Urination - Pain or Burning 

Also known as “Dysuria”

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credit: Sourced from the MSD Manual, Consumer Version; authored by Dr Anuja P. Shah (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Burning or pain during urination may be felt at the opening of the urethra or, less often, over the bladder (in the pelvis, the lower part of the abdomen just above the pubic bone). Burning or pain during urination is an extremely common symptom in women, but it can affect men and can occur at any age.

Causes

Burning or pain during urination is typically caused by inflammation of the urethra or bladder. In women, inflammation in the vagina or in the region around the vaginal opening (called vulvovaginitis) can be painful when exposed to urine. Inflammation that results in burning or pain is usually caused by infection but sometimes by non-infectious conditions.

Common causes

Overall, the most common causes of burning or pain during urination are:

• Bladder infection (cystitis)
• Infection of the urethra (urethritis) possibly due to a sexually transmitted disease (STD)

Evaluation

Not every person who has pain or burning during urination needs to see a doctor right away. The following information can help people decide how quickly a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people who have pain or burning during urination, certain symptoms and characteristics are cause for concern. They include:

• Fever
• Pain in the back or side (flank pain)
• A recent history of insertion of a bladder catheter or other instrument
• Immune system disorders
• Repeat episodes (including frequent childhood infections)
• A known urinary tract abnormality

When to see a doctor

People with immune system disorders and pregnant women with warning signs should see a doctor that day (or in the morning if symptoms develop overnight) because complications of a urinary tract infection can be serious in such people. Other people with warning signs should see a doctor in a day or two, as should those whose symptoms are particularly bothersome. For people without warning signs who have mild symptoms, a delay of 2 or 3 days is not harmful.

Women with frequent bladder infections may recognize characteristic symptoms that suggest another episode.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What they find during the history and physical examination often suggests a cause of the burning or pain during urination and the tests that may need to be done (see section: Some Causes and Features of Painful Urination).

Doctors may ask whether similar symptoms have occurred in the past. Doctors ask about symptoms that may accompany the pain and provide clues to the cause.

For example, doctors may ask whether:

• The urine is bloody, cloudy, or foul smelling
• Any discharge is noticed
• There has been any recent unprotected intercourse
• Potential irritants have been applied to the genitals
• A bladder catheter has recently been inserted or another urinary tract procedure has been done
• Women are asked whether they might be pregnant.

In women, the physical examination may include a pelvic examination and possibly taking of samples of cervical and vaginal fluid to check for STDs. In men, the penis may be examined, and doctors may also do a digital rectal examination to examine the prostate depending on the situation.

Doctors can often get clues to the cause based on where symptoms are most severe. For example, if symptoms are most severe just above the pubic bone, a bladder infection may be the cause. If symptoms are most severe at the opening of the urethra, urethritis may be the cause. In men with a penile discharge, urethritis is often the cause. If burning affects mainly the vagina and the woman has a discharge, vaginitis may be the cause. Cervical discharge suggests cervicitis.

Some Causes and Features of Painful Urination

Please note: Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Cystitis (bladder infection)

• Both sexes, more common in women and girls
• A frequent and urgent need to urinate
• Burning or pain during urination
• Sometimes fever and pain in the lower back or side
• Sometimes blood in the urine or foul-smelling urine

Epididymo-orchitis (infection of an epididymis and a testis)

• Only in men
• Tenderness and swelling in a testis
• Possibly frequent urination or a discharge from the urethra
• Sometimes fever or nausea

Urethritis (infection of the urethra)

• Both sexes
• Often due to an STD
• Usually a visible discharge from the urethra in men
• Sometimes a discharge from the vagina in women
• In people who have recently had unprotected intercourse

Prostatitis (infection of the prostate)

• Only in men
• A tender prostate detected during a digital rectal examination
• Often fever, difficulty starting urination, frequent urination, the need to urinate during the night, and burning or pain during urination
• Sometimes blood in the urine
• Often symptoms of a long-standing blockage in the urinary tract (including a weak urine stream, difficulty passing urine, or dribbling at the end of urination)

Vulvovaginitis (infection of the vulva and vagina)

• Only in women
• A discharge from the vagina
• Often redness in the genital area

Cervicitis (infection of the cervix)

• Only in women
• Often a cervical discharge
• Possible history of unprotected intercourse

Connective tissue disorders

• Both sexes
• Cause inflammation (such as reactive arthritis or Behçet syndrome)
• General or body wide symptoms (including body pain and joint pain) that develop before urination becomes painful
• Sometimes sores on the skin, mouth, eyes, or genital area, including inside the vagina

Dermatitis - contact

• Both sexes, more common in women
• Contact with a substance that irritates the area or causes an allergic reaction (such as a spermicide, lubricant, or latex condom)
• Sometimes redness in the genital area
• In people who have been exposed to a substance that could cause irritation or an allergic reaction

Interstitial cystitis (inflammation of the bladder without infection)

• More common among women
• A frequent and urgent need to urinate
• Long-standing symptoms

Atrophic vaginitis or urethritis (thinning of tissues in the vagina or urethra)

• In postmenopausal women
• Vaginal dryness
• Often pain during intercourse
• A discharge from the vagina
• Changes in the interior of the vagina (it becomes smooth and pale)

Tumours (usually bladder, prostate, or urethral cancer)

• Both sexes
• Long-standing symptoms, such as a weak urine stream or difficulty starting urination
• Usually blood in the urine

Testing

Doctors do not always agree on the need for tests for certain adult women who have symptoms that suggest a bladder infection. Some doctors do urine tests, whereas others treat without doing any testing. All doctors do tests when the diagnosis is unclear. The first test is usually urinalysis. In many cases, doctors also do a urine culture to identify organisms causing infection and determine which antibiotics would be effective. For women of childbearing age who are not known to be pregnant, a pregnancy test may be done. Testing for STDs may be done, for example, for men who have a discharge from the penis and for many women who have a vaginal discharge.

Cystoscopy and imaging of the urinary tract may be needed to check for anatomic abnormalities or other problems, especially if antibiotics have not been effective. People who are male, older, or pregnant may need closer attention and a more thorough investigation.

Treatment

The cause is treated. Often the cause is an infection, and antibiotics provide relief in a day or two. If pain is severe, doctors may give phenazopyridine for a day or two to relieve discomfort until antibiotics start to work. Phenazopyridine turns the urine a red-orange colour and may stain undergarments.

Key Points

• Although bladder infections are a common cause, many other disorders may cause painful urination.
• Burning or pain during urination may be a sign of an STD.
• Doctors may decide to treat women with an antibiotic and see whether symptoms resolve rather than do testing.

About the author

Dr Anuja P. Shah

MD

Assistant Professor, David Geffen School of Medicine at UCLA, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center

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