Dysuria
Dysuria is painful, burning, or uncomfortable sensation during urination, commonly caused by urinary tract infections, urethritis, or other genitourinary conditions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute uncomplicated cystitis | Storage LUTS (FUN) + suprapubic pain + no fever + F > M [6] | 「有冇去廁所密咗、急住去、下腹痛？有冇發燒？」(frequency/urgency/suprapubic pain without fever) |
| Serious Not To Miss | Acute pyelonephritis | Fever > 38°C + loin pain/tenderness + N/V [3][6] | 「有冇發燒、腰側痛、作嘔？」(fever + CVA tenderness) |
| PID (female) | Lower abd pain + cervical motion tenderness + abnormal discharge [7] | 「有冇下腹痛？性行為痛唔痛？有冇異常分泌？」 | |
| Bladder/renal malignancy | Painless gross haematuria in older patient, weight loss | 「有冇見到尿好紅色？有冇消瘦？」(gross haematuria + weight loss) | |
| Acute prostatitis (male) | High fever + perineal pain + exquisitely tender prostate on PR [8] | 「有冇發高燒、會陰位痛？」(PR: tender swollen prostate) | |
| Pitfalls | STI — Gonococcal urethritis | Purulent urethral discharge + short incubation (2–7 d) [4][5] | 「有冇尿道出膿？幾時有過性接觸？」(purulent discharge) |
| STI — Chlamydial urethritis | Scanty watery discharge + longer incubation (5–10 d) [4][5] | 「有冇少少水樣分泌物？」(scanty mucoid discharge) | |
| Nephrolithiasis | Colicky loin-to-groin pain + haematuria [9] | 「有冇突然腰痛痛到落去陰囊／大髀內側？」(loin→groin colic) | |
| Vaginitis (F) | External dysuria + vaginal itch + discharge (candida/trichomonas) | 「痛係外面定裏面？有冇痕？有冇白色或者黃綠色分泌？」 | |
| Interstitial cystitis | Chronic > 6 wk, sterile urine, diagnosis of exclusion [2] | 「呢個痛有冇超過個幾月？每次驗尿有冇細菌？」 | |
| Masquerades | Diabetes mellitus | Polyuria/polydipsia, recurrent UTI, glucosuria | 「有冇口渴、飲好多水、去好多廁所？」 |
| Drug-induced (e.g. cyclophosphamide, SGLT2i) | Medication Hx | 「食緊乜嘢藥？」 | |
| BPH (older male) | Obstructive LUTS predominant + large prostate on PR [10] | 「尿流有冇變弱？要唔要等一陣先出到尿？」 | |
| Fear of STI / relationship concern | New partner, guilt, partner symptoms | 「你有冇擔心係性病？伴侶有冇類似症狀？」 | |
| Anxiety / health anxiety | Excessive worry about kidney damage or cancer | 「你最驚呢個病會點？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我幫你睇症。你可以叫我X醫生。請問點稱呼你？今日嚟睇咩嘢唔舒服呀？」 | Patient-centred greeting; confirms patient name; open question scores interpersonal marks |
| 0:30–2:00 | HPI – symptom analysis (SOCRATES) | 「你小便痛係幾時開始㗎？係咩位置痛？痛嘅感覺係點㗎—例如灼熱定刺痛？嚴重咗定好咗？有冇其他嘢跟住一齊嚟，例如去廁所密咗、急住去、見到尿有血、或者有分泌物？有冇發燒、腰痛、作嘔？」 | Covers onset, character, associated LUTS (FUN DISH [1]), red flags for upper UTI, STI |
| 2:00–3:00 | Targeted systems review & red flags | 「有冇陰道／尿道有分泌物？有冇下腹痛？最近有冇新嘅性伴侶或者性接觸？月經正唔正常？（男性：有冇睪丸痛？）」 | Screens STI, PID, prostatitis; sexual history is commonly the hidden agenda |
| 3:00–3:45 | PMHx, DHx, allergy, FHx, social Hx | 「你以前有冇乜嘢病？食緊乜嘢藥？有冇藥物敏感？屋企人有冇糖尿病或者腎病？你做咩工作？有冇飲酒食煙？」 | DM → complicated UTI; drugs (antibiotics recently → resistance); occupation/functional impact |
| 3:45–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得呢個問題係咩嚟㗎？（Idea）你最擔心嘅係啲乜嘢？（Concern）你今日最希望我幫到你啲咩？（Expectation）」 | ICE is directly tested on the Case Report Form; hidden agenda often surfaces here |
| 4:30–5:15 | Hidden agenda probe & empathy | 「我明白你好擔心，呢啲感覺好正常㗎。你除咗小便痛之外，有冇其他嘢想同我傾？」 | "Why did the patient come TODAY?" — may fear STI, cancer, infertility, or relationship issue. Show empathy. |
| 5:15–6:00 | Summarise, signpost, safety-net, close | 「等我總結一下：你嚟咗X日小便痛，有（症狀），我初步考慮係尿道感染，我建議做個小便檢查同埋開啲抗生素。如果食完藥仲未好、發高燒、或者腰痛，要即刻返嚟睇。你有冇嘢想問？」 | Summarising + safety-net + checking understanding = high interpersonal marks |
Uncovering the hidden agenda: Ask "Why today?" (「點解今日先嚟睇？」). Patients with dysuria may have been self-treating; the real concern could be STI from a new partner, fear of cancer/kidney damage, worry about infertility (PID), or relationship conflict from suspected partner infidelity.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & duration | When did the burning start? | 「小便痛幾時開始㗎？」 | Acute (days) → UTI/STI; chronic → interstitial cystitis, chronic prostatitis | Acute: UTI, STI; Chronic: interstitial cystitis |
