Physiuria or initial painful urination

Specialty: Nephrology and urology.

• initial dysuria
• urinary burning at the beginning of urination

Why it occurs

• Acute anterior urethritis (inflammation of the distal portion of the urethra due to pathogens such as Neisseria gonorrhoeae, Chlamydia trachomatis or Trichomonas vaginalis, where the passage of the first stream of acidic urine irritates the nociceptors of the denuded mucosa)
• Previous urethral stenosis (the effort of the bladder muscles to propel urine through a narrowed anterior canal causes painful overdistension of the pre-stenotic mucosa)
• External urethral caruncle (benign hypervascularized lesion in the extremely sensitive female urethral meatus that hurts intensely upon contact with the initial stream of urine)
• Iatrogenic distal urethral trauma (due to insertion of catheters, passage of urological instruments or recent endoscopy)

Initial workup

Smear from the urethral meatus for Gram stain and culture of common bacteria, together with nucleic acid amplification (PCR) test for Chlamydia, Gonococcus and Mycoplasma; urinalysis with urine culture of the first fraction of urine; Transperineal ultrasound or urethrosonography in suspected urethral stricture.

Standard management

• Ceftriaxone — 500 mg intramuscularly in a single dose) associated with Azithromycin (1 g orally in a single dose for the empirical treatment of acute anterior urethritis
• Phenazopyridine — 100-200 mg every 8 hours orally for a maximum of 2 days to relieve urethral burning at the beginning of urination
• Ibuprofen (400 mg every 8 hours orally with meals to relieve acute inflammatory pain).