Dysuria in Primary Care for New Nurse Practitioners
Watch
Show notes:
As a new grad, I'd latch on to a symptom and top differential diagnosis, spending my whole visit chasing that idea instead of stepping back to consider the other possibilities.
Super easy to do when it comes to dysuria.
Likely it's a UTI, right? But asking the right history questions can help you save time in the visit and more accurately diagnose patients.
Diagnosing and Managing Dysuria in Primary Care
You'll learn:
The top differentials for dysuria in women, including a few sneaky diagnoses
What history questions to ask and red flags not to miss
First line treatments, and deciding who to test & treat
Dysuria Diagnosis & Management Cheat Sheet
This episode comes with a cheat sheet to keep at your desk for quick reference! Get your cheat sheet here.
-
0:00
dysuria and women is a super super
0:02
common chief complaint in primary care
0:04
so in this video I won't be talking
0:06
about the top differential diagnoses
0:08
including some sneaky ones that you
0:09
might not remember might not think of I
0:12
also am going to be talking about the
0:13
important history questions when it
0:15
comes to dysuria specifically to not
0:17
forget to ask those and then I'm also
0:19
going to be talking about treatment to
0:21
treat to not treat to send out cultures
0:23
tuna which antibiotics to use that whole
0:25
thing so if you're new here and list for
0:27
from real-world Enki and you're watching
0:29
MV practice made simple the weekly
0:31
videos to help save you time frustration
0:33
and help you learn faster so you can
0:34
take the best care of your patients so
0:36
two important notes three important
0:38
notes one I'm talking about dis area and
0:40
women number two is that I have a cheat
0:42
sheet down below this video with all
0:44
that kind of notes from this whole talk
0:46
so definitely
0:47
pause don't want that and follow along
0:49
print it out keep it at your desk and
0:50
then three the lab interpretation crash
0:52
course for new nurse practitioners is
0:54
coming out this month as you can tell
0:56
I'm super excited I'm obsessed with it
0:58
it's all the labs in primary care and
0:59
it's especially relevant for this topic
1:01
because I go really deep into your
1:03
analysis and feeling super confident
1:05
with ordering them and interpreting them
1:07
so if you want to join us for that go
1:09
ahead over to real world in pecan sauce
1:11
labs and you can get on the interest
1:12
lesson and you'll get some emails when
1:14
it opens up for enrollment so jumping
1:16
right in the top differential diagnosis
1:18
for this area in women again because men
1:21
is a different story but for women the
1:23
top thing that you think about probably
1:24
is a urinary tract infection which most
1:27
likely it is it's pretty pretty common
1:28
in primary care the other thing too the
1:30
kind of red flags do not forget about
1:32
though and especially if you're thinking
1:34
that it's a UTI
1:34
you always want to make sure it's not
1:36
pyelonephritis it hasn't migrated all
1:39
the way up to the kidneys right a couple
1:40
of the red flags that you they're a
1:43
little bit sneaky telev it inflammatory
1:44
disease and retinitis and so most of the
1:47
time when patients come in the complaint
1:49
of burning when they pee and it might be
1:52
in the front of your mind that to go
1:53
down the urinary path but it's very
1:54
easily a vaginal source and so you want
1:57
to think about those types of history
1:59
questions to ask and pelvic inflammatory
2:01
disease less likely to present with
2:03
dysuria but just on the back of your
2:05
mind to be thinking about it making sure
2:06
that you're asking those types of
2:07
questions
2:08
so to two to three oh they're kind of
2:11
sneaky
2:12
one is dehydration right and so I always
2:14
ask about that in my history questions
2:16
especially for your analysis is coming
2:18
up as nothing nothing special and it
2:20
doesn't really seem classic and it's
2:22
just kind of you in there
2:23
I always ask about hydration status
2:25
because sometimes people aren't drinking
2:26
anything all day and then they had this
2:27
like irritation when they pee which
2:30
makes sense because it's very
2:31
concentrated on two other ones one is
2:33
called interstitial cystitis if you
2:35
haven't heard of that one before it's a
2:37
diagnosis of exclusion and it basically
2:38
just means the bladder gets really
2:41
irritated and it gets painful and those
2:43
are the types of people where they have
2:44
recurrent symptoms that aren't going
2:45
away that aren't presenting as an
2:47
infectious source again a diagnosis of
2:49
exclusion and you kind of are targeting
2:51
what is causing the symptoms like acidic
2:53
foods and coffee tea and things like
2:56
that and trying to eliminate them
2:57
I don't want to get too much into that
2:59
but just knowing that that's an option
3:00
and then the last kind of sneaky one is
3:02
atrophic vaginitis and so especially in
3:05
geriatric adults when you have somebody
3:07
who's gone through menopause it's been a
3:09
couple years they have atrophic
3:10
