Sexual Health and Genital Medicine in Clinical Practice

Chapter 9. Frequency-Dysuria Syndrome

Frequency and dysuria in the female are usually due to the following:

 Cystitis

 Urethritis/urethral syndrome

 Vulvitis.

Women with vulvitis will often complain of more generalized vulval irritation or soreness in addition to dysuria. The urinary symptoms are due to urine touching an inflamed labial epithelium or due to periurethral inflammation.

It is impossible to distinguish between cystitis and urethritis/ urethral syndrome by symptoms alone. As a useful rule of thumb, if urine dipstix testing is entirely normal and the midstream urine culture is negative or shows sterile pyuria, consider urethritis/ urethral syndrome.

9.1 CYSTITIS

In cystitis, the MSU should contain >105 uropathogens per ml. This criterion was originally established for diagnosing acute pyelonephritis and several studies have since suggested that a lower bacterial count of between 103 and 105 per ml indicates bladder infection, particularly when Gram-positive bacteria (e.g. Staphylococcus saprophyticus) or atypical organisms (e.g. Proteus) are involved. Studies have reported that between one-third to one-half of women with bacterial cystitis have "low-count" bacteruria. The commonest causes of cystitis are E. coli, S. saprophyticus, Proteus mirabilis, Klebsiella pneumoniae, and Enterobacter spp.

9.2 URETHRITIS/URETHRAL SYNDROME

Women with frequency and dysuria and urine containing <10uropathogens per ml with or without pyuria are usually diagnosed as having "urethral syndrome." Some will have a true urethritis that may be diagnosed by finding polymorphs on a Gram-stained urethral smear, an investigation often performed in GU medicine.

Chlamydia trachomatis is the most important organism to consider. Appropriate swabs should be taken from the cervix in addition to the urethra as infection at both sites is common.

Although some studies have suggested that fastidious bacteria colonizing the vulval vestibule, such as lactobacilli and diphtheroids, may occasionally infect the urethra and produce frequency and dysuria, this continues to be a topic of debate. Other causes of urethral syndrome include the following:

- Gonorrhea (very unusual to present with frequency and/or dysuria as the only symptoms)

- Herpes (usually associated with vulval or periurethral ulceration)

- Trichomoniasis (usually associated with an increased vaginal discharge)

- HPV infection (a small intrameatal/distal urethral genital wart).

9.3 INVESTIGATION OF FREQUENCY - DYSURIA

Dipstix testing and looking at the urine are useful first-line tests. Cystitis is highly unlikely if the urine looks clear and dipstix testing is negative for nitrites, leucocytes, blood, and protein.

As a general rule, consider sending an MSU for microscopy and culture if dipstix testing is positive for nitrites, leucocytes, blood, and protein, although bear in mind that contamination with vaginal discharge may yield positive dipstix results for leucocytes, protein, or blood. Women with recurrent symptoms should ideally have tests repeated at the onset of each symptomatic episode.

If these tests prove negative, consider the following:

- Checking for chlamydial infection by taking urethral and cervical swabs (if either are positive, sexual partners must be assessed)

- Taking a vaginal swab for Trichomonas vaginalis and Candida culture

- Referring to GU medicine for colposcopic examination of the urethral meatus, distal urethra, and periurethral area for evidence of tiny genital warts, small herpetic ulcers, or a localized area of vulvitis. Examination should be performed when symptoms are present.

9.3.1 Recurrent Frequency - Dysuria

 Women with recurrent episodes of proven cystitis should be referred to urology for investigation of urinary tract pathology.

 Some women with a "low-set," almost intravaginal, urethral meatus are prone to recurrent postcoital cystitis. Attacks may be prevented by urinating directly after intercourse or by using prophylactic single dose antibiotics pre- or post-coitus.

 Advise wiping from "front-to-back" after defecation.

 Consider a 10-14 day course of a tetracycline. The currently available EIA tests for diagnosing chlamydial infection are not 100% sensitive and so a false negative result should be considered. Nucleic acid amplification tests are more sensitive and hence reliable but a course of tetracycline is still worth trying, remembering that doxycycline has an anti-inflammatory as well as antibacterial action.

 Cranberry juice may have a protective effect against recurrent urinary tract infection in women at risk of developing such infections. Cranberry juice has been shown to interfere with bacterial adherence in vitro and also may act by eliminating uropathogenic bacteria from the gut.

 Urethral dilatation or urethrotomy will benefit some women.

 The use of intravaginal estrogen may help to prevent recurrent urinary tract infections in postmenopausal women.

A number of women suffer chronic urinary symptoms for which no obvious cause can be found. Underlying psychological issues should be carefully sought and discussed openly with the patient. Suggesting that symptoms are "in the mind" is usually unhelpful whereas an approach that recognizes the symptoms as real and attempts to help the patient to "de-focus" the mind from the urinary tract by way of hypnosis, behaviour therapy, meditation or low-moderate dose antidepressants, as used for chronic pain relief, may prove helpful.


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