvic, or groin lumps?
  • Any urinary incontinence? – discussed in more detail here
  • Are there any lower urinary tract symptoms? – discussed in more detail here
  • Any scrotal/groin pain and lumps? – discussed in more detail here

Is there any chance the person may be pregnant?

Review of systems

  • Screen for general features:
    • Any fever, rigours, myalgia, nausea, or vomiting – may suggest pyelonephritis?
    • Constitutional features – such as fever, night sweats, and weight loss:
      • These may suggest malignancy
  • Screen for pain:
    • Is there any abdominal, pelvic, perineal, rectal, or back pain? 
  • Screen for other genitourinary features:
    • Any abnormal urethral and/or vaginal discharge?
    • Any pruritus in the genital region?
    • If necessary, consider taking a sexual history
  • If relevant, screen for gynaecological features:
    • Any abnormal bleeding, pelvic pain, or dyspareunia?

Past Medical History

Questions include:

  • Do they have any other medical conditions?
    • New back pain in someone with a history of prostate cancer can suggest bone metastases
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Have they been exposed to any chemicals at work?
    • Exposure to aromatic amines such as dyes and rubber manufacturing materials can increase the risk of bladder cancer
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?
    • Travelling to an area endemic to schistosomiasis can increase the risk of bladder cancer

Physical Examinations

Overview

Physical examinations may not be necessary in simple situations such as an uncomplicated lower UTI. If necessary, some may involve:

  • Vital signs:
    • May identify fever suggesting infection
  • Abdominal examination:
    • May identify tenderness such as flank tenderness suggesting pyelonephritis or suprapubic tenderness suggesting cystitis
  • Testicular and external genital examination:
    • May identify balanitis, penile lesions, or abnormal discharge
    • May identify tenderness, swelling, or erythema of the testes and/or scrotum
  • Digital rectal examination (DRE):
    • May identify a tender and boggy prostate suggesting acute prostatitis
    • May identify prostatic enlargement:
      • Benign prostatic hyperplasia: smoothly enlarged prostate with a maintained central sulcus
      • If hard, asymmetrical, craggy/nodular, or irregular with loss of the median sulcus, prostate cancer may be possible
  • Pelvic examination:
    • If pelvic organ pathology is suspected, such as uterine prolapse, gynaecological malignancy, or cervicitis

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
  • Orifice tests:
    • Urine dipstick and urinalysis:
      • May identify haematuria, leukocytes, and nitrites
    • Urine microscopy, culture, and sensitivity:
      • May identify causative pathogen in infection
    • Pregnancy test (urine or serum):
      • In people with childbearing potential in cases where a simple UTI in the absence of known pregnancy is not likely
    • STI testing:
      • Via urinary nucleic acid amplification tests for Chlamydia and gonorrhoea
  • Special tests:
    • Ultrasound:
      • If there is suspicion of obstruction or masses
    • Non-contrast CT kidneys, ureters, and bladder (CT-KUB):
      • If renal stones are suspected
    • Cystoscopy and urinary cytology:
      • Performed in a specialist setting if malignancy is suspected

Differential Diagnoses: Urologic Causes

Uncomplicated urinary tract infection (UTI)

  • A history and physical examination may reveal:
    • Dysuria, may have associated frequency, urgency, nocturia, and suprapubic tenderness
    • Urine may be cloudy, offensive-smelling, and haematuria may be present
    • No costovertebral (renal angle) tenderness, fever is usually mild/absent, and no nausea or vomiting
  • Investigations may reveal:
    • Urine dipstick:
      • Positive for nitrites or leukocytes + red blood cells: UTI likely
      • Negative for nitrites but positive for leukocytes: UTI equally likely to other diagnoses
      • Negative for all nitrites, leukocytes, and red blood cells: UTI unlikely, consider alternate diagnosis
    • Urine culture:
      • Identifies causative pathogen
      • Should be performed if >65 years old, catheterised, or if visible/non-visible haematuria is present

Pyelonephritis

  • A history and physical examination may reveal:
    • Classic triad of flank pain, high fever, and nausea/vomiting
    • Features of a lower UTI are present such as dysuria, frequency, urgency, nocturia
    • Costovertebral (renal angle) tenderness may be seen
  • Investigations may reveal:
    • Arrange hospital admission if urosepsis likely
    • Urine with/without blood cultures:
      • Identifies causative pathogen

