Operational Medicine Medical Education and Training

Problems with Urination

Painful Urination

Painful urination is one of the classical symptoms of bladder infection, along with frequency, urgency and sometimes hematuria. Such an infection can be confirmed by a positive urine culture (>100,000 colonies/ml), or strongly supported by a positive "dipstick" (for bacteria or leukocyte esterase) and a clinically tender bladder (normally the bladder is not the least bit tender).

Bladder infections are treated with broad-spectrum oral antibiotics (Gantrisin, Bactrim DS, ampicillin, Keflex, Macrodantin, etc.). Immediate relief of symptoms will occur with Pyridium 200 mg PO TID for 2 days.

In operational settings, cystitis is often treated on the basis of symptoms and without confirming with cultures or dipsticks. A woman complaining of urgency, frequency and dysuria very likely has cystitis. With only limited resources, the main goal is to quickly treat any possible UTI's, return the patient to full duty, and avoid the much more serious problem of pyelonephritis.

Should symptoms persists despite a course of broad spectrum antibiotics, a careful examination should be made and further testing is appropriate.

Bladder infections among women in operational settings are common:

  • Because of the difficulty in urinating (undressing in field environments, limited sanitation, etc.), many women will intentionally dehydrate, simply to avoid having to urinate. When successful, this dehydration leads to urinary stasis, predisposing them toward bladder infection.

  • To further avoid urinating in field settings, many women will try to hold their urine as long as possible. This, too, leads to urinary stasis and predisposes towards UTIs.

Gonorrheal Urethritis

Urinary frequency and burning in a patient with a history of exposure to gonorrhea suggests gonorrheal urethritis.

The urethra is normally not tender. Should the urethra be tender, particularly if combined with a purulent discharge, urethritis should be suspected.

Paraurethral abscesses (infected Skene's glands), and eversion of urethral epithelium are often found.

This diagnosis is confirmed by gram-negative intracellular diplococci on Gram Stain or positive culture on Thayer-Martin media (chocolate agar).

 

Urine Cup for Urinalysis

Problems with Urination

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Kidney Stone in the left mid-ureter

Should the operational environment disallow this precise workup, treatment is often provided on the basis of clinical suspicion and symptoms, or after a failed course of broad-spectrum antibiotics provided for a suspected UTI.

Treatment is:

  • Cefixime 400 mg orally in a single dose, OR

  • Ceftriaxone 125 mg IM in a single dose, OR

  • Ciprofloxacin 500 mg orally in a single dose, OR

  • Ofloxacin 400 mg orally in a single dose,

PLUS

  • Azithromycin 1 g orally in a single dose, OR

  • Doxycycline 100 mg orally twice a day for 7 days.

Sexual partners also need to be treated. Skene's abscesses should have I&D followed by daily packing with iodoform gauze for 2-4 days.

Non-gonorrheal Urethritis

These patients complain of symptoms suggesting cystitis (frequency, burning, and urgency), but the urine culture is negative and they do not improve on conventional antibiotic therapy.

A purulent discharge from the urethra may or may not be present, but the urethra is tender to touch.

Cultures from the urethra may be positive for chlamydia, Mycoplasma or Ureaplasma, but will be negative for gonorrhea.

Treatment may be started on the basis of clinical suspicion alone.

Treatment is:

  • Azithromycin 1 g orally in a single dose, OR

  • Doxycycline 100 mg orally twice a day for 7 days, OR

  • Erythromycin base 500 mg orally four times a day for 7 days, OR

  • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, OR

  • Ofloxacin 300 mg twice a day for 7 days, OR

  • Erythromycin base 250 mg orally four times a day for 14 days, OR

  • Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days.

Herpes

Painful urination in which the vulva burns when the urine drips across it can the primary symptom of herpes. In this case, inspecting the vulva will reveal multiple, small (1-2 mm), tender ulcers filled with grayish material and perhaps some blisters that have not yet ruptured. Sometimes, the pain is so intense that urination becomes complete misery. A Foley catheter until the symptoms resolve is merciful.

Preferred treatment (CDC) for an initial outbreak is:

  • Acyclovir 400 mg orally three times a day for 7-10 days, OR

  • Acyclovir 200 mg orally five times a day for 7-10 days, OR

  • Famciclovir 250 mg orally three times a day for 7-10 days, OR

  • Valacyclovir 1 g orally twice a day for 7-10 days.

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This website is dedicated to the development and dissemination of medical information that may be useful to those who practice Operational Medicine. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

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Problems with Urination

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Operational Medicine

This website is dedicated to the development and dissemination of medical information that may be useful to those who practice Operational Medicine. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

© 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved

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