Chapter 41 Dysuria (Case 12)
Patient Care
Clinical Thinking
• Bacterial cystitis can progress to pyelonephritis with possible risk for sepsis, renal scarring, and/or hypertension.
• Dysuria is more common in females because of the presence of a short urethra, thin prepubertal vaginal mucosa, and urethral proximity to the anus.
Physical Examination
• Abdominal examination: Note abdominal or costovertebral angle (CVA) tenderness; palpate for bladder distention and tenderness; check for palpable fecal masses.
Tests for Consideration
• Urine dipstick: Any nitrite or moderate leukocyte esterase (LE) is highly specific for UTI (98%, 99%). $95
• Urine culture and antibiotic sensitivity: Gold standard for UTI diagnosis: urethral catheterization or suprapubic aspiration (SPA) if in diapers; clean catch midstream (CCMS) urine if toilet-trained. Diagnosis of UTI is dependent on the method of urine specimen collection. $148
• CCMS specimen: In males, ≥10,000 CFU/mL of a single organism; in females, ≥100,000 CFU/mL of a single organism. Pure growth of fewer pathogens may be significant in appropriate clinical settings. $148
• Urethral catheterization specimen: Per the American Academy of Pediatrics (AAP) guideline: ≥10,000 CFU/mL of a single pathogen is considered positive. Other authors have noted that ≥50,000 CFU/mL are more likely to correspond to true pathogens, and hence UTI, and a repeat catheterized specimen is suggested for 10,000 to 50,000 CFU/mL.1,2
• Cervical/vaginal cultures: For gonorrhea (GC), chlamydia, or bacterial vaginosis if indicated $290
Imaging Considerations
→ Renal ultrasound: Was routine with most first UTIs to identify anomalies; this practice is currently under scrutiny given prenatal ultrasound and low yield in identifying treatable conditions (see Chapter 64, Antenatal Hydronephrosis). $590
→ Radiographic voiding cystourethrography (VCUG): To detect and grade vesicoureteral reflux (VUR). Radionuclide cystogram identifies VUR without grading. The relevance of VCUG for first UTIs is also being investigated. $600
→ Renal scintigraphy with dimercaptosuccinic acid (DMSA): If indicated to identify acute pyelonephritis and chronic scars. $1524
Clinical Entities: Medical Knowledge
| Urinary Tract Infection | |
|---|---|
| Pϕ | A urinary tract infection is bacteria in the urinary tract with an inflammatory response (pyuria). Cystitis involves the lower-tract with focal symptoms, whereas in pyelonephritis there is upper tract (kidney) involvement with a systemic inflammatory response. Pyelonephritis results from ascending infection, and it is difficult to distinguish upper from lower tract infection in infants and young children. Anomalies such as hydronephrosis, VUR, duplication of ureters, or posterior urethral valves in males are predisposing risk factors. Eighty percent of first community-acquired UTIs are due to Escherichia coli. Other organisms include Klebsiella pneumoniae, Proteus, Enterobacter, Proteus vulgaris, and enterococcus. Rare pathogens tend to emerge with prior treatment, hospitalization, instrumentation, or urinary tract anomalies. |
| TP | Dysuria is the typical chief complaint in cystitis without fever or other systemic signs. There may be suprapubic pain along with urinary frequency, urgency, and hesitation; young children may have daytime enuresis. Toilet-trained children may have poor toilet hygiene, constipation, and/or dysfunctional voiding. Examination is generally unremarkable, but check for CVA or suprapubic tenderness (both more common in upper tract infection) and signs of fecal retention. Children with pyelonephritis may be quite ill or toxic-appearing and have fever, chills, vomiting, and dehydration, along with generalized abdominal or flank pain. Infants typically have fever and may lack other signs or may be irritable, with poor feeding. Risk factors in infants are white females, uncircumcised males, fever >39° C (102.2° F), and fever for at least 2 days.3 |
| Dx | Urine dipstick is the initial screen, and findings may include nitrites, leukocyte esterase, blood, and/or protein. Microscopic examination of urine may demonstrate white blood cells (WBCs) greater than 5 to 10 per high power field, WBC casts, and/or bacteria. Urine culture is diagnostic. Specimen collection and diagnostic criteria are discussed above. Renal ultrasound can be done at any time. Although VCUG is presently the subject of a large clinical study, the AAP as of this writing recommends VCUG in all children with first UTI between the ages of 2 months and 2 years; however, its utility has been questioned.4 A VCUG is also advised for school-age girls with two or more UTIs and any male with a UTI regardless of age. |
| Tx | Empirical antibiotic therapy is recommended in suspected UTI pending culture results. Third-generation cephalosporins such as cefixime or cefdinir are recommended first-line agents for febrile UTI in the outpatient setting. Nitrofurantoin is good empirical treatment for cystitis. Amoxicillin and trimethoprim-sulfa may be less useful because of resistance patterns. Intravenous treatment, such as ampicillin and gentamicin to cover gram-negative pathogens and enterococci, is indicated if the child is toxic appearing or unable to tolerate oral therapy. Coverage is narrowed based on sensitivities. Duration of therapy varies by age and level of infection. Under 12 years of age, guidelines recommend treatment for 7 to 10 days, whereas in adolescents a 3-day course for cystitis may suffice. Infants and children with pyelonephritis are treated for 10 to 14 days. Standard of care has been antimicrobial prophylaxis after treatment is complete, pending VCUG. With documented VUR, prophylaxis is continued with annual VCUG until resolution, or in cases of significant anatomic abnormalities or high-grade reflux, surgical correction. The utility of prophylaxis to prevent recurrent UTI/renal scarring is currently being questioned. Furthermore, the practice may predispose to infection with resistant organisms (See Practice-Based Learning and Improvement and Chapter 46, Neonatal Fever). See Nelson Essentials 114. |
| Trauma | |
|---|---|
| Pϕ | Straddle injury is the most common traumatic cause of dysuria. However, other mechanisms of injury to the genitourinary area are always of concern and should elevate concern for abuse. The history of injury should be consistent with physical examination findings. |
| TP | Girls present with pain, bruising, dysuria, and difficulty voiding. Boys may have blood at the meatus or penile bruising and swelling. Examination of the testes for swelling or hematoma is important. Check for bladder distention because severe pain may cause urinary retention. |
| Dx | Imaging is usually not required; however, with concern for compromised blood flow, particularly to the testes, a scrotal ultrasound is recommended. |
| Tx | Treatment is supportive. For female straddle injuries, ice packs and analgesics generally suffice. Consultation with urology is indicated for extensive injury. |
| Sexually Transmitted Infection/Child Abuse | |
|---|---|
| Pϕ | Some STIs that cause dysuria include gonorrhea (GC), chlamydia, and herpes simplex. Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus. Chlamydia trachomatis is an obligate intracellular parasite, and herpes simplex (HSV) is a double-stranded DNA virus, with genital infection more commonly resulting from type 2 HSV. |
| TP | Chlamydia and gonorrheal infections may be asymptomatic or present with vaginal or urethral discharge and dysuria. Fever and other systemic symptoms are usually absent. Herpes simplex is suspected with vesicular or ulcerative genital lesions. |
| Dx | Urine nucleic acid amplification tests (NAATs) have made diagnosis of chlamydia and GC faster and simpler. However, cervical cultures and pelvic examination to exclude pelvic inflammatory disease (PID) may be warranted. Pathogen-specific cultures are still considered the gold standard for forensic evidence in child abuse; adherence to specimen collection requirements is critical in such cases. |
| Tx | Treatment is tailored toward the organism. Current treatment for chlamydia is a 5-day course of azithromycin; gonorrhea is treated with a single dose of ceftriaxone. The CDC website is the best source for current recommendations. Mandatory public health reporting is required for many STIs. STIs in young children should always be reported to the appropriate child welfare agencies. See Nelson Essentials 22 and 116. |
| Nonvenereal Vulvovaginitis | |
|---|---|
| Pϕ | Pediatric nonvenereal vulvovaginitis has multiple causes, and the most common is nonspecific inflammation resulting from poor hygiene in young toilet-trained girls. Adolescents may experience transient dysuria from perineal irritation following sexual intercourse. |
| TP | Other causes include chemical irritation from bubble bath, retained foreign body, group A beta-hemolytic streptococcus (GAS) infection, pinworm infestation, or candidal infection. |
| Dx | Diagnosis is clinical. Check for poor hygiene. Chemical irritation presents with vulvar redness and possible excoriations. Vaginal foreign bodies cause persistent foul-smelling discharge. Florid, well-circumscribed inflammation of the perineum in girls occurs with group A streptococcus (GAS). Monilial infections cause diaper rash in infants and pruritus, redness, and vaginal discharge in adolescents. |
| Urine dip may show leukocyte esterase. Pinworm infection is diagnosed by parental visualization or the cellophane tape test. GAS is diagnosed by culture. KOH prep and/or culture will confirm monilial infection in teens. Recurrent or refractory inflammation should prompt further investigation, such as STI or occult foreign body. Rarely, examination under anesthesia may be necessary to exclude a foreign body, tumor, and/or to obtain valid cultures. | |
| Tx | Supportive treatment may include sitz baths and topical treatment for itching. Elimination of inciting factors and correction of hygiene practices is key. Failure to respond in several days to conservative therapy should prompt reevaluation. Specific therapy is instituted against specific pathogens. See Nelson Essentials 115. |
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