Renal stones

  • A history and physical exam may reveal:
    • Severe, colicky abdominal pain that radiates from the loin to the groin
    • Haematuria may be present
    • Costovertebral (renal angle) tenderness may be seen
    • Features of obstruction or co-existing UTI may be present
  • Investigations may reveal:
    • Urine dipstick:
      • May be positive for blood and positive for nitrites if infection present
    • Non-contrast CT KUB:
      • Investigation of choice except pregnant or a child, use ultrasound instead

Urethritis

  • A history and physical exam may reveal:
    • Many patients are asymptomatic but the main feature is urethral discharge
    • There may be urethral pruritus and balanitis
    • Patients are generally sexually active
  • Investigations may reveal:
    • Refer to sexual health clinic
    • First-void urine sample for nucleic acid amplification testing (NAAT):
      • Screens for gonorrhoea and Chlamydia
    • Urethral swab:
      • Performed if NAAT is unavailable
      • Leukocytes are present and Gram-negative diplococci may be seen, suggesting Neisseria gonorrhoeae

Genital herpes

  • A history and physical examination may reveal:
    • Painful genital ulceration with dysuria
    • There may be pruritus, fever, and malaise
    • Tender inguinal lymphadenopathy may be present
    • Vesicular painful lesions are seen in the genital area
  • Investigations may reveal:
    • NAAT:
      • Investigation of choice

Urethral stricture

  • A history and physical examination may reveal:
    • Recent urethral instrumentation (e.g. surgery/catheterisation), STI, recurrent UTIs, lichen sclerosus, or trauma
    • Mainly voiding symptoms are present (decreased urinary stream, feeling of incomplete emptying, straining when passing urine)
  • Investigations may reveal:
    • Residual urine assessment:
      • The patient urinates and residual volume is measured via ultrasound
    • Uroflowmetry:
      • Involves passing urine into a special toilet with a device present that measures the volume and rate of urine released
    • Urethroscopy:
      • May identify stricture directly, but may not be possible as the urethroscope tube may not be able to pass through the stricture
    • Urethrography:
      • A radiographic study using contrast media, may identify stricture

Interstitial cystitis

  • A history and physical examination may reveal:
    • More common in middle-aged and older women
    • Chronic suprapubic discomfort and pain
    • Dysuria, frequency, and urgency in the absence of UTI 
  • Investigations may reveal:
    • Urine dipstick, microscopy, and culture are normal

Balanitis

  • A history and physical examination may reveal:
    • Uncircumcised person with penile/foreskin soreness, itching, bleeding, odour, or swelling
  • Diagnosis is usually clinical unless STIs, secondary infection, or other underlying causes are likely
  • Investigations may reveal:

Vulvovaginitis

  • A history and physical examination may reveal:
    • Irritation, pruritus, dyspareunia, and changes in vaginal discharge (such as cottage cheese-like discharge for vaginal candidiasis)
    • Erythema of the vulva

Epididymo-orchitis

  • A history may reveal:
    • May present similarly to testicular torsion
    • Acute scrotal pain and or swelling
    • Fever, dysuria, urethral discharge
    • Parotitis may be present if mumps orchitis is present
  • A physical examination may reveal:
    • Prehn’s sign is positive
    • Cremasteric reflex is present
    • Epididymis and/or testis are tender and swollen
    • Scrotal erythema may be seen
  • Investigations may reveal:
    • Younger people (<35 years old) and sexually active:
      • Assess for STI (e.g. nucleic acid amplification testing, NAAT)
    • >35 years old and low-risk sexual history:
      • Send a mid-stream urine sample for microscopy and culture

