Dysuria

Question 1

What are your differentials for DYSURIA?

Answer 1

trauma
sexual abuse
STD
Urolithiasis
UTI

Question 2

Trauma

Answer 2

TRAUMA
- Secondary to masturbation, sexual intercourse, sexual
abuse
CM
1. Localized erythema/superficial abrasion/ laceration
2. + bloody discharge

Question 3

Sexual abuse

Answer 3

CH 40: SEXUAL ABUSE
- Exploitative/ unwanted sexual behavior/action
towards children
CM
1. Behavioral changes – 1st indication
- Social withdrawal, acting out, inc clinginess/fearfulness
2. Dysuria/ anogenital pain – genital exam may be N,
rapid healing time. A child may report abuse after
wks/mos/yrs
3. Genital laceration/abrasion or bruising/ perianal
laceration
- A complete transection of the hymen to the base
between 4-8 o’clock is considered diagnostic of trauma
Dx
1. Abuse within 72h – forensic evidence “rape kit”
2. NAAT/ vaginal GS/CS – r/o gonorrhea, chlamydia
- In prepubertal child, (+)C/S for the ff is almost always
sexual abuse:
o NB – gonorrhea
o >1yo – trichomonas
o >3yo – chlamydia, syphilis, HIV
- Genital warts – low specificity
Mgt
1. Refer to social services
2. Psychologic counseling
3. Abx if with infection

Question 4

Sexually transmitted disease

Answer 4

CH 120: SEXUALLY TRANSMITTED INFECTIONS (STD)
Epid
- RF: traumatic sex, uncircumcised male, poverty,
adolescent, sexual abuse
CM
1. Urethritis – discharge, dysuria, pruritus, urgency,
frequency, burning pain
- Classic sx: mucoid/purulent discharge from urethral
meatus
- Secondary to Chlamydia, N.gonorrhea
2. Epididymitis – sec. to C.trachomatis, N.gonorrhea
- Unilateral scrotal swelling/tenderness, urethral
discharge
3. Vaginitis – vaginal discharge, pruritus, pain, swelling,
redness, dysuria
- Trichomonas: diffuse, malodorous yellow-green
discharge with irritation
- Candida: curdy discharge
4. Cervicitis – sec. to Chlamydia and N.gonorrhea
- Purulent/mucopurulent endocervical exudate via swab
- Sustained endocervical bleeding by gentle passage of
swab
- Irregular postcoital bleeding
5. Pelvic inflammatory disease (PID) – spectrum of
inflammatory disorder of upper genital tract +
endometritis + salphyngitis + tuboovarian abscess +
peritonitis
- Sec. to N.gonorrhea and C.trachomatis
- At least 1 of the ff:
o Cervical motion tenderness
o Uterine motion tenderness
o Adnexal motion tenderness
- Fever (T>38.3C), mucopurulent d/c, elev ESR/CRP

Question 5

Signs, symptoms and presumptive and definitive diagnosis of Genital ulcers

Answer 5

—–HERPES SIMPLEX VIRUS—–
ulcers: vesicles rupture to form shallow ulcers
painful? yes
number of lesions: usually multiple
inguinal LAD: 1st-time infections may cause constitutional symptoms and LAD
Clinical suspicion: Typical lesions: positive HSV-2 type specific serology test
Definitive diagnosis: detection of HSV by culture or PCR from ulcer scraping or aspiration of vesicle fluid

—–SYPHILIS—–
ulcers: ulcer with well-demarcated indurated borders and a clean base (chancre)
painful? NO (PAINLESS)
number of lesions: usually single
inguinal LAD: usually mild and minimally tender
Clinical suspicion: early syphilis: a typical chancre plus a reactive nontreponemal test (RPR, VDRL) and no history of syphilis or a 4-fold increase in quantitative nontreponemal test in a person with history of syphilis, positive treponemal EIA with reactive nontreponemal test (RPR, VDRL) and no prior history of syphilis treatment
Definitive diagnosis: detection of treponema pallidum from a chancre or LN aspirate on dark-field microscopy

—–CHANCROID—–
ulcers: unindurated and undermined borders and a purulent base
painful? yes
number of lesions: multiple
inguinal LAD: unilateral or bilateral painful adenopathy in >50%; inguinal bubo formation and rupture may occur
Clinical suspicion: exclusion of other causes of ulcers; in the presence of (a) typical ulcers and LAD; (b) typical Gram stain and a history of contact with contact with a high risk invidual (prostitute) or living in an endemic area
Definitive diagnosis: detection of Haemophilus ducreyi by culture

Question 6

Diagnostics

Answer 6

Dx:
1. NAAT – for C.trachomatis and N.gonorrhea
2. PCR – for HSV
3. Treponemal test, nontrep test – for syphilis

Question 7

Management

Answer 7

Mgt
1. Chlamydia – Azithromycin 1g SD, Doxycycline 100mg
BIDx7d
2. N.gonorrhea – cotri 250mg IM SD
3. Treponema – Ben Pen G 2.4 MU IM SD
4. H.ducreyi – Azith 1g SD
5. Trichomonas – Metronidazole 2g SD