vaginitis the urethra can also get
3:12
irritated and so that is most common
3:15
when I see my geriatric patients or they
3:17
have recurrent dysuria and everything is
3:19
coming up normal when when you do a
3:21
workup and it doesn't seem like it's an
3:22
infectious source or anything like that
3:23
and when you treat the atrophic
3:25
vaginitis usually usually with topical
3:28
hormone treatment it tends to improve
3:31
the disturbia symptoms as well so
3:32
important history questions I always
3:34
take the same approach when it comes to
3:35
my acute visits and I recommend that you
3:38
do the same just pick a system that
3:40
works for you so I use old card so onset
3:42
location duration and etc etc and then
3:44
asking all of the review of systems
3:46
questions that are relevant to that
3:47
system so genitourinary vaginal symptoms
3:51
abdominal symptoms things like that what
3:53
are the things that are around there and
3:54
if you don't know what history questions
3:55
to ask just ask all of them and it's
3:57
totally fine no worries but specific
4:00
ones that I wanted to mention that I'm
4:01
looking down for they have my notes here
4:02
and I've mentioned this a couple of
4:04
different times but as you progress in
4:07
your practice and you have those
4:08
differentials in the front of your mind
4:10
as you come into a visit you can work
4:12
your history backwards by keeping those
4:14
in the front of your mind right so if
4:16
you're thinking it's a UTI or
4:17
pyelonephritis
4:18
what are the things that would present
4:19
with that
4:20
so abdominal pain fever chills vomiting
4:23
new back pain hematuria to syria
4:26
frequency things like that asking all of
4:28
those questions versus do they have a
4:30
vaginal source do they have discharge
4:32
odor dyspareunia do they have itching
4:34
and then the two other really important
4:36
ones for dis Tyria is how many have they
4:38
had in the last year or have they had
4:40
this before always ask if they had this
4:42
before I recommend that because when I
4:43
haven't asked that and I've gone through
4:45
this whole 20 minute questioning
4:47
answering this whole path and they could
4:50
have just if I had only asked that they
4:51
could have told me the whole thing and I
4:53
wouldn't have to spend all that time to
4:54
go down that path asking all those
4:55
questions they would have just
4:56
volunteered it so always ask if they've
4:58
to have this before but how many they've
4:59
had because if it's a recurrent UTI
5:01
that's very different than if it's the
5:03
first time they've ever had one or the
5:05
firt last one that they had was a year
5:06
ago because if they have recurrent UTIs
5:08
they might need a different treatment
5:09
not only today but also in the future of
5:12
what what are we gonna do for them the
5:14
other one to really ask and I always ask
5:16
this but it's especially relevant for
5:18
dis area what have they tried what have
5:19
they taken for it because if they take
5:21
an over-the-counter dysuria supplement
5:23
there's like cranberry or other things
5:26
that I want to use brand names but
5:27
people don't tend to use those
5:29
over-the-counter and that can
5:30
contaminate or alter the results of your
5:32
urinalysis in your urine death and so
5:35
making sure that you always are asking
5:37
that so treatment so does it seem like
5:39
they have a really classic UTI right
5:41
they have frequency urgency no hematuria
5:44
it started yesterday they have no
5:45
vaginal symptoms they've had this before
5:47
it feels the exact same like okay they
5:49
probably have a UTI so if you're
5:51
deciding about treatment you can do a
5:53
couple of things so one is if you're in
5:55
the clinic you can do it your analysis
5:58
and a dipstick or urine dipstick at
5:59
least to start and considering sending
6:01
out of here analysis again I go into
6:03
this in the live interpretation crash
6:04
course like the full thing of how to
6:05
interpret all of those but if it seems
6:07
like they have a UTI based on the dip
6:09
you can complete reit them versus
6:11
sending over a culture and then treating
6:13
them based off the culture the things to
6:15
think about when it comes to that are do
6:16
they have any comorbidities do they have
6:19
any reasons why you would consider
6:20
reasons to think that they might have
6:22
resistance like do they live in a
6:24
skilled nursing facility where they
6:25
recently hospitalized if they recently
6:26
take antibiotics do they have other
6:29
medical comorbidities happening versus
6:31
if
6:32
a healthy 20 year old woman who comes in
6:34
and just has this right and so for those
6:36
patients you can empirically treat them
6:38
with the first-line agents without
6:39
sending out a culture again this is also
6:42
practiced preference right and if you're
6:45
a brand new grad you're probably gonna
6:46
want to text everybody and that's
6:47
totally normal that's totally fine
6:49
however if there is somebody who has
6:51
risk factors for resistance you always
6:53
want to send out that urine culture to
6:55
make sure that you're treating them with
6:57
the right antibiotic so a first-line
