Family doctor

OVERVIEW

Dysuria - a painful, burning sensation during urination - is a common complaint for young women. It often indicates urinary tract infection but can also indicate sexually transmitted infection.

Tests and examinations are important to make the correct diagnosis , so that the right treatment can be given

Urinary Tract Infection (UTI) or Sexually transmitted Disease (STD)?

Studies show no significant difference in symptoms between UTI and STDs. Sexually transmitted diseases can cause dysuria from external lesions on the vagina or urethral inflammation, with or without vaginal discharge.

Acute urethral syndrome secondary to candida or trichomonial vaginitis can result in both dysuria and vaginal discharge, however many women with urinary tract infections also complain of vaginal discharge. Frequency and urgency can be a symptom of both UTIs and STDs.

The incidence of sexually transmitted diseases is higher in sexually active adolescents than women in other age groups. For instance even when risky behaviour is controlled, the incidence of chlamydia is twice as high among women of 15-19 years than others. Susceptible columnar epithelium on the outer cervix of adolescents does not change to "flatter" (squamous) epithelium until women reach their 20s and this may in part explain the higher incidence.

Untreated chlamydial or gonorrheal infections can lead to pelvic inflammatory disease, a condition that can damage the fallopian tubes and ovaries. Studies show sexually active adolescent girls have a much greater chance of developing pelvic inflammatory disease than women in other age groups (1 in 8, compared with 1 in 80). Apart from chronic pelvic pain often associated with pelvic inflammatory disease, the risk of infertility and ectopic pregnancy is obviously serious to a woman entering her reproductive years.

Diagnosis

A Pelvic examination is usually necessary if pelvic inflammatory disease is suspected.

A vaginal examination can help diagnose pelvic inflammatory disease, usually indicated by low abdominal pain, cervical motion tenderness and tenderness of the fallopian tube area.

However diagnosis is not highly accurate - 65% - when compared with laparoscopy. Other indicators can help confirm diagnosis, such as nausea, dysuria, fever, irregular bleeding, dyspareunia and vaginal discharge. Ultrasound scanning may also prove useful to aid diagnoses.

If pelvic inflammatory disease is diagnosed or suspected, a cervical culture is needed to identify the particular pathogen as these can vary widely.

An external exam is invaluable to detect any lesions associated with herpes simplex virus. Sensitive urine tests for gonorrhea and chlamydia are now available (ligase chain reaction) and, coupled with a vaginal vault swab, can produce accurate diagnosis.

Lab tests

More detailed urine and swab tests are important in making an accurate diagnosis

Lab tests that yield quick results can be useful but are not definitive. Urine dipstick analyses can indicate bacteria in the urine through the detection of leukocyte esterase produced by white blood cells. However this may be an indication of either urethral syndrome or UTI, or be a false negative from a variety of substances such as cephalexin and tetracycline. Nitrate presence can mean UTI is probable but this test does not indicate the presence of Staphylococcus saprophyticus, This bacterium is non-nitrate reducing and a common cause of UTIs, especially amongst adolescents.

Microscopic exams can prove useful - half the UTIs occurring in the lower tract and the majority of those in the upper will show >100,000 bacteria/mL.

Patients with acute urethral syndrome may have any number of white blood cells or bacteria present, however they usually have lower white blood cell and bacterial count than those with UTIs.

Special culture swabs of the cervix,vagina and possibly urethra can help diagnose of exclude infections like chlamydia or gonnorhoea.

Treatment

Treatment of symptomatic infection, be it sexually transmitted or a urinary tract infection, should aim to relieve discomfort and prevent complications such as pelvic inflammatory disease. Preventing future re-infection of sexually transmitted conditions is important as well as tracing and checking sexual partners.

As urine ligase chain reaction lab tests become more readily available it will be reasonable to limit full pelvic examinations. If a patient is low risk, presenting dysuria with or without discharge, has no abdominal pain and external exam and vaginal swabs are normal, she may be treated for cystitis while awaiting ligase chain reaction results.

A speculum exam can be sometimes be avoided as long as follow up of lab results can be assured, and careful follow up arrangements are made.

Pain or vaginal bleeding , when pregnant will still need both speculum and vaginal exams to evaluate the risk of ectopic pregnancy.

Getting Help

It is best to seek advice and an accurate diagnosis from your doctor if you have symptoms described in this article.