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Etiology and evaluation of dysuria in children and adolescents

Etiology and evaluation of dysuria in children and adolescents
Authors:
Gary R Fleisher, MD
Pradip P Chaudhari, MD
Section Editors:
Stephen J Teach, MD, MPH
Teresa K Duryea, MD
Deputy Editor:
James F Wiley, II, MD, MPH
Literature review current through: Dec 2022. | This topic last updated: Apr 18, 2022.

INTRODUCTION — This topic will review the causes of dysuria and the approach to the child with dysuria. The evaluation of adult women and men with dysuria, the features and diagnosis of urinary tract infections in children, and the evaluation of sexual abuse in children and adolescents are discussed elsewhere:

(See "Acute simple cystitis in females" and "Approach to infectious causes of dysuria in the adult man" and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis" and "Evaluation of sexual abuse in children and adolescents".)

(See "Approach to infectious causes of dysuria in the adult man".)

(See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis".)

(See "Evaluation of sexual abuse in children and adolescents".)

DEFINITION — Dysuria describes symptoms of pain and/or burning associated with urination. This commonly reported sensation is produced by the muscular contraction of the bladder and the peristaltic activity of the urethra, both of which stimulate the pain fibers of the edematous and inflamed mucosa. In addition, pain may occur when urine comes into contact with the inflamed mucosa.

In young children, the caregiver may report dysuria because of crying associated with urination or a wet diaper. In these patients, the chief complaint of dysuria is not as specific and may reflect other sources of discomfort. As examples:

Young children may complain of painful urination when they are instead experiencing related symptoms, such as pruritus as is seen with Enterobius vermicularis (pinworms). (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Pinworms'.)

Diaper dermatitis may present with dysuria caused by skin irritation after voiding. (See "Diaper dermatitis".)

Children who have experienced sexual abuse may present with a complaint of dysuria, which has no physical basis, or they may exhibit behaviors that are interpreted by adult observers as indicative of genital pain. (See "Evaluation of sexual abuse in children and adolescents", section on 'Presentation'.)

CAUSES — Dysuria has a wide range of infectious and noninfectious causes, but it usually stems from one of several common disorders of childhood and adolescence (table 1). Most children with dysuria as a chief complaint will have primary disorders of the genitourinary tract. Although patients with urethritis secondary to systemic illnesses may have dysuria as one of their many symptoms, this specific complaint is only occasionally the principal reason for seeking care.

Life-threatening conditions — Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous reactions, most commonly triggered by medications, characterized by extensive necrosis and detachment of the epidermis, which may affect the mucous membranes throughout the body; this produces conjunctivitis, oral ulceration, and urethritis. Infection with Mycoplasma pneumoniae may cause a similar constellation of findings, referred to as Mycoplasma-induced rash and mucositis (MIRM). Dysuria may be present, but the primary finding is a rash consisting of ill-defined, coalescing erythematous macules with purpuric centers, although many cases of SJS/TEN may present with diffuse erythema (picture 1A-D). The skin is often tender to the touch and skin pain can be prominent and out of proportion to the cutaneous findings. Lesions start on the face and thorax before spreading to other areas and are symmetrically distributed. The scalp is typically spared, and palms and soles are rarely involved. Atypical target lesions with darker centers may be present. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis" and "Mycoplasma pneumoniae-induced rash and mucositis (MIRM)".)

Common conditions — Although children with dysuria may have an infection of the genitourinary tract, noninfectious processes that irritate periurethral tissue also often cause dysuria, especially in the prepubertal female.

Infectious causes — Infections of the genitourinary tract and perineum, and less commonly systemic infections, frequently cause dysuria.

Urethritis — Urethritis is a localized infection that commonly produces a discharge. In adolescents, Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly isolated pathogens [1]. When herpes simplex virus (HSV) causes urethritis, vesicles and/or ulcers are usually apparent on examination [2]. Note that HSV in prepubertal children may occur from autoinoculation, in conjunction with either herpetic stomatitis or herpetic whitlow, or may result from sexual contact. Autoinoculation of HSV in prepubertal children is more common in males. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

A sexually transmitted etiology in prepubertal children should raise concern for sexual abuse. (See "Evaluation of sexual abuse in children and adolescents".)