6:59
treatment there's there's kind of two
7:00
main options that I typically see in
7:02
primary care one is nitrile for Rancho
7:04
in and I hopefully I'm saying that right
7:06
I have a hard time pronouncing things
7:07
that is specific to cystitis though that
7:11
is not to be used for renal infections
7:13
and so if you feel like it's a simple
7:15
Sustaita it's just contained to the
7:16
bladder you can use nature for enjoyin
7:18
again it's on the cheat sheet all that
7:19
stuff hope I'm saying that right and
7:21
then the other one is my method prim
7:23
sulfamethoxazole which has a brand name
7:27
that's easier to say what I'm trying out
7:28
these brand names also on the cheat
7:30
sheet and the metro for when twin is
7:33
twice a day for five days and then the
7:35
other one is recipe for three days if
7:36
it's an uncomplicated first presentation
7:39
don't have any risk factors for
7:40
resistance three days and that's it and
7:42
depending on your comfort level and
7:44
their risk factors do you want to send
7:47
it out for culture and so if you treat
7:49
somebody they're not getting better then
7:51
you definitely do want to have them come
7:52
in giving urine sample and then send it
7:54
over culture and in terms of
7:56
telemedicine there's different levels of
7:58
comfort there as well and so for for me
8:01
personally as a clinician if I have
8:02
somebody with zero risk factors has
8:03
never had a UTI before it doesn't it
8:06
sounds a very classic UTI I'm
8:08
comfortable treating them over the phone
8:09
whereas if they have any risk factors
8:12
they're older adults things like that
8:14
and I might be more likely to have them
8:16
in some way drop off a urine sample so
8:19
that we can test it and then possibly
8:20
culture it if we need to and then I
8:22
always wrap up my mind dysuria visits
8:24
especially if I've diagnosed a UTI by
8:27
discussing urination before and after
8:30
intercourse
8:31
especially after but before if they're
8:33
getting these more often I'm talking
8:35
about panty liner use and it not
8:37
necessarily associated with UTI as much
8:39
as like a vaginitis but daily you know
8:41
daily panty liner use can be irritating
8:44
in that
8:44
general area always wiping from front to
8:46
back you might think that that's really
8:47
simple and everybody knows that but they
8:48
really don't because no more then when I
8:51
was a brand-new bread and I started to
8:52
say that more and more I felt really
8:53
stupid because obviously people know
8:55
that but they don't they really don't
8:57
and it's like revolutionary for some
8:58
people so definitely make sure that
8:59
you're talking about that so let me know
9:02
if you have any questions that's all I
9:03
have to say for today don't forget to
9:05
head over to real world in pecan slash
9:07
labs if you want to check out the lab
9:08
interpretation crash course for new
9:09
nurse practitioners it's really the best
9:11
and then also you can grab your chichi
9:12
dumble in this video thank you so much
9:14
for watching hang in there and I'll see
9:15
you soon0:00
dysuria and women is a super super
0:02
common chief complaint in primary care
0:04
so in this video I won't be talking
0:06
about the top differential diagnoses
0:08
including some sneaky ones that you
0:09
might not remember might not think of I
0:12
also am going to be talking about the
0:13
important history questions when it
0:15
comes to dysuria specifically to not
0:17
forget to ask those and then I'm also
0:19
going to be talking about treatment to
0:21
treat to not treat to send out cultures
0:23
tuna which antibiotics to use that whole
0:25
thing so if you're new here and list for
0:27
from real-world Enki and you're watching
0:29
MV practice made simple the weekly
0:31
videos to help save you time frustration
0:33
and help you learn faster so you can
0:34
take the best care of your patients so
0:36
two important notes three important
0:38
notes one I'm talking about dis area and
0:40
women number two is that I have a cheat
0:42
sheet down below this video with all
0:44
that kind of notes from this whole talk
0:46
so definitely
0:47
pause don't want that and follow along
0:49
print it out keep it at your desk and
0:50
then three the lab interpretation crash
0:52
course for new nurse practitioners is
0:54
coming out this month as you can tell
0:56
I'm super excited I'm obsessed with it
0:58
it's all the labs in primary care and
0:59
it's especially relevant for this topic
1:01
because I go really deep into your
1:03
analysis and feeling super confident
1:05
with ordering them and interpreting them
1:07
so if you want to join us for that go
1:09
ahead over to real world in pecan sauce
1:11
labs and you can get on the interest
1:12
lesson and you'll get some emails when
1:14
it opens up for enrollment so jumping
1:16
right in the top differential diagnosis
1:18
for this area in women again because men
1:21
is a different story but for women the
1:23
top thing that you think about probably
1:24
is a urinary tract infection which most
1:27
likely it is it's pretty pretty common
1:28
in primary care the other thing too the
1:30
kind of red flags do not forget about