Acute prostatitis

  • A history and physical examination may reveal:
    • Prostate features:
      • Pain that may be referred to the perineum, penis, rectum, or back
        • Ejaculation may be painful as well
      • Obstructive voiding symptoms (e.g. acute urinary retention, weak stream, straining etc.)
    • UTI features – (e.g. dysuria, urgency, frequency)
    • Bacteraemia features – fever, rigours, myalgia, joint pain
    • DRE may identify a tender, boggy prostate (it feels like it has fluid in it) which may be enlarged
  • Investigations may reveal:
    • Mid-stream urinary sample for dipstick, culture, and sensitivity:
      • May identify features of UTI such as leukocytes, nitrites, and blood
      • Identifies causative pathogen
    • Full blood count (FBC):
      • May show leukocytosis suggesting infection
    • Blood cultures:
      • May identify causative pathogen
    • Consider screening for STIs in people who are at an increased risk

Chronic prostatitis

  • A history and physical examination may reveal:
  • >3 months of pelvic pain, commonly in the perineum, may be inguinal, scrotal, penile, in the lower abdomen, lower back, or rectum
  • Lower urinary tract symptoms (LUTS) – voiding symptoms, storage symptoms, 
  • Sexual dysfunction – erectile dysfunction, painful ejaculation, premature ejaculation, decreased libido
  • Features of irritable bowel syndrome – such as painful bowel movements
  • DRE: prostate may be enlarged and tender, hard from calcification, or normal
  • Investigations may reveal:
    • Urine dipstick:
      • May identify features suggesting bacterial infection such as nitrites and leukocytes
    • Mid-stream urine sample for microscopy, culture, and sensitivity:
      • Screens for urinary tract infection
    • Sexually transmitted infection (STI) screen:
      • Consider if STI is suspected, particularly people <35 years old with multiple sexual partners or a recent partner change

Benign prostatic hyperplasia

  • A history and physical examination may reveal:
    • Older patient with lower urinary tract symptoms
    • DRE: smoothly enlarged prostate with a maintained central sulcus
  • Investigations may reveal:
    • Urine dipstick and analysis:
      • To screen for urinary tract infection (UTI), normal in BPH
    • Urea and electrolytes (U&Es):
      • If chronic urinary retention is suspected as this may lead to renal dysfunction
    • Volume charting:
      • This is a diary of the frequency and volume of urine passed to assess patterns of passing urine (e.g. nocturia) and impact
      • Should be done for at least 3 days
    • International Prostate Symptom Score (IPSS):
      • Classifies the severity of symptoms into mild (0-7), moderate (8-19), and severe (20-35)
    • Consider prostate-specific antigen (PSA) testing:
      • Normal or may be elevated

Prostate cancer

  • A history and physical examination may reveal:
    • May be asymptomatic
    • Locally advanced prostate cancer: lower urinary tract symptoms (LUTS), pelvic pain
    • Metastatic disease pain in the lower back or bones – suggests bone metastases
    • Constitutional symptoms – such as unexplained weight loss, lethargy, anorexia, and night sweats
    • Haematuria
    • Erectile dysfunction
    • DRE: prostate feels hard, asymmetrical, craggy/nodular, or irregular with loss of the median sulcus
      • A normal gland does not exclude prostate cancer.
  • Investigations may reveal:
    • Multiparametric MRI is the first-line investigation before a biopsy:
      • The results are reported on a 5-point Likert scale
    • Pre-biopsy PSA:
      • If not already performed, elevated
    • Prostate biopsy:
      • If Likert scale ≥3, offer a prostate biopsy
      • If Likert scale is 1-2, discuss the advantages/disadvantages of the prostate biopsy and reach a shared decision

Bladder cancer

  • A history may reveal:
    • Smoking or exposure to chemicals with aromatic amines such as dyes, rubber manufacturing etc.
    • The hallmark feature of bladder cancer is painless gross haematuria (up to 85%) 
  • Investigations may reveal:
    • Cystoscopy – key in diagnosis:
      • Allows direct visualisation of the bladder and biopsy of suspicious lesions
    • Urinalysis:
      • To exclude infection
      • Red cells are present, white cells may be seen and may lead to confusion with UTI
    • Urine cytology:
      • May identify malignant cells, but cannot exclude a diagnosis of bladder cancer
    • CT/MRI abdomen and pelvis:
      • Screens for other causes such as renal stones and may identify bladder cancer and metastases
      • Often performed before transurethral resection of bladder tumour (TURBT)
    • Transurethral resection of bladder tumour (TURBT):
      • May be used to take a biopsy or remove bladder cancer in early stages