Bulbar urethritis, a urological problem that affects adolescent males, presents with dysuria and microscopic hematuria. It is presumably of viral origin [3].

Cystitis — Patients with cystitis or lower urinary tract infection (UTI) often present with suprapubic pain or tenderness. They may or may not have fever, which, if present, is usually low grade. (See "Acute infectious cystitis: Clinical features and diagnosis in children older than two years and adolescents" and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Clinical presentation'.)

Balanitis and balanoposthitis — Younger males may develop a nonspecific bacterial infection of the distal penis with involvement of the glans penis (balanitis) or, if uncircumcised, both the glans and the prepuce (balanoposthitis) (picture 2). Painful swelling of the glans penis and foreskin are typically present. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis".)

Vaginitis and cervicitis — Vaginitis may cause dysuria in both prepubertal females and adolescents [4,5]. In many cases, the physical examination reveals a discharge, which varies from scant (nonspecific vaginitis) to thick and green (gonorrhea) to white and cheesy (Candida). (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment" and "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

Sexually transmitted pathogens and Candida albicans are frequently isolated in postpubertal females. Cervicitis is seen in postpubertal females and is associated with sexually transmitted infection (STI). Like vaginitis, it typically presents with vaginal discharge. However, isolated dysuria is also well described. (See "Acute cervicitis".)

These same organisms occur much less frequently in prepubertal females, one must consider nonsexually transmitted agents, such as Group A Streptococcus and Shigella species. When sexually transmitted pathogens are isolated in prepubertal females, the clinician should suspect sexual abuse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

Pyelonephritis — Pyelonephritis, defined as infection of the upper genitourinary tract, is the most serious infection of the genitourinary tract among nonsexually active children and adolescents. It usually manifests with fever, frequently above 38.5 to 39°C, and flank pain or tenderness (older children and adolescents). (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Older children'.)

Pelvic inflammatory disease — Asymptomatic infections of the lower genitourinary tract by N. gonorrhoeae and C. trachomatis may lead to the development of pelvic inflammatory disease (PID) in postpubertal females, which can have serious consequences if left untreated. Although PID may be accompanied by dysuria, fever and abdominal/pelvic pain are usually the chief complaints. Vaginal discharge and cervical motion tenderness are frequently present upon examination. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

Noninfectious conditions — Irritation around the urethra from any source can cause dysuria.

Nonspecific (chemical) urethritis — Potential local irritants include detergents, fabric softeners, perfumed soaps, and possibly bubble baths. Patients may have either no physical findings or only mild erythema, but they generally do not develop a discharge.

Local trauma — Minor injury is another relatively common cause of urethral irritation. In both older children and adolescents, normal self-exploratory sexual play, masturbation, voluntary sexual activity, placement of a urethral foreign body, or sexual abuse may be the source of the trauma. As in patients with chemical urethritis, the examination is generally unremarkable.

Urinary stones — Urinary stones (nephrolithiasis) develop occasionally in children and adolescents, often in the setting of anatomic abnormalities and/or recurrent infection. Although flank pain and hematuria is the usual presentation, stone passage may occasionally be associated with a complaint of dysuria. Children with idiopathic hypercalciuria and idiopathic hyperuricosuria, known antecedents of renal calculi, may complain of dysuria even in the absence of an observable stone and may also have hematuria. A minority of patients with urinary stones may also have a UTI. The evaluation of children with hematuria due to kidney stones, hypercalciuria, or hyperuricosuria is discussed separately. (See "Kidney stones in children: Clinical features and diagnosis" and "Evaluation of microscopic hematuria in children" and "Evaluation of gross hematuria in children".)

Other conditions — A variety of other conditions may uncommonly cause dysuria in children.

Urethral strictures – Urethral strictures, both congenital and acquired, may present with signs of obstruction such as urinary retention, as well as dysuria [3].

Dysfunctional elimination – Dysfunctional elimination is a condition that may mimic UTI or urethritis, but it does not usually present acutely. (See "Evaluation and diagnosis of bladder dysfunction in children".)

Varicella – Varicella usually begins with a febrile prodrome. After two to three days, a characteristic pruritic rash appears centrally and then spreads peripherally (picture 3 and picture 4). By the second or third day of the eruption, lesions may involve the perineum and vagina and lead to a complaint of itching and/or dysuria. (See "Clinical features of varicella-zoster virus infection: Chickenpox".)

Labial adhesions – Labial adhesions occur relatively often in young females and may be partial, involving only the upper or lower labia (picture 5), or complete. Although they are most frequently asymptomatic, microtears may occasionally cause dysuria [6]. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Labial adhesions'.)

Lichen sclerosus – Lichen sclerosus or lichen sclerosus et atrophicus, which affects primarily older women, occurs occasionally in prepubertal females. Affected females most often seek care for a perineal rash, but they may complain of pruritus. The appearance of lichen sclerosus, which consists of a depigmentation around the vagina and anus in the shape of an hourglass, is usually diagnostic (picture 6 and picture 7). (See "Vulvar lichen sclerosus", section on 'Epidemiology' and "Overview of vulvovaginal conditions in the prepubertal child".)

Virginal vaginal ulcers – Virginal vaginal (Lipschütz) ulcers are an unusual idiopathic condition that principally affects prepubertal females. The characteristic clustered vesicles resemble herpes simplex infection, which must be ruled out definitively by appropriate testing. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vulvar ulcers' and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Diagnosis' and "Acute genital ulceration (Lipschütz ulcer)".)

Reactive arthritis (postinfectious) with conjunctivitis and urethritis (formerly, Reiter syndrome) – Reactive arthritis is more common in males; it may be accompanied by conjunctivitis and urethritis. It is rarely seen in children. (See "Reactive arthritis".)

Behçet syndrome – Behçet syndrome is a rare multisystem disease characterized by recurrent oral ulcerations (picture 8), ocular panuveitis, vasculitis and, less commonly, genital ulcerations that may produce dysuria (picture 9 and picture 10). (See "Clinical manifestations and diagnosis of Behçet syndrome", section on 'Urogenital lesions'.)

Eosinophilic cystitis – Eosinophilic cystitis is a rare condition, more commonly seen in adults, that is characterized by eosinophilic infiltration of the bladder wall and confirmed by biopsy [7].

Psychogenic – Throughout childhood and into adolescence, a complaint of dysuria may be psychogenic in origin, occurring in the absence of inflammation in the genitourinary tract.

EVALUATION — The evaluation focuses on determining the underlying cause of dysuria.

History — Important historic questions relate to the presence of symptoms outside of the genitourinary tract, fever, local exposures, trauma, and sexual activity.

Symptoms outside of the genitourinary tract – A history of conjunctival erythema, oral lesions, joint pain or swelling, and/or a generalized rash suggests systemic inflammatory or infectious conditions, such as Stevens-Johnson syndrome (SJS), Mycoplasma-induced rash and mucositis (MIRM), reactive arthritis, Behçet syndrome, or varicella. Specific combinations of findings help to distinguish among these conditions. (See 'Physical examination' below.)

Fever – Fever points to infections, such as varicella, pyelonephritis, or pelvic inflammatory disease (PID), most of which have other findings rather than dysuria alone.

Local exposures and trauma – Both local trauma and exposure to chemicals, such as detergents, fabric softeners, perfumed soaps, and bubble baths, may irritate the mucosal lining of the urethra or bladder. A negative history for injury may not be accurate, however, because most traumas are not recalled by young patients or, in the case of masturbation or abuse, may be denied.

Sexual activity – The detection of sexually transmitted infections (STIs), a common cause of dysuria in adolescents, will be facilitated by obtaining a history about the nature and extent of sexual activity; however, a denial of sexual activity does not exclude this possibility (table 2).

Physical examination — Specific findings on physical examination may suggest a particular underlying cause of dysuria:

Fever – Fever may occur with any infection, particularly varicella, urinary tract infection (UTI; especially pyelonephritis), and PID.

