Approach To A Child With Dysuria

A child may present with difficult or painful urination and it is important to ask a few questions that will help to reach an appropriate diagnosis.

Immediate Questions

1. When did the painful urination begin?
Trauma to the urinary tract must be ruled out if pain develops after an injury. Bicycle and straddle injuries commonly cause damage to the kidneys or urethra, leading to hematuria or dysuria or both. Consider behavioral problems , including attention seeking , if symptoms occur only at a particular time of day (e.g during school)

2. Where is the pain located?
An older child can locate the pain in the urethra, in the pelvis or in the abdomen. some children alos complain of a back pain. Pain originating from other organ system may be referred to the urethra. an intra abdominal abscess or a low lying inflamed appendix may produce complaints of dysuria. Dysuria associated with back pain is a common presentation of pyelonephritis. Renal stones in the pelvis, calyx, or ureter can cause abdominal or flank pain with radiation into the scrotum or vulva. Stones in the urethra or distal ureter Stones in the bladder are not associated with pain.

3. Are there any associated complaints?Fever, dark and foul smelling urine, frequency and urgency are all symptoms associated with UTI’s.

4. What is the quality and strength of the urinary stream?Patients with obstructive processes e.g posterior urethral valves have small, frequent voidings. Patients with urethral strictures or meatal stenosis have a decrease in the force of their urinary stream.

5. Has there been any bleeding?Bleeding may be present after trauma or associated with infection or congenital anomalies. excess calcium excretion and renal stones cause dysuria as well as hematuria.

6. What medications does patient take?
Some medications like cyclophosphamide may cause irritation to the urethra and painful urination.

7. Has there been any change in brand of soap, detergent or fabric softner?Certain soaps or cleansers can be associated with urethral irritation and pruritis. Bubble baths for example, remove protective lipids from the urethra, causing irritation.

Physical Examination

1. Vital Signs
Evaluate for fever, tacycardia or hypotension which suggest upper tract involvement and in case of hypotension also consider urosepsis.

2. Abdomen and BackExamine for abdominal and flank masses. suprapubic tenderness, or costovertebral angle tenderness.

3. Genitalia
Inspect skin and perineum for evidence of rashes, redness or irritation. look for evidence of discharge. Perform pelvic exam in sexually active adolescent girls who present with dysuria to rule out vaginitis and pelvis inflammatory disease.