DYSURIA- Burning Micturition

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Burning Micturition — Find the Cause, Test & Treat

Burning micturition is one of the commonest complaints in women. This sheet gives how to tell cystitis from vaginitis and infection of the urethra, which tests to send, which antibiotics to choose, and when to worry.

🎯 AT A GLANCE — BURNING MICTURITION

Burning micturition (dysuria) means pain or burning on passing urine; the commonest cause is acute cystitis

E. coli causes about 86% of uncomplicated cystitis; others are Staph. saprophyticus, Klebsiella and Proteus

The history matters most: one classic symptom raises the chance of UTI from about 5% to about 50%

New dysuria and frequency with no vaginal discharge or irritation has about 90% positive predictive value for UTI

Vaginal discharge or irritation points to vaginitis or cervicitis rather than UTI

A midstream dipstick for nitrite and leucocyte esterase is enough for a typical case

Nitrofurantoin for 5 days is first-line in most guidelines; avoid fluoroquinolones as first choice

Do not assume every burning is a UTI: ask about discharge, examine, and send a culture when there are red flags or when the symptoms come back.

🚨 DO NOT JUST GIVE A SHORT COURSE IF…

She has fever, chills, loin pain, vomiting, a fast pulse or looks ill — suspect pyelonephritis; culture and treat as complicated

She is pregnant — send a culture; treat per obstetric protocol

Symptoms lasted over 7 days, or she has diabetes, is over 65, or has had a UTI in the last 4 weeks — complicated cystitis

Symptoms do not settle, or return within 2 to 4 weeks — urine culture

There is discharge, a new partner, or ulcers — examine and swab for vaginitis and sexually transmitted infection

Haematuria persists, or there is colic — think of stones or other disease and image the urinary tract (from memory)

She cannot take tablets — admit for IV treatment

STEP 1 · FIND THE CAUSE — bladder, vagina, urethra or something else?

🔍 CAUSES OF BURNING MICTURITION

Cause	Clues	Test
Acute cystitis	Dysuria, frequency of small volumes, urgency; sometimes haematuria; no discharge	Dipstick: nitrite, leucocyte esterase
Pyelonephritis	Fever, loin pain or tenderness, tachycardia, ill	Culture; consider ultrasound or CT if no response
Vaginitis: candida, bacterial vaginosis, trichomonas	Discharge, itch, irritation; burning when urine touches the skin	Speculum, vaginal pH, microscopy or swab
Urethritis, cervicitis (chlamydia, gonorrhoea)	New partner or partner with symptoms; discharge; lower abdominal pain (from memory)	NAAT or swabs from the endocervix
Genital herpes	Painful vulval ulcers or blisters; severe burning (from memory)	Swab for PCR (from memory)
Atrophic vaginitis	After the menopause; dryness, discomfort (from memory)	Examination
Stone, bladder pain syndrome, irritants, tuberculosis	Colic or haematuria; pain with a clean culture; soaps, spermicide or scented products; sterile pyuria (from memory)	Culture, imaging, further tests as clinically indicated

🩺 HISTORY, EXAMINATION AND TESTS

Ask about onset, frequency, urgency, haematuria, fever, loin pain, discharge, itch, a new partner, spermicide or diaphragm use, diabetes, pregnancy, and recent antibiotics

Examine the temperature, suprapubic and loin tenderness, and look at the vulva; do a speculum if there is discharge

Collect a midstream clean-catch specimen; cleansing first makes no significant difference

Use a dipstick for nitrite and leucocyte esterase; both are the most accurate

Send a culture for suspected pyelonephritis, symptoms that persist or recur within 2 to 4 weeks, atypical symptoms, pregnancy, complicated cystitis, or relapse

A count of 10³ CFU/mL or more is diagnostic; over 10² CFU/mL with typical symptoms is positive

Do not send routine tests after treatment when she is well

STEP 2 · TREAT — by the cause, and by local resistance

🧭 FROM THE SYMPTOM TO THE TREATMENT

💊 ANTIBIOTICS FOR CYSTITIS

Tier	Drug	Notes
First line	Nitrofurantoin 100 mg twice daily for 5 days	Avoid if early pyelonephritis is suspected; take with food
First line	Fosfomycin 3 g single dose	May be less effective; availability varies
If local resistance is 20% or less	Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days	Avoid if used in the last 3 months
Alternative	Cephalexin 250 mg four times daily for 5 days	Beta-lactams are generally less effective than first-line drugs
Second tier	Ciprofloxacin 250 mg twice daily for 3 days	Reserve for allergy or serious infection; avoid fluoroquinolones first-line because of resistance
Complicated cystitis	Culture first; ciprofloxacin 500 mg twice daily or cefpodoxime 200 mg twice daily for 10 to 14 days	Choose by the culture; resistance to both drugs is common in India (from memory)
Pregnancy	Culture; treat according to the obstetric protocol	Asymptomatic bacteriuria in pregnancy: treat if more than 100,000 CFU/mL
Cannot take tablets, or pyelonephritis	Admit; IV ceftriaxone 1 g daily is one option	Adjust to the culture and local guidance

Other measures: a urinary analgesic for the first 1 to 2 days, plenty of fluids and rest. (from memory) Cranberry products have no proven benefit once symptoms are present. Review if she is not better in 2 to 3 days.

🧪 WHEN IT IS NOT A UTI

Cause	Treatment
Candidal vaginitis	Antifungal, vaginal or oral, as in your local protocol (from memory)
Bacterial vaginosis, trichomonas	Metronidazole; treat the partner for trichomonas (from memory)
Chlamydia, gonorrhoea	Treat per the current STI protocol, test and treat the partner, advise no sex until treated, offer HIV and syphilis testing (from memory)
Herpes	Antiviral and pain relief (from memory)
Atrophic vaginitis	Vaginal oestrogen (from memory)

STEP 3 · COUNSEL AND PREVENT — what she needs to hear

🗣️ WHAT TO TELL HER

Finish the antibiotic even when she feels better, and come back if there is no improvement in 2 to 3 days

Drink enough water; pass urine after sex; wipe from front to back; avoid scented soaps and washes, and spermicide or a diaphragm if she gets repeated UTIs (from memory)

Return at once for fever, loin pain, vomiting or blood in the urine

If she has repeated UTIs: send a culture each time, consider low-dose prophylaxis or post-coital treatment, and in post-menopausal women vaginal oestrogen (from memory)

Treat her partner when a sexually transmitted infection is found

⚠️ COMMON PITFALLS

Treating every burning as a UTI without asking about discharge

Using a fluoroquinolone first, or repeating the drug she had in the last 3 months

No culture in pregnancy, relapse or suspected pyelonephritis

Giving nitrofurantoin when pyelonephritis is likely

Routine culture after treatment in a well woman

Treating asymptomatic bacteriuria in a non-pregnant woman (from memory)

Missing a sexually transmitted infection, herpes or genitourinary tuberculosis (from memory)

Forgetting diabetes (from memory)

Memory Aid

BURNS

Five steps for burning micturition.

B

Bladder or vagina? — ask about discharge and examine

U

Urine dipstick — nitrite and leucocyte esterase; culture when indicated

R

Red flags — fever, loin pain, pregnancy, diabetes, relapse

N

Nitrofurantoin first — chosen by local resistance

S

Swab and stay alert — STIs, herpes, recurrence

Remember: the cause may be the bladder, the vagina or the urethra: look before you prescribe.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the AAFP article “Diagnosis and Treatment of Acute Uncomplicated Cystitis” (2011): causes, symptom probabilities, dipstick, culture indications, first-line and second-line drugs; and WikEM “Acute cystitis” (edited 2023): diagnosis, uncomplicated and complicated regimens, urethritis, pregnancy, red flags and resistance. Both are from the United States and are not Indian guidelines; E. coli resistance to fluoroquinolones, cephalosporins and cotrimoxazole is high in India, so use your local antibiogram and national antimicrobial guidance. Items marked “from memory” (other causes, STI treatment, symptomatic relief, recurrence, counselling) were not checked. Doses are from these sources: confirm against your own formulary.