KEYWORDS: ..배뇨 전후 또는 배뇨 중 치골 상부나 요도부에 통증이나 작열감, 불쾌한 증상 등을 느끼는 것으로 주로 방광염, 요도염, 전립선염 등의 급만성 염증 등이 하부 요로에 있을 때 생긴다. ..여성에서는 25세에서 54세 사이의 성적활동이 왕성한 시기에, 남성에서는 Benign prostatic hyperplasia가 생길 수 있는 40세에서 60세 사이에 의미있게 증가한다. ..환자는 주로 배뇨시작 시기나 도중에 화끈거리는 증상을 호소한다. Infection : Pyelonephritis, Cystitis, Prostatitis, Urethritis, Cervicitis, most common Epididymo-orthitis, Vulvovaginitis Hormonal conditions Hypoestrogenism(Atrophic vaginitis), Endometriosis Malformations Bladder neck obstruction(BPH), Urethral strictures or diverticula Neoplasms Renal cell tumor, Bladder cancer, Prostatecancer, Vaginal/Vulvar cancer, Penile cancer Inflammatory Spondyloarthropathies, Drug side effects, conditions Autoimmune disorders Trauma Catheter placement, “honeymoon”cystitis Psychogenic Somatization disorder, Major depression, Stress disorders, conditions Anxiety, Hysteria Female urethral syndrome : Symptoms consistent with a lower UTI but without the presence of significant bacteriuria and conventional pathogens. Dysuria 487 The Root of ambulatory care 1. Onset/Duration Longer duration and more gradual onset → may be C.trachomatis Sudden onset → may be bacterial infection 2. Initial dysuria/terminal dysuria? Initial dysuria → urethral inflammation Terninal dysuria (suprapubic pain after voiding) → bladder inflammation or infection 3. Is there frequency/urgency/hesitancy/nocturia/gross hematuria? 4. Any vaginal discharge/itching? 5. External pain/Internal pain? External pain (pain as the urine passes over the inflamed vaginal labia) → vaginal infection or inflammation Internal pain (pain felt inside the body) → bacterial cystitis or urethritis 6. Associated symptoms such as nausea, vomiting, diarrhea, headache, dizziness, or fatigue : often associated with primary dysmenorrhea. 7. Is there fever, chills, nausea, vomiting? 8. Is there any history of recurrence of genital or urinary infections, renal stone, tumor, prostatitis? 9. Are there new or multiple sexual partners, sexual abuse? 10. Is a diaphragm or foam used as contraceptives? 1. Dipstick urinalysis : positive for nitrate suggests a probable UTI ; however a negative test does not rule out the diagnosis. 2. Urinalysis : nitrites, leukocyte esterase, pyuria, hematuria, proteinuria 3. Urine culture and sensitivities : A reliable collected midstream urine culture is the mainstay in the diagnosis of UTI, but uncomplicated UTI in women may not require culture. 4. Vaginal discharge for wet mount and potassium hydroxide solution : if indicated 5. STD tests : N.gonorrhoeae, C.trachomatis, H.simplex if indicated. 6. Urodynamics, Cystoscopy, Renal ultrasound, Intravenous urography to narrow the definitive diagnosis Key questions Key tests Dysuria Fig 1. Algorithm for the evaluation of acute dysuria Localizing signs and symptoms Location of pain on urination Joint or back pain Suprapubic pain Cystitis, bladder distension, bladder neoplasm, or subclinical pyelonephritis Spondyloarthropathy Pyelonephritis, ureteral stone, ureteral obstruction Costovertebral or flank pain or tenderness Internal External Pyuria Urine culture UTI Hematuria > 1000 CFU per ml, single organism < 1000 CFU per ml, two or more organisms Neoplasm, tuberculosis, nephrolithiasis, BPH Neoplasm, ureteral stone, or bladder stone Mechanical cause of dysuria(e.g. bladder dysfunction), ureteral stricture, diverticuli, BPH, prostatodynia, epididymis, orchitis, perineal inflammation, interstitial cystitis, psychogenic factors Neoplasm, tuberculosis, prostatitis, epididymitis Prostatitis, cystitis, subclinical pyelonephritis, pyelonephritis Urethritis, perineal inflammation or Infection, contact sensitivity Yes Yes Yes Negative No No No Positive ..Radiologic studies and other diagnostic tests are indicated when the diagnosis is in doubt, when patients are severely ill or immunocompromised and do not respond to antibiotic therapy, and when complications are suspected. 489 The Root of ambulatory care 1. Treat suspected underlying disease 1. Avoid over the counter decongestants and caffeine. 2. Cranberry or orange juice may help. 3. Avoid perfumed soaps and toilet paper 4. Use of condom for sexual intercourse needs to be encouraged. 5. Adequate fluid intake (8~10 glasses of water) needs to be encouraged, along with frequent emptying of bladder. Key treatments 참고 문헌 Syed M. ahmed : Dysuria, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 693-695 김윤진 : 배뇨곤란, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1288-1291 Judy D. Bremnor, M.D., Richard Sadovsky, M.D. : Evaluation of Dysuria in Adults. A journal of the American Family Physicains 2002 ; 65 : 1589 -1596, 1597