| Character | Burning? Stinging? Internal or external? | 「痛嘅感覺係灼熱定刺痛？係裏面定外面痛？」 | Internal dysuria → UTI/urethritis; external → vulvovaginitis [2] | External: vaginitis, dermatitis |
| Storage LUTS | Frequency? Urgency? Nocturia? | 「有冇去廁所密咗？急住去？半夜起身去？」 | FUN = Frequency, Urgency, Nocturia → irritative symptoms of cystitis [1] | Cystitis, BPH, overactive bladder |
| Voiding LUTS | Weak stream? Hesitancy? Incomplete emptying? | 「尿流有冇變弱？要唔要谷先出到？覺唔覺得去完仲未去乾淨？」 | DISH = Dribbling, Incomplete emptying, Straining, Hesitance [1] | BPH, urethral stricture, prostatitis |
| Haematuria | Any blood in urine? | 「有冇見到尿有血？」 | Red flag → bladder Ca, stones, upper UTI, GN | Malignancy, nephrolithiasis, pyelonephritis |
| Fever/loin pain | Any fever, chills, or back/loin pain? | 「有冇發燒、打冷震、或者腰側痛？」 | Fever > 38°C + loin pain → upper UTI (pyelonephritis) [3] | Pyelonephritis, renal abscess |
| Discharge | Any urethral or vaginal discharge? | 「有冇尿道出分泌物？（女：陰道有冇異常分泌？）」 | Urethral discharge + dysuria → gonococcal (purulent) vs chlamydial (watery/mucoid) urethritis [4][5] | Gonorrhoea, chlamydia, NGU |
| Sexual history | New sexual partner? Condom use? | 「最近有冇新嘅性伴侶？有冇用安全套？」 | Essential for STI risk; often the hidden concern | STI, PID |
| Lower abdominal/pelvic pain | Any lower belly pain or pain during sex? | 「有冇下腹痛？性行為嗰陣有冇痛？」 | Deep dyspareunia + abd pain → PID | PID, endometriosis |
| Menstrual Hx (F) | LMP? Irregular bleeding? Could you be pregnant? | 「上次月經幾時？有冇亂經或者經期之間出血？有冇機會懷孕？」 | Pregnancy changes UTI management; intermenstrual bleeding → cervicitis/PID | Complicated UTI in pregnancy, cervicitis |
| PMHx | Diabetes? Kidney disease? Previous UTIs? Stones? | 「你有冇糖尿病、腎病？以前有冇試過尿道炎？有冇腎石？」 | DM → complicated UTI; recurrent UTI needs evaluation; stones → dysuria | Complicated UTI, nephrolithiasis |
| Drug Hx | Recent antibiotics? OTC meds? | 「最近有冇食過抗生素？有冇自己買藥食？」 | Prior Abx → resistance; self-treatment delays presentation | Resistant UTI |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Penicillin/sulfa allergy affects Rx choice | — |
| Social/functional | Does this affect your work/daily life? | 「呢個問題有冇影響到你返工或者日常生活？」 | Functional impact is a biopsychosocial problem | — |
| Psychological | Feeling worried or stressed about this? | 「你有冇因為呢件事覺得好擔心或者有壓力？」 | Screens for anxiety, relationship stress | Anxiety, depression |
Case Report Form Answer Builder
CC: Dysuria for ___ days
HPI high-yield points to capture:
- Onset, duration, character of pain (burning/stinging, internal/external)
- Associated storage LUTS: frequency, urgency, nocturia
- Associated voiding LUTS: weak stream, hesitancy, incomplete emptying
- Haematuria (gross/microscopic)
- Urethral/vaginal discharge (colour, amount, smell)
- Fever, rigors, loin pain, N/V (upper tract features)
- Lower abdominal/pelvic pain
- Sexual history: new partner, unprotected sex, partner symptoms
- Menstrual/obstetric history if female (LMP, pregnancy possibility)
- PMHx: DM, previous UTI, kidney stones, structural urological abnormality
- DHx, allergy
| Likely RFC Examples | How to Phrase |
|---|---|
| Symptom relief (pain on urination) | "Dysuria causing significant discomfort affecting daily activities" |
| Concern about STI after new sexual contact | "Worried about sexually transmitted infection after recent unprotected sex" |
| Recurrent UTI — wants to know why | "Recurrent urinary symptoms; seeking explanation and prevention" |
| Fear of serious disease (cancer/kidney damage) | "Concerned about possible serious urological disease" |
