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Dysuria
Is painful micturition from urethral or bladder inflammation, typically from infection
Strangury
Is pain in the urethra referred from the base the of the bladder, associated with constant distressing
desire to urinate even when there is little urine to void. Causes include; a stone, an indwelling
catheter, cystitis, prostatitis and bladder cancer.
Structure of the urinary tract
Defence
mechanisms
against
infections
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History
Stinging/burning?
Urgency?
Change in smell of urine?
Incontinence?
Blood in urine?
Abdominal pain?
Frequency?
Back pain?
Regular
flushing
during
voiding,
removes
organisms
from the
distal urethra
Antibacterial
secretions
into urine
and urethra
Previous episodes of dysuria?
Previous sexually transmitted diseases?
Sexual history
Firstly, set the agenda and state that you would like to ask some questions about sexual
health, making it clear why asking for this information is relevant to the patient’s
complaint. Make a simple statement such as, “I would like to ask you some personal
questions about your sex life. Would that be okay?” When the patient has given you a
verbal or non-verbal signal that he or she is happy to proceed, use the following
structured approach:
(1) When did you last have sex/sexual intercourse?
(2) Was it with a man or a woman?
(3) Was the person a casual or regular partner?
(4) Where was the partner from, and what is his or her ethnicity?
(5) In which country did you have sex?
(6) What kind of sex did you have?
(7) For each type—for example, oral, vaginal, anal—did you use a condom? (For
heterosexual sex: was any contraception used? Relate to risk of pregnancy when asking
about last menstrual period in gynaecology history). Assess whether they were the
active/insertive partner or passive/receptive partner, as appropriate.
(8) Does/did your partner have any symptoms?
(9) When did you last have sex with someone different? Return to question 2. Repeat
this for all sexual contacts in at least the preceding 12 weeks. Tip: never assume the sex
of previous partners. For men who report recent sexual activity with women, it might be
useful to ask if they have ever had sex with men in the past.
(10) Have you ever had any previous sexually transmitted infections?
(11) Have you ever had a sexual health check up before?
(12) Have you, or have any of your sexual partners, ever injected drugs or shared
injecting drug equipment? For women, have you ever had sex with a gay or bisexual
man? For men, ask about any history of sex with men, as per point (9).
(13) Have you ever had an HIV, hepatitis, syphilis test before? (Assess risk and offer
tests as appropriate)
(14) Have you been vaccinated against hepatitis B, or have you ever had hepatitis?
(Assess risk and offer vaccination if appropriate)
Investigations
urinary dipstix; midstream urine; cervial swab/smear; urethral swab
Sexually transmitted diseases
NHS (Venereal Diseases) Regulations 1974
Allows limited disclosure of information for contact-tracing in the case of sexually transmitted
diseases. Such disclosure can only be made to a doctor, or to someone working on a doctor’s
instruction in connection with treatment or prevention. It forbids those working in a genito-urinary
clinic to inform an insurance company of a patient’s sexually transmitted disease – even with the
patient’s consent. GP’s are not routinely informed of the patient’s attendance at such clinics,
although the patient may request that the GP be informed.
When the first PN discussion takes place, a plan should be agreed with the index patient about
which contacts to contact and, if so, how this should be done. All contacts in the appropriate lookback interval should be included. All contacts include those considered not traceable, as well as
those who had attended a service for management of the relevant infection before the index patient
was first seen. In deciding whether a contact is traceable, appropriate use of all information sources
should be considered.
Common index conditions
Urinary tract infection
>105 organisms/ml of fresh MSU
Sites:
Urethra
Urethritis
Baldder
Cystitis
Prostate
Prostatitis
Renal pelvis
pyelonephritis
UTIs are…
Uncomplicated- normal renal tract + function
Complicated- abnormal renal/GU tract, decreased renal function, impaired host defense, virulent
organisms e.g. staph aureus
NB. Assume UTI in men is complicated until proven otherwise
Recurrent UTI- further infection different organism
Relapse UTI- further infectionsame organism
Organisms- in community >70% e. coli, <4% in hospital
Other: staph saprphylicus, proteus mirabilis,
Rarer: enterococcus faecalis, klebsiella, candida albicans, staph. Aureus
Symptoms:
Cystitis- frequency, dysuria, urgency, strangury, haematuria, suprepubic pain
Prostatitis- flu-like symptoms, low backache, few urinary symptoms, swollen/tender prostate on
DRE
Acute pyelonephritis- high fever, rigors, vomiting, loin pain, tenderness, oliguria (if acute kidney
injury)
Signs:
fever, abdominal or loin tenderness, foul smelling urine. Occasionally distended bladder, enlarged
prostate
Tests:
Dipstick, MSU, MC+S, bloods-FBC, U+E, CRP and blood cultures, imaging- ultrasound or
IVU/cystoscopy if failure to respond, recurrence, persistent haematuria, children
Treatment:
Fluids, urinate often,
Cystitis- trimethoprim/cefalexin, 2nd line ciprofloxacin or co-amoxiclav
Acute pyelonephritis- cefuroxime
Prostatitis- ciprofloxacin
Urinary tract infection in children
Structual abnormalities of urinary tract
identify children for investigation who are at the most risk of renal damage. Such children would be
considered to be those who:
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have a known antenatal renal anomaly
are infants
are boys
have had more than one UTI
have had septicaemia
have had a prolonged clinical course or fever >48 hours
have a family history of reflux
have unusual organisms (i.e. not E. coli).
An initial ultrasound will identify:

serious structural abnormalities and urinary obstruction renal defects.
o Multicystic renal dysplasia
o Autosomal recessive polycystic kidney disease
o Autosomal dominant polycystic kidney disease
o Horseshoe kidney
o Duplex kidney
o Hydronephrosis- relflux from anomaly of the vesicoureteric junction