Painful Urination (Dysuria)

Painful urination (technically known as Dysuria) is often described as a burning or stinging sensation during or after passing urine. Painful urination can be a symptom of many infections and is not exclusively related to STIs.

Painful urination is usually the symptom of an underlying infection. Trying to determine the cause of this pain requires a thorough consultation looking at your medical history, sexual history and a physical examination. Depending on this discussion, we will consider the necessary tests that may be needed to determine the exact cause of your pain.

If your pain upon urination is suspected to be due to an underlying STI, we will recommend testing for the following infections:

1. Urine-analysis
2. Chlamydia PCR
3. Gonorrhoea PCR
4. Trichomonas vaginalis PCR
5. Mycoplasma genitalium PCR
6. Urine culture & sensitivity

This will be done using a urine sample from men and a high vaginal swab from women.

Our standard practice is to perform a urine dipstick test which gives the results within 2 minutes. It looks for the presence of blood, protein, nitrites, leukocytes (pus cells) and glucose in the urine which can help us in optimising your care. A high specific gravity of urine, determined by this test, is a simple way to see if your urine is very concentrated and potentially could be responsible for your painful urination.

UTIs can be easily overlooked as focus tends to be on diagnosing STIs. If your symptoms remain a concern with normal STI test results, it will be a prudent idea to check the urine sample for Microscopy and Culture. One can receive the appropriate antibiotics based on the type of bacteria detected by this test. The best sample to perform this test is a Mid Stream Urine sample (MSU).

Stones in the kidneys and ureters are well known causes of painful urination. Clinicians diagnose this based on history, examination and findings from urine dipstick and may request specialist tests like x-ray and ultrasound.

Infections like Tuberculosis and Schistosomiasis also can cause painful urination. However, this is rare and may be suspected based on travel history.

There are two ways to approach treating painful urination:

1. As symptomatic relief – drink plenty of fluids.
2. Treatment of underlying cause, whether it is an STI or a general infection. This is why it is essential to first identify the cause of the pain before administering antibiotics.

If the cause of your dysuria is sexually transmitted, then yes, we would recommend your partner receive testing and treatment as soon as possible.

If the cause of your painful urination is a UTI, your partner will not require treatment, as UTIs are not infectious, nor transmissible to another partner.

If sexually transmitted, then we recommend you wait until after you and your partner(s) have completed treatment before resuming sexual intercourse. This will ensure the infection has completely cleared, and that you will not reinfect each other.

If non-sexually transmitted, we recommend waiting until you have finished treatment, and symptoms have resolved before having sex again. This will help to reduce any unnecessary pain, prevent further bacteria from getting into the urinary tract and worsening the infection, or delaying the healing process.

Again, this depends on the cause of the pain. Drinking lots of water helps to flush out bacteria, dilute the urine and may alleviate some pain, but this alone is very unlikely to clear the infection itself. It’s important to get the proper treatment for the cause of your dysuria, so do not delay seeking medical advice.

There is some evidence to suggest that drinking lots of water may help to prevent the development of urinary tract infections.

It is widely believed that consuming cranberry juice/products alleviates symptoms and prevents UTIs, but there is no hard medical evidence at this time to confirm the efficacy of this method. However, consuming cranberry products is very unlikely to cause any harm to the patient, so it’s no problem if patients do wish to try this.

If the problem persists with no resolution of symptoms after treatment, and no clear cause identified, further investigations may have to be carried out with a urologist. In this case, we will write to your GP to ensure you are referred to the appropriate service.

Yes. STIs such as Chlamydia, Gonorrhoea, Trichomonas vaginalis, Mycoplasma genitalium and Genital Herpes, can all cause painful urination.

This symptom is often a tell-tale sign of an infection, especially when presenting with other symptoms such as abnormal discharge or bleeding. If you suspect you may have an STI, we recommend you visit a sexual health clinic to get tested as soon as possible to prevent further complications to your health.