Tip: Choose the ONE that best matches what the patient is most worried about (usually elicited by the ICE questions), NOT the medical diagnosis.
| Component | Likely Content | Example Wording for CRF |
|---|---|---|
| Idea | "I think I have a urine infection" / "I'm worried it might be an STI" | Patient thinks symptoms are due to UTI / STI |
| Concern | Fear of STI, kidney damage, cancer, infertility (if PID), embarrassment | Patient is worried about STI and impact on relationship |
| Expectation | Wants antibiotics, urine test, STI screen, reassurance, referral | Patient expects urine test and antibiotics; wants to rule out STI |
Acute uncomplicated cystitis (in a young/middle-aged female)
Minimum supporting evidence: Acute onset dysuria + frequency + urgency + suprapubic discomfort, absence of fever/loin pain/systemic upset, no vaginal discharge.
If male or has fever/loin pain: consider acute pyelonephritis, prostatitis, or STI instead.
GC Lecture High Yield
E. coli accounts for ~90% of acute uncomplicated cystitis. Diagnosis is clinical in uncomplicated cases; urine culture is NOT routinely required in young women with classic symptoms. Urine culture IS indicated in: treatment failure, upper UTI, complicated UTI (pregnant, male, children), recurrent UTI [6][11].
| DDx | One Key Discriminator |
|---|---|
| Acute pyelonephritis | Fever > 38°C + CVA tenderness + systemic upset (N/V, rigors) |
| Urethritis (gonococcal / chlamydial) | Urethral discharge (purulent vs watery) + recent sexual exposure + no suprapubic pain |
| Vaginitis / vulvovaginal candidiasis (F) | External dysuria + vaginal itch + abnormal vaginal discharge; no frequency/urgency |
(Adjust for stem: if male, replace vaginitis with acute prostatitis or epididymitis)
| Domain | Problem |
|---|---|
| Biological | Acute lower urinary tract infection causing pain and haematuria |
| Psychological | Anxiety about possible STI or serious disease (e.g. cancer); embarrassment |
| Social/Functional | Impact on work/school attendance and daily activities; relationship stress if STI suspected |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Acute cystitis | Suprapubic tenderness | Palpate suprapubic area with patient supine, bladder partially full | Localised bladder inflammation causes tenderness; no CVA tenderness or fever distinguishes from pyelonephritis |
| Acute pyelonephritis | CVA (costovertebral angle) tenderness | Percuss over renal angle posteriorly with fist | Upper tract infection → renal capsule inflammation → tenderness at renal angle |
| STI urethritis | Urethral discharge on milking the urethra | Gently milk urethra from base to meatus (or observe discharge at urethral meatus) | Purulent → GC; scanty mucoid → chlamydia; confirms urethritis over cystitis |
| Acute prostatitis (M) | Tender, boggy prostate on PR examination | Digital rectal exam — prostate exquisitely tender, swollen | Confirms prostatitis; NB: do NOT massage vigorously (risk of bacteraemia) |
| Vaginitis (F) | Abnormal vaginal discharge on speculum exam | Speculum examination; note colour, consistency, odour of discharge | Candida: white curd-like; Trichomonas: frothy yellow-green; BV: thin greyish + fishy odour |
| Nephrolithiasis | No reliable sign in brief FM station | Best clue: loin-to-groin colic + haematuria on dipstick; Ix: KUB X-ray or CT KUB | Diagnosis is primarily clinical + imaging; stone may not produce physical sign |
| PID (F) | Cervical motion tenderness (chandelier sign) | Bimanual pelvic exam — gently move cervix side to side | Pain on cervical motion indicates peritoneal irritation from upper genital tract infection |
Top Traps That Lose Marks
- Forgetting to ask sexual history — STI urethritis is a key DDx for dysuria and is commonly the hidden agenda. Skipping this loses both history AND ICE marks.
