Painful Urination in Women

A healthy woman under 65 y.o. (or older, if very healthy), not pregnant, has painful urination, urinating small amounts frequently.  Possible Diagnoses:

We do a rapid dipstick Urinalysis (UA) in office.

1.ย  Urinalysis positive for Leukocyte Esterase โ†’ We diagnose UTI,ย ย  ifโ€ฆ

  • No vaginal discharge (if present, may need โ€œcomplete UAโ€ that gets sent to lab)
  • Pain is internal, NOT felt on outside skin
  • Bloody urine strongly suggests UTI
  • No fever, nausea / vomiting (if so, we diagnose Kidney Infection, see #4 below)
  • Symptoms present less than a week (if longer, we diagnose Kidney Infection)
  • If STD risks, we also test the urine for Gonorrhea & Chlamydia

We give appropriate antibiotics for 3-5 days

If NOT BETTER in 3 days, we:

  • Repeat the UA.ย  If still positive, we do โ€œcomplete UAโ€ (lab examines with microscope)
  • We order a Culture & Sensitivity (C&S) (spaced a few days from antibiotics, if possible)
  • We may test urine for Gonorrhea & Chlamydiaย  โ†’ treat if positive
  • We clarify the pain.ย  If seems to be felt externally, on the skin, we perform a pelvic exam. See topic Vaginal Discharge
  • If risks for STD, and tests negative, test or just treat for Mycoplasma genitalium

2.  Urinalysis negative for Leukocyte Esterase  โ†’  Not a UTI

  • If urine very dilute (specific gravity <1.005)  โ†’  Repeat the test
  • We consider performing a pelvic exam, especially if the pain seems to be felt externally, on the skin

3.  Telephone Call from woman with new painful urination  โ†’  We Treat for a UTI if:

  • Pain is felt internally (in the bladder area above the pubic bone, not on the outside skin) AND ALSO there’s a frequent, urgent need to urinate small amounts
  • No fever, nausea / vomiting, or severe mid-back pain (if present, suggest Kidney Infection, needs tests in office)
  • Symptoms present less than a week (longer suggests Kidney Infection, needs tests in office)

4.  If fever, or nausea / vomiting, suggesting Kidney Infection, and UA is positive, we:

  • Obtain Culture & Sensitivity (C&S)
  • Treat immediately
  • Advise patient to go to an E.R. if getting worse, or if vomits up the medicine
  • If results of C&S show we gave wrong antibiotic:
    • If symptoms persist, change the antibiotic
    • If all better anyway, finish treatment as is

5.  Elderly, pregnant, or weak immune system due to other diseases:

  • Assume a Kidney Infection, manage as in #4 above
  • Hospitalize if any suggestion she feels fairly ill

See Diagram: Urinary System — Anatomy and also Diagram: Female Genital System — Anatomy

See Painful Urination in Women โ€” Full Text for more in-depth explanations and discussions.

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