• Chlamydia: symptoms may also include unusual discharge from the vagina, penis or rectum, abdominal pain, bleeding after sex and pain and/or swelling in the testicles.
• Gonorrhoea: symptoms may also include increased urgency or frequency of urination, typically green or yellow discharge from the penis or vagina, abdominal pain and pain during sexual intercourse.
• Trichomonas vaginalis: women with TV are more likely to experience symptoms than men, most notably a change in vaginal discharge (a strong smell, green or yellow in colour, thick, thin or frothy consistency), as well as intense itching, painful urination and pain whilst having sex. Men may experience painful urination, pain whilst ejaculating as well as increased frequency, urgency to urinate, unusual smell and a mild rash on the penis.
• Mycoplasma genitalium: symptoms may also include unusual discharge from the vagina, penis or rectum, abdominal pain, bleeding after sex and pain and/or swelling in the testicles.
• Genital herpes: symptoms primarily include ulcers, blisters or sores on their genitalia. Many patients develop general symptoms like feeling unwell, fever, sore throat, swollen lymph nodes, fatigue and body aches. Both men and women can also experience symptoms which mimic UTIs and have severe pain when passing urine, although this is not a typical presentation of a herpes outbreak. However, if your symptoms are not getting better despite being on antibiotics for UTIs, this should be an important consideration.

No. There are many possible causes of painful urination, including both infectious and non-infectious causes. Other infectious causes of painful urination include:

• Urinary tract infection (UTI): is a general term to describe infections in both the upper and lower urinary tract.
• Lower urinary tract infections: affect the bladder and urethra. The infection of the bladder is called Cystitis, whilst the infection of the water pipe is called urethritis. Lower UTIs are generally caused by non-sexually transmitted infections. UTIs are more common in women, and are most often caused by bacteria entering the urethra. Symptoms of UTI include painful urination, increased urinary frequency and urgency, cloudy, dark, or strong smelling urine, as well as generalised symptoms such as fatigue, aches and pains.
• Upper urinary tract infections: affect the kidneys, renal pelvis and ureters. This generally presents as loin pain, tenderness on one side of the lower spine and fever. The urinary symptoms are generally absent. Upper UTIs are not caused by STIs, but by other general infections. By nature, Upper UTIs are more serious infections than Lower UTIs as the former can damage the kidneys, if not treated on time or if they are recurrent infections.
• Cystitis: is an infection of the bladder, commonly caused by bacteria entering the urethra. This can happen during sex, in those who wipe from back to front after going to the toilet, or even through imbalance of the natural bacteria of the vagina. The risk of Cystitis can be reduced by urinating after sex. Cystitis has a higher prevalence in women due to a shorter urethra. In older men, a bladder infection is normally associated with prostate enlargement, inflammation or infection.
• Urethritis: is an inflammation of the urethra (the tube that carries urine), normally caused by infection (either sexually transmitted or non-sexually transmitted). When not caused by gonorrhoea, urethritis is also referred to as non-gonococcal urethritis (or NGU), and when no clear cause has been identified, it may be referred to as non-specific urethritis (NSU). Urethritis is the most commonly diagnosed condition in men at sexual health clinics. Men and women can both get urethritis. Anatomically, men have longer urethras than women. The urethral opening in men is distinct and clear, whereas in women, the urethral opening is found in the introitus and does not look as distinctive. The meatus of both men and women can become inflamed (meatitis) and cause urethritis. Chlamydia, Gonorrhoea, Trichomonas vaginalis and Mycoplasma genitalium can infect the urethra, producing urethritis.
• Non-specific Urethritis: is a common situation where a patient presents with symptoms and signs of inflammation in the water pipe including pain on passing urine. However, the test results for all common STIs may come back negative. These patients are said to have non-specific urethritis and are treated with a course of antibiotics.
• Vulvitis & Vaginitis (in women): When the urine comes in contact with the inflamed mucosa of the vulva, it can produce discomfort on passing urine. This is essentially ‘contact’ dysuria. This is why a woman with thrush, bacterial vaginosis and eczema can report painful urination due to underlying inflammation of the vulval and vaginal mucosa. Clearly the patients with vulvitis and vaginitis can have other symptoms including unusual discharge, increase in discharge, change in smell of discharge, vaginal itching, vaginal irritation, soreness, pain during sexual contact, pain during urination, and a sense of being swollen in the genitalia. Vulvitis and vaginitis can be caused by various infections as well as exposure to chemicals, allergens (eg. spermicide, heavily scented bath or sanitary products) and estrogen deficiencies seen in menopausal women.

Yes. painful urination can have a wide range of non-infectious causes, including:

• Skin conditions (eczema, lichen sclerosus etc)
• Foreign body or stone in the urinary tract
• Trauma
• Benign prostatic hypertrophy
• Tumors
• Interstitial cystitis
• Certain medications
• Specific anatomic abnormalities
• Atrophic vaginitis (Menopause)

• Have protected sex to prevent sexually transmitted causes of painful urination.
• Urinate after having sex to flush out any bacteria.
• After having sex, ensure the genital areas are cleaned with warm water.
• If female, wipe from front to back after using the toilet.
• Regularly drink lots of water as a preventative measure to flush out any bacteria before a UTI infection can develop.

There are a wider range of complications from untreated STIs, but these can be avoided if you get tested and treated promptly.

In men and women:

• Sexually Acquired Reactive Arthritis (SARA) can develop from untreated Chlamydia and Gonorrhoea. It’s more common in men, and usually develops within the first few weeks of contracting either infection and can cause inflammation in the eyes, joints, and/or urethra.
• Untreated Trichomonas vaginalis and Mycoplasma genitalium are thought to put you at a higher risk of contracting and transmitting other sexually transmitted infections, such as HIV.
• If the infection and subsequent complications remain untreated, there is a risk of infertility in both men and women.

In men:

• Epididymitis or Epididymo-orchitis are painful conditions which cause inflammation of the testicles and the epididymis - the tube carrying sperm from testicles. This often occurs as a result of untreated Chlamydia, Gonorrhoea and Mycoplasma genitalium.
• Urethral narrowing or stricture: Untreated urethritis may result in scarring or inflammation of the urethral tissue, which then restricts or blocks the flow of urine through the tube. This causes the patient to become more prone to inflammation and infection, and can cause a number of side effects depending on the severity of the stricture including symptoms similar to UTI, as well as pelvic pain, discharge, swelling, and haematuria (blood in urine). This is classically seen in cases of gonorrhoea, and the risk becomes higher in those with recurrent infections and delay in treatment.

In women:

• Chlamydia, Gonorrhoea and Mycoplasma Genitalium can all cause Pelvic Inflammatory Disease (PID) in women. This can cause chronic pelvic pain, difficulty conceiving and even progress to infertility.
• An increased risk of ectopic pregnancy (where the foetus develops outside of the uterus ie. in the fallopian tubes) is associated with Chlamydia, Gonorrhoea, and Mycoplasma gentalium, as well as premature birth.
• Chlamydia, Gonorrhoea and Mycoplasma genitalium also pose a risk of transmission of infection to newborn during vaginal delivery.
• Mycoplasma genitalium may be associated with miscarriage and stillbirth in newborns.
• Low birth weight in newborns can be linked with untreated Gonorrhoea and Trichomonas infections in the mother.

• Kidney Infection and damage: If left untreated, the bacteria causing the UTI can travel further up the urethra and into the kidneys, causing a kidney infection (pyelonephritis). If this is left untreated, there may be serious consequences including kidney scarring and kidney disease or failure. Kidney infections are usually easy to treat with antibiotics, but some people can experience chronic kidney infections.
• Urosepsis: Urosepsis is a type of blood poisoning which is caused by infections in the urinary tract. Sepsis is very serious and can be life threatening. Physical symptoms include kidney pain, nausea and/or vomiting, reduced urine volume, breathing difficulties and extreme fatigue, sweating, changes in heart rate, weak pulse, fever, and neurological symptoms include brain fog, confusion and unusual levels of anxiety. Untreated sepsis can lead to multiple organ failure, and requires immediate medical attention. A multi-resistant and highly serious type of infection called Extended Spectrum Beta-Lactamases Escherichia coli (ESBL E. coli) has become more common in recent times due to widespread use of antibiotics. This requires immediate specialist attention as it can cause septicaemia and serious consequences.
• Recurrences: A recurrent infection is when women experience two or more UTI’s in a six month period, or 4 or more within a year.
• In pregnancy: Pregnant women with untreated UTI’s may be at a higher risk of premature delivery, or delivering a baby of low birth weight.