Renal cancer

  • A history and physical examination may reveal:
    • >50% of cases are asymptomatic
    • Classic triad (only seen in <10% of people, but individual features may be seen) or haematuria, flank pain, abdominal mass
  • Constitutional symptoms – fever, unexplained weight loss, night sweats (up to 20%):
  • Non-reducing or isolated right-sided varicocele
  • Bilateral lower limb oedema due to compression of the inferior vena cava
  • Paraneoplastic features (up to 30%):
    • Endocrine:
      • Erythropoietin secretion leading to polycythaemia
      • Parathyroid hormone-related protein secretion leading to hypercalcaemia
      • Adrenocorticotrophic hormone secretion leading to Cushing’s syndrome
    • Liver dysfunction:
    • Myopathy
  • Investigations may reveal:
    • Full blood count (FBC):
    • Urea and electrolytes (U&Es) and calcium:
      • May show renal dysfunction
      • May show hypercalcaemia due to paraneoplastic parathyroid hormone-related protein secretion
    • Urinalysis:
      • Shows haematuria and/or proteinuria, but these findings are non-specific
    • Liver function tests (LFTs):
      • May show elevated transaminases due to hepatic metastases
      • May show cholestatic liver function tests due to Stauffer syndrome
    • Abdominal ultrasound:
      • May identify suspicious masses, but not useful for diagnosis or further assessment
    • Contrast-enhanced CT or MRI abdomen and pelvis:
      • Diagnostic for RCC and used in staging
      • MRI may be used if contrast media is contraindicated (e.g. allergy or poor renal function)
    • Renal biopsy may be considered:
      • Considered if RCC is indeterminate, metastatic, medical management may be implemented, or alternate diagnoses are being considered

Differential Diagnoses: Non-Urologic Causes

Appendicitis

  • A history and physical examination may reveal:
    • Dysuria can occur due to irritation of nearby urinary structures
    • Acute-onset constant, severe, central abdominal pain that classically moves to the RLQ
    • Anorexia is commonly seen
    • More common in children and young adults
    • Fever and tachycardia may be present
    • Rovsing’s sign may be present – palpating the lower left quadrant elicits pain in the right lower quadrant
  • Investigations may reveal:
    • Full blood count (FBC):
      • May show leukocytosis
    • Ultrasound:
      • Considered to screen for pelvic pathology (e.g. ovarian torsion, ectopic pregnancy), may identify appendicitis 

Ectopic pregnancy

  • A history and physical examination may reveal:
    • Dysuria can occur due to irritation of nearby urinary structures
    • Severe sudden-onset unilateral pain in the LLQ or RLQ with associated vaginal bleeding
    • There is usually a 6-8-week period of amenorrhoea
    • An adnexal mass may be felt during a pelvic examination
    • Rebound tenderness may be seen if a ruptured ectopic pregnancy is seen
    • Shoulder tip pain may be seen when passing urine or opening the bowels due to peritoneal bleeding
  • Investigations may reveal:

Reactive arthritis

  • A history and physical examination may reveal:
    • Usually 1-6 weeks after an STI or GI infection
    • Usually lower limb joints affected
    • “Can’t see, pee, or climb a tree” – conjunctivitis, urethritis, arthritis
  • Investigations:
    • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP):
      • These are both increased
    • Anti-nuclear antibody (ANA):
      • Negative
    • Rheumatoid factor (RF):
      • Negative
    • Urogenital NAAT testing for Chlamydia trachomatis/Neisseria gonorrhoeae:
      • Negative
    • Stool cultures:
      • Negative
    • Plain X-rays:
      • Sacroiliitis may be present
    • Arthrocentesis and synovial fluid analysis:
      • Negative

Behçet’s disease

  • A history and physical examination may reveal:
    • Recurrent oral and genital ulcers without the presence of sexually-transmitted infections
    • Anterior uveitis
    • Erythema nodosum
    • Gastrointestinal ulceration – may present with features similar to inflammatory bowel syndrome
  • Investigations:
    • Pathergy testing:
      • Subcutaneous skin prick with a sterile needle shows induration with or without a pustule within 48 hours

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