- Labelling pyelonephritis as cystitis — If there is fever > 38°C + loin pain, it is upper UTI until proven otherwise. This changes management (IV Abx, longer course) and urgency.
- Not distinguishing internal vs external dysuria in females — External dysuria with vaginal symptoms points to vaginitis, NOT UTI.
- Forgetting to ask about pregnancy in women of childbearing age — UTI in pregnancy = complicated UTI; requires urine culture, safe antibiotics, and follow-up culture.
- Not asking about recurrence — Recurrent UTI (≥2 in 6 months or ≥3 in 12 months) [3] needs evaluation for underlying cause.
- Writing the diagnosis as the main RFC — The RFC is the PATIENT'S reason for coming, not the disease label.
Must-Not-Miss Red Flags — Refer Urgently:
- Fever + rigors + haemodynamic instability → urosepsis → A&E
- Inability to pass urine (acute urinary retention) → A&E catheterisation
- Persistent gross haematuria in patient > 50 → urgent urology referral (r/o bladder Ca)
- Bilateral loin pain + oliguria → obstructive uropathy → urgent imaging
Safety-Net Line (for closing the consultation):
「如果食完藥兩三日都冇好轉、發高燒、或者腰痛加劇，要即刻返嚟或者去急症室。」
Topical intravaginal oestrogen effectively decreases recurrent cystitis in post-menopausal women [12] — this was tested in the 2021 Fourth Summative MCQ (Q73).
High Yield Summary
What to ASK: Dysuria character (internal vs external), full LUTS (FUN DISH), haematuria, fever/loin pain, discharge (urethral/vaginal), sexual history, pregnancy status, DM, prior UTI, and ICE.
What to WRITE: CC with duration → HPI covering symptom analysis + red flags + sexual/menstrual Hx → RFC = patient's concern (often STI worry or recurrence) → ICE → Most likely Dx = acute cystitis (if classic) → DDx: pyelonephritis, STI urethritis, vaginitis → Biopsychosocial problems → Physical sign: suprapubic tenderness (cystitis) or CVA tenderness (pyelo).
What NOT to MISS: Sexual history, pregnancy, fever + loin pain (upper tract), urethral discharge (STI), and gross haematuria in older patients (malignancy screen).
Active Recall - Family Medicine Clinical Test
[1] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai), p.779 — LUTS mnemonic FUN DISH [2] Senior notes: Ryan Ho Urogenital, p.121 — Approach to Dysuria, clinical pointers [3] Senior notes: Adrian Lui Pediatrics Notes, p.343 — UTI classification (lower vs upper) [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai), p.1049–1054 — Gonococcal vs Chlamydial urethritis [5] Lecture slides: Dermatology STD Teaching by Dr KM Ho 2, p.12–13 — STI syndromes and clinical assessment [6] Senior notes: Maksim Medicine Notes, p.192 — UTI definitions, investigations, management [7] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai), p.1052 — PID presentation [8] Senior notes: Ryan Ho Urogenital, p.128 — Acute bacterial prostatitis [9] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai), p.790–792 — Nephrolithiasis presentation [10] Lecture slides: GC 180. Benign prostatic hyperplasia, bladder outlet obstruction and urinary retention [11] Lecture slides: GC 210. Urinary tract infection [12] Past papers: 2021 Fourth Summative Assessment MCQ, Q73 — Topical intravaginal oestrogen for recurrent cystitis
Dysphagia
Dysphagia is difficulty in swallowing solids, liquids, or both, resulting from functional or structural impairment of the oral, pharyngeal, or esophageal phases of deglutition.
Ear Discharge (otorrhoea)
Otorrhoea is the drainage of fluid—serous, mucoid, purulent, or bloody—from the external auditory canal, arising from conditions affecting the external ear, middle ear, or rarely the intracranial compartment.