1:32
though and especially if you're thinking
1:34
that it's a UTI
1:34
you always want to make sure it's not
1:36
pyelonephritis it hasn't migrated all
1:39
the way up to the kidneys right a couple
1:40
of the red flags that you they're a
1:43
little bit sneaky telev it inflammatory
1:44
disease and retinitis and so most of the
1:47
time when patients come in the complaint
1:49
of burning when they pee and it might be
1:52
in the front of your mind that to go
1:53
down the urinary path but it's very
1:54
easily a vaginal source and so you want
1:57
to think about those types of history
1:59
questions to ask and pelvic inflammatory
2:01
disease less likely to present with
2:03
dysuria but just on the back of your
2:05
mind to be thinking about it making sure
2:06
that you're asking those types of
2:07
questions
2:08
so to two to three oh they're kind of
2:11
sneaky
2:12
one is dehydration right and so I always
2:14
ask about that in my history questions
2:16
especially for your analysis is coming
2:18
up as nothing nothing special and it
2:20
doesn't really seem classic and it's
2:22
just kind of you in there
2:23
I always ask about hydration status
2:25
because sometimes people aren't drinking
2:26
anything all day and then they had this
2:27
like irritation when they pee which
2:30
makes sense because it's very
2:31
concentrated on two other ones one is
2:33
called interstitial cystitis if you
2:35
haven't heard of that one before it's a
2:37
diagnosis of exclusion and it basically
2:38
just means the bladder gets really
2:41
irritated and it gets painful and those
2:43
are the types of people where they have
2:44
recurrent symptoms that aren't going
2:45
away that aren't presenting as an
2:47
infectious source again a diagnosis of
2:49
exclusion and you kind of are targeting
2:51
what is causing the symptoms like acidic
2:53
foods and coffee tea and things like
2:56
that and trying to eliminate them
2:57
I don't want to get too much into that
2:59
but just knowing that that's an option
3:00
and then the last kind of sneaky one is
3:02
atrophic vaginitis and so especially in
3:05
geriatric adults when you have somebody
3:07
who's gone through menopause it's been a
3:09
couple years they have atrophic
3:10
vaginitis the urethra can also get
3:12
irritated and so that is most common
3:15
when I see my geriatric patients or they
3:17
have recurrent dysuria and everything is
3:19
coming up normal when when you do a
3:21
workup and it doesn't seem like it's an
3:22
infectious source or anything like that
3:23
and when you treat the atrophic
3:25
vaginitis usually usually with topical
3:28
hormone treatment it tends to improve
3:31
the disturbia symptoms as well so
3:32
important history questions I always
3:34
take the same approach when it comes to
3:35
my acute visits and I recommend that you
3:38
do the same just pick a system that
3:40
works for you so I use old card so onset
3:42
location duration and etc etc and then
3:44
asking all of the review of systems
3:46
questions that are relevant to that
3:47
system so genitourinary vaginal symptoms
3:51
abdominal symptoms things like that what
3:53
are the things that are around there and
3:54
if you don't know what history questions
3:55
to ask just ask all of them and it's
3:57
totally fine no worries but specific
4:00
ones that I wanted to mention that I'm
4:01
looking down for they have my notes here
4:02
and I've mentioned this a couple of
4:04
different times but as you progress in
4:07
your practice and you have those
4:08
differentials in the front of your mind
4:10
as you come into a visit you can work
4:12
your history backwards by keeping those
4:14
in the front of your mind right so if
4:16
you're thinking it's a UTI or
4:17
pyelonephritis
4:18
what are the things that would present
4:19
with that
4:20
so abdominal pain fever chills vomiting
4:23
new back pain hematuria to syria
4:26
frequency things like that asking all of
4:28
those questions versus do they have a
4:30
vaginal source do they have discharge
4:32
odor dyspareunia do they have itching
4:34
and then the two other really important
4:36
ones for dis Tyria is how many have they
4:38
had in the last year or have they had
4:40
this before always ask if they had this
4:42
before I recommend that because when I
4:43
haven't asked that and I've gone through
4:45
this whole 20 minute questioning
4:47
answering this whole path and they could
4:50
have just if I had only asked that they
4:51
could have told me the whole thing and I
4:53
wouldn't have to spend all that time to
4:54
go down that path asking all those
4:55
questions they would have just
4:56
volunteered it so always ask if they've
4:58
to have this before but how many they've
4:59
had because if it's a recurrent UTI
5:01
that's very different than if it's the
5:03
first time they've ever had one or the
5:05
firt last one that they had was a year
5:06
ago because if they have recurrent UTIs
5:08
they might need a different treatment
5:09
not only today but also in the future of
5:12
what what are we gonna do for them the
5:14
other one to really ask and I always ask
5:16
this but it's especially relevant for
5:18
dