Approach To Dysuria In Children

Introduction
Dysuria is any discomfort with urination but particularly refers to pain or burning during urination. Generally stemming from irritation of the bladder or urethra, it is a commonly reported sensation that affects men, women, and children alike.

Although dysuria can be caused by any condition associated with inflammation, irritation, or obstruction of the urinary tract, in children and adolescents it most commonly accompanies urinary tract infections (UTIs), urethritis, and chemical or traumatic irritation. Identifying the underlying
cause of dysuria requires a detailed history, a careful physical examination, and a focused laboratory evaluation as needed.

Clinical History
The younger the child, the less precise is the complaint of painful urination. Other symptoms, such as pruritus or pain in the genital or perineal area, may be more noticeable while the child is voiding and not distracted. Although dysuria may be the only complaint, it is more often accompanied by associated symptoms.

Regardless of the child’s age, dividing the associated symptoms into either specific urinary symptoms or nonspecific symptoms is helpful.

Symptoms specific to the urinary tract include

• hematuria, 
• discharge, 
• malodorous urine, 
• frequency, 
• urgency, 
• refusal to void, 
• new-onset nocturnal enuresis, and 
• daytime incontinence. 

The physician should inquire about exposure to detergents, perfumed soaps, bubble baths, or ointments and about the type of underwear fabric, any of which can irritate the mucosal lining of the urethra or bladder.

A thorough history of the timing of toilet training, last occurrence of daytime accidents, nocturnal enuresis, withholding maneuvers, and constipation can help elucidate a diagnosis of dysfunctional elimination syndrome.The lack of a history of trauma may not be accurate because children often do not recall it or, in the case of masturbation or sexual abuse, may deliberately deny it.

To judge the possibility of a sexually transmitted infection, adolescents should be asked about sexual activity and safety practices.

A family history of nephrolithiasis should focus attention on hypercalciuria as a cause for dysuria, and a more detailed dietary history should be elicited, including intake of salt, dairy products, and vitamins.

Symptoms outside the urinary tract, such as conjunctival injection, oral and genital ulcers, arthralgia, or a generalized rash, could suggest a systemic inflammatory condition, such as Stevens-Johnson syndrome, Reiter syndrome, or Behçet disease.

A history of fever suggests an infectious condition such as pyelonephritis, appendicitis, or pelvic inflammatory disease.


Physical Examination
The presence of a fever (body temperature >101.3°F [38.5°C]) can indicate inflammation or an upper UTI such as pyelonephritis; cystitis and urethritis of any cause do not usually produce significant fever.

Inspection of the skin may reveal vesicles with varicella or herpes simplex, or target lesions with Stevens-Johnson syndrome, which can be accompanied by conjunctival inflammation and oral lesions.

Arthritis, particularly of the knee joint, in an adolescent should raise suspicion of Reiter syndrome.

In children of any age presenting with dysuria and a history of voiding dysfunction, particularly when accompanied by a history of chronic constipation, an occult spina bifida should be excluded by careful examination of the lower back looking for midline defects, such as a sacral cyst, a fistula, or a tuft of hair.

The neurologic examination should include careful evaluation of the lower extremities for strength and reflexes, and, when suspicion is raised, the bulbocavernosal reflex should be evaluated as well.

Special attention should also be paid to the abdominal examination, which may reveal a flank or suprapubic mass, suggestive of urethral obstruction. Costovertebral tenderness suggests pyelonephritis, and suprapubic tenderness often accompanies cystitis.

On inspection of the genital area, the examiner should evaluate for discharge; if present, its character should be noted. In female patients, clear discharge may be a normal finding, whereas an odorless, cottage cheese–like appearance suggests an infection with Candidaspp. A greenish discharge, suggestive of gonorrhea, should raise the possibility of pelvic inflammatory disease if accompanied by lower abdominal tenderness. Any discharge in male patients should be considered abnormal. Scratch marks around the mucosal area in females may suggest contact dermatitis or chemical irritation. Examination should include looking for labial adhesions and a urethral prolapse, which appears as a red circumferential protrusion of the mucosa from the urethral orifice. Attention should be paid to whether or not the male patient is circumcised; if not, note whether the foreskin is age-appropriately retractable. The location and the size of the meatus should be examined for hypospadias
or stenosis.

Differential Diagnosis:
Dysuria can be caused by any inflammation, irritation, or obstruction of the bladder or urethra, but most often it is a symptom of a common disorder of childhood and adolescence, such as a UTI, urethritis, or a chemical or traumatic injury

Common Conditions

Urinary Tract Infection
UTIs are the most common cause of dysuria in children. The localization of the infection within the urinary tract may be challenging in young children because they tend to develop systemic symptoms such as fever, vomiting, and diarrhea even in the absence of pyelonephritis. Older children, who are likely to mount a fever with pyelonephritis rather than cystitis, can report suprapubic pain with cystitis or flank and costovertebral tenderness with pyelonephritis.

All children younger than 2 years and boys of all ages should be evaluated for congenital anatomic abnormalities, such as vesicoureteral reflux, after the first UTI.

Urethritis
Urethritis can present with dysuria accompanied by discharge or blood spotting on the child’s underwear. Causes of urethritis include infection, trauma, chemical irritation, and foreign body. Infectious causes in children are uncommon. Patients suspected of having infectious urethritis should have a urethral smear and urine culture included as part of their laboratory evaluation. Sexually transmitted infections are the major cause of urethritis in adults and adolescents. The finding of Neisseria gonorrhea or Chlamydia trachomatis in a child should prompt immediate investigation to rule out sexual abuse.

Irritants/Trauma
Irritants such as soap, bubble baths, and laundry detergents cause mild erythema at most. Localized trauma can result from foreign bodies, masturbation, voluntary sexual activity, or sexual abuse. Bicycle accidents and other traumas usually generate more extensive injuries than isolated genitourinary lesions.

Meatal Stenosis
Meatal stenosis occurs relatively commonly in boys after circumcision. Typically, the urinary stream is deflected upward, and the boy has difficulty aiming. It may be accompanied by dysuria, increased frequency, and delayed bladder emptying. Consultation with a pediatric urologist is warranted.

Dysfunctional Voiding
Dysfunctional voiding can result from neuropathic or non-neuropathic voiding disorders.

Neuropathic voiding is associated with conditions affecting the innervation of the muscles involved in coordinated micturition.

Non-neuropathic voiding dysfunction encompasses all other causes of lack of coordination between the bladder, the bladder outlet, and the pelvic floor muscles. If the patient is also constipated, then the condition is referred to as dysfunctional elimination syndrome, which is an important cause of idiopathic urethritis in childhood; the history should focus on timing of completion of toilet training, episodes of bed wetting, and daytime incontinence.

Uncommon Conditions
Labial Adhesions
Urethral Strictures
Urethral Prolapse
Pelvic Inflammatory Disease
Vulvovaginitis
Balanitis and Balanoposthitis
Hypercalciuria and Urolithiasis

When to Refer A Child To A Pediatrician For Further Workup
• Voiding dysfunction
• Nephrolithiasis
• Girl younger than 2 years with a UTI for the fi rst time
• Boy of any age with a UTI or meatal stenosis
• Genitourinary tract anomalies

When to Admit
• Systemic inflammatory or infectious cause of dysuria
• Suspicion of sexual abuse