Extragenital findings – The following findings suggest specific systemic diseases or infections:

Ocular involvement, manifesting as conjunctival inflammation, occurs with:

-SJS (see "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical presentation')

-Mycoplasma pneumoniae-induced rash (see "Mycoplasma pneumoniae-induced rash and mucositis (MIRM)")

-Behçet syndrome (see "Clinical manifestations and diagnosis of Behçet syndrome", section on 'Clinical manifestations')

Oral ulcers are seen in SJS, MIRM, and Behçet syndrome as well as following autoinoculation of the genital tract in patients with herpes stomatitis.

Arthritis in association with urethritis and conjunctivitis is present in some children with reactive arthritis. (See "Reactive arthritis", section on 'Clinical manifestations'.)

A generalized rash may suggest SJS (target lesions) (picture 1A), MIRM, or varicella (vesicles) (picture 3).

Genital findings – Findings to note in the genital area include:

Urethral, vaginal, or cervical discharge accompanies a variety of vaginal and urethral infections. The character of a discharge may suggest a specific pathogen: scant (nonspecific or chlamydial vaginitis or chlamydial urethritis in the male), cheesy (candidal vaginitis), green (gonorrhea in either the male of female), or bloody (Group A Streptococcus or Shigella in the prepubertal female). In males, penile edema may accompany gonococcal urethritis (picture 11).

Cutaneous ulcerations or vesicles (eg, herpes simplex virus [HSV] infection (picture 12 and picture 13), SJS, MIRM, Behçet syndrome, varicella virus infection, virginal vaginal [Lipschütz] ulcers) and other less common disorders (table 3).

Labial adhesions (picture 5).

Depigmentation (eg, lichen sclerosus (picture 6 and picture 7)).

Laboratory studies — Ancillary testing should always be guided by the history and physical examination. Urine testing and, in selected patients, testing to detect STIs are frequently indicated. Additional studies may be appropriate depending upon preliminary results.

All patients — Unless the cause of dysuria is obvious on physical examination (eg, balanoposthitis, obvious local trauma, or virginal vaginal ulcers) a urine specimen for rapid dipstick urinalysis should be obtained in all patients. If the dipstick urinalysis is suggestive of a UTI, specimens for urine culture and, if indicated, microscopic urinalysis should be collected by catheter or, rarely, suprapubic aspiration in diapered children. Clean catch specimens may be used in those who are toilet-trained. (See "Urine collection techniques in infants and children with suspected urinary tract infection".)

The results of urine testing help determine causes of dysuria and further evaluation as follows:

Pyuria – In prepubertal children, pyuria increases the likelihood of bacterial infection (urethritis, cystitis, vaginitis, or pyelonephritis), but the diagnosis must be confirmed by culture or, in patients with STI, nucleic acid amplification testing (NAAT) or culture. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Laboratory evaluation and diagnosis' and "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing' and "Sexually transmitted infections: Issues specific to adolescents", section on 'Diagnostic testing for STI'.)

Pyuria may also be observed in inflammatory conditions, such as chemical urethritis, and nonbacterial infections. Conversely, UTIs may occasionally occur in infants and children under two years of age in the absence of pyuria on routine urinalysis. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Special circumstances' and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Differential diagnosis'.)

Hematuria – A positive dipstick for blood may reflect a false-positive result, hematuria, hemoglobinuria, myoglobinuria, or, in females, vaginal bleeding (eg, menstruation, vaginal lesions, or vaginal bleeding from trauma). In females with a vaginal origin of bleeding, a catheterized urine specimen may be necessary to determine if hematuria is also present. Hematuria without casts, particularly with associated pyuria, in an otherwise healthy child with dysuria suggests a UTI, particularly hemorrhagic cystitis, hypercalciuria or nephrolithiasis, or local conditions such as trauma or urethritis. (See "Evaluation of microscopic hematuria in children" and "Evaluation of gross hematuria in children".)

Indications for blood culture — We suggest obtaining a blood culture in infants ≤3 months of age with febrile UTIs, those three to six months of age who have fever >39°C or are ill-appearing, and any other patient warranting hospital admission (eg, patients with UTI and a known genitourinary anomaly). Additional management of infants and children with UTIs is discussed separately. (See "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis", section on 'Decision to hospitalize' and "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis".)

As many as 10 percent of infants under one year of age with UTIs who are highly febrile (>39°C) may be bacteremic. There is limited evidence suggesting that similar outcomes occur among young children with bacteremic UTIs and those with nonbacteremic UTIs. Thus, some experts do not routinely obtain a blood cultures in otherwise well-appearing febrile patients older than two months of age. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Other laboratory tests'.)

Possible sexually transmitted infection — Patients with urethral, vaginal, or cervical discharge, sexually active patients, or those with suggestive genital lesions warrant testing for STIs. The choice of specific testing depends upon whether the evaluation is due to suspicion of sexual abuse or relates to evaluation of an adolescent engaging in consensual sexual intercourse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing' and "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

Examples of commonly used tests include:

Nucleic acid amplification testing – Urine obtained without cleansing of the urethra ("dirty urine") can be tested for the presence of C. trachomatis, N. gonorrhoeae, and Trichomonas vaginalis using NAAT. These tests offer an accurate screening tool for STIs without performing a culture of the cervix or, in the male, of the urethra. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

Although highly accurate and able to detect infection when cultures for chlamydia and gonorrhea are negative, NAAT alone may not be accepted as forensic evidence of sexual abuse in all jurisdictions. In such regions, suspected victims of sexual abuse should also undergo culturing for gonorrhea and chlamydia. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing'.)

Gram stain – A Gram stain of urethral discharge in all males and vaginal discharge in prepubertal females with the finding of Gram-negative intracellular diplococci suggests the diagnosis of gonorrhea and, in some settings, is rapidly available. The identification of Gram-negative diplococci in prepubertal patients warrants evaluation for sexual abuse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims' and "Evaluation of sexual abuse in children and adolescents", section on 'Laboratory'.)

Cultures for gonorrhea and chlamydia – As noted above, NAAT studies are a reliable method of identifying gonorrhea and chlamydia infections. Urethral cultures in males, vaginal cultures in prepubertal females, and cervical cultures in adolescents may be performed instead of NAAT on dirty urine specimens but are more invasive. (See "Evaluation of sexual abuse in children and adolescents".)

Testing for genital herpes simplex virus – HSV infection may be detected by a scraping for direct fluorescent antibody (DFA) testing, polymerase chain reaction (PCR), or viral culture. DFA provides a relatively rapid result, but PCR or viral culture is more accurate. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Diagnosis'.)

Postmenarchal females — Postmenarchal females warrant pregnancy testing in addition to urine tests and, if indicated based upon clinical findings, testing for sexually transmitted infection. Several of the conditions causing dysuria occur more frequently in sexually active and/or gravid women. In addition, pregnancy may influence the subsequent therapeutic choices.

DIAGNOSTIC APPROACH — For all patients, initial consideration should be given to serious systemic syndromes that can cause dysuria. Subsequent evaluation will be determined by the age and gender of the patient (algorithm 1A-D). Dysuria suggests urinary tract infection (UTI) and, even in the absence of pyuria, merits culture of the urine unless the etiology is obvious on physical examination (eg, balanoposthitis).

Systemic syndromes — To avoid missing recognition of rare but serious systemic syndromes, the evaluation begins with a search for a generalized process. In patients with conjunctival inflammation, oral ulcers, joint findings, or a generalized rash, likely etiologies include Stevens-Johnson syndrome (SJS), Mycoplasma-induced rash and mucositis (MIRM), Behçet syndrome, reactive arthritis (formerly Reiter syndrome), or varicella.

Prepubertal male — Dysuria in the prepubertal male is most often caused by a UTI or irritation of the urethra (algorithm 1A).

Genitourinary examination and urinalysis provide important etiologic clues as follows:

Diaper rash or urethral irritation support local trauma, chemical irritation, or candidal infection as the cause of dysuria.

Redness or swelling of the glans and/or foreskin indicates balanitis or balanoposthitis.

Penile discharge points to gonorrhea while genital ulcers or vesicles suggest herpes simplex virus (HSV). These are unusual causes and, if present, should prompt consideration of sexual abuse. However, HSV is well described as a result of autoinoculation, particularly in males with active herpetic stomatitis. (See "Evaluation of sexual abuse in children and adolescents", section on 'Evaluation' and "Evaluation of sexual abuse in children and adolescents", section on 'Diagnosis'.)

Fever or urine results suggesting infection (pyuria, Gram stain positive, or positive leukocyte esterase and/or positive nitrites on urine dipstick) most often occur in the presence of a bacterial UTI (cystitis or pyelonephritis) but may also be seen with balanoposthitis (uncircumcised patients) and viral cystitis. (See 'Cystitis' above.)

Hematuria with episodic severe abdominal or flank pain suggests urinary stones. Otherwise, hematuria may arise from cystitis. If cystitis is not confirmed, additional evaluation is necessary. (See "Evaluation of gross hematuria in children", section on 'Symptomatic hematuria'.)

Many prepubertal males will be afebrile, lack any systemic or local findings, and have a negative urinalysis. In these patients, the most likely cause is nonspecific urethritis, perhaps due to chemical exposures, or local trauma, as occurs with masturbatory play. (See 'Cystitis' above and 'Nonspecific (chemical) urethritis' above and 'Local trauma' above.)

Further workup for less common conditions, such as strictures, hypercalciuria, and chlamydial urethritis, should be considered in those with persistent unexplained dysuria. (See 'Other conditions' above.)

Prepubertal female — In the prepubertal female, common causes of dysuria include infections of the urinary tract and nonspecific vaginitis (algorithm 1B).

Important findings on physical examination include:

Urethral irritation due to chemical exposure (eg, bubble baths) or diaper dermatitis with candidal infection.

Depigmentation in the perivaginal and perianal area points to lichen sclerosus. (See 'Other conditions' above.)

A vaginal discharge with vaginitis, which may be caused by several different pathogens. Sexual abuse is an important consideration and testing for N. gonorrhoeae and C. trachomatis is often warranted. Other important causes include Streptococcus pyogenes infection, nonspecific vaginitis, and vaginal foreign body (eg, toilet paper or other objects).

Vesicles and ulceration usually indicate herpes simplex virus infection but can also represent virginal vaginal ulcers, impetigo, contact dermatitis, or, rarely, an early manifestation of a systemic disease such as SJS, MIRM, Behçet syndrome, or Kawasaki disease. Although genital herpes in the prepubertal female may occur secondary to autoinoculation, particularly in patients with active herpetic stomatitis, this diagnosis warrants the investigation for the possibility of sexual abuse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Evaluation' and "Evaluation of sexual abuse in children and adolescents", section on 'Diagnosis'.)

In the girl with fever or suggestive findings on urine dipstick testing (pyuria, positive Gram stain, or positive leukocyte esterase and/or positive nitrites on urine dipstick), infection of the urinary tract is highly likely and should be pursued with a urine culture and, if indicated, a microscopic urinalysis. Pyuria in the absence of fever usually represents a bacterial or viral cystitis. (See 'Cystitis' above and 'Pyelonephritis' above.)

Hematuria with episodic severe abdominal or flank pain suggests urinary stones. Otherwise, hematuria may arise from cystitis, particularly with associated pyuria. If cystitis is not confirmed, additional evaluation is necessary. (See "Evaluation of gross hematuria in children", section on 'Symptomatic hematuria'.)

Patients without fever, systemic or local findings, or pyuria, are likely to have either a relatively quiescent lower UTI, chemical irritation, local trauma, or nonspecific vaginitis. Further evaluation at this stage should be limited to a urine culture unless the dysuria persists. (See 'Cystitis' above and 'Vaginitis and cervicitis' above.)

Adolescent male — Similar to adult males, the adolescent male with dysuria is likely to have either a UTI or a sexually transmitted infection (algorithm 1C). (See "Approach to infectious causes of dysuria in the adult man".)

Key findings include:

Genital ulcers/vesicles point to herpes simplex and a urethral discharge suggests either a gonococcal or chlamydial infection. (See 'Urethritis' above.)

Redness or swelling of the glans and/or foreskin indicates balanitis or balanoposthitis.

Fever occurs predominantly with infections of the urinary tract. Pyuria in the absence of fever most often represents a mild cystitis or chlamydial urethritis and merits both a urine culture and testing for sexually transmitted infection. (See 'Urethritis' above and 'Cystitis' above.)

Hematuria with episodic severe abdominal or flank pain suggests urinary stones. Otherwise, hematuria, particularly with associated pyuria, may arise from cystitis. If cystitis is not confirmed, additional evaluation is necessary. (See "Evaluation of gross hematuria in children", section on 'Symptomatic hematuria'.)

In the adolescent male who has no findings on examination and no pyuria, frequent masturbation should be considered as a cause for dysuria. Further workup is necessary only with persistent symptoms and negative cultures. (See 'Local trauma' above.)

Adolescent female — Common etiologies for dysuria in the adolescent female include UTIs and sexually transmitted infections (algorithm 1D) [5,8,9].

Distinguishing features include:

Genital ulcers and vesicles are almost always caused by herpes simplex, but virginal vaginal ulcers occur occasionally, usually in younger, nonsexually active, females. Vulvar vesicles may also arise from a variety of conditions including contact dermatitis or inflammatory bowel disease (table 3).

Likely causes of a vaginal discharge include urethritis, cervicitis, vaginitis, and pelvic inflammatory disease (PID) [5]. Of these, PID is the most serious, but it infrequently causes isolated dysuria without fever and/or pelvic and abdominal pain. Pathogens that involve the lower genital tract include the sexually transmitted agents and C. albicans (table 1). (See 'Vaginitis and cervicitis' above and 'Pelvic inflammatory disease' above.)

Fever and pyuria points to a UTI, which may arise from either the bladder or the kidneys, or, in patients who also have hematuria and episodic abdominal pain, a urinary stone with a secondary infection. (See 'Cystitis' above and 'Pyelonephritis' above.)

Pyuria in the absence of fever most likely indicates relatively mild cystitis, urethritis, or cervicitis. A urine culture and testing for sexually transmitted infections and pregnancy are indicated. (See 'Cystitis' above and 'Urethritis' above.)

Hematuria with episodic severe abdominal or flank pain suggests urinary stones. Otherwise, hematuria, particularly in association with pyuria, may arise from cystitis. If cystitis is not confirmed, additional evaluation is necessary. (See "Evaluation of gross hematuria in children", section on 'Symptomatic hematuria'.)

Further evaluation in the well-appearing teenager should be undertaken only for persistent symptoms in the face of negative results from the laboratory.

SUMMARY AND RECOMMENDATIONS

Definition – Dysuria, defined as symptoms of pain or burning associated with urination, may be caused by a wide range of infectious and noninfectious causes, but it usually stems from one of several common disorders of childhood and adolescence (table 1). (See 'Causes' above.)

Evaluation – Most causes of dysuria in children can be identified based upon careful history, physical examination, and targeted ancillary testing:

History – Important historic questions for children with dysuria relate to the presence of symptoms outside of the genitourinary tract, fever, local exposures, trauma, and sexual activity. (See 'History' above.)

Physical examination – On physical examination, key findings include fever, evidence of systemic disease (eg, conjunctivitis, arthritis, or rash), genital discharge, or genital lesions. (See 'Physical examination' above.)

Testing

-All patients – Unless the cause of dysuria is obvious on physical examination (eg, balanoposthitis or virginal vaginal ulcers), a urine specimen for rapid dipstick urinalysis and urine culture, and microscopic urinalysis if indicated (if pyuria or hematuria is suggested by dipstick results), should be obtained in all patients. (See 'All patients' above.)

-Sexually transmitted infections (STIs) – Patients with urethral, vaginal, or cervical discharge; sexually active patients; or those with suggestive genital lesions warrant testing for STIs. The choice of specific testing depends upon whether the evaluation is due to suspicion of sexual abuse or relates to evaluation of an adolescent engaging in consensual sexual intercourse. (See 'Possible sexually transmitted infection' above.)

-Postmenarcheal females – Postmenarchal females warrant pregnancy testing in addition to urine tests and, if indicated based upon clinical findings, testing for sexually transmitted infection. Several of the conditions causing dysuria occur more frequently in sexually active and/or gravid women. In addition, pregnancy may influence the subsequent therapeutic choices. (See 'Postmenarchal females' above.)

Diagnostic approach – The algorithms provide a suggested diagnostic approach to the child or adolescent with dysuria, based upon age and sex (algorithm 1A-D). (See 'Diagnostic approach' above.)

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