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 |
|---|---|---|---|---|
| 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) | ~60% |
| 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) | ~5% |
| 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？」 | ~2% | |
| 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) | ~1% | |
| 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) | < 1% | |
| Pitfalls | 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？」 | ~15% |
| 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) | ~5% | |
| 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) | ~2% | |
| 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) | ~2% | |
| 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？」 | ~1% | |
| Masquerades | 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？」 | ~5% |
| 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？」 | ~5% | |
| Anxiety / health anxiety | Excessive worry about kidney damage or cancer | 「你最驚呢個病會點？」 | ~3% | |
| Diabetes mellitus | Polyuria/polydipsia, recurrent UTI, glucosuria | 「有冇口渴、飲好多水、去好多廁所？」 | ~3% | |
| Drug-induced (e.g. cyclophosphamide, SGLT2i) | Medication Hx | 「食緊乜嘢藥？」 | ~1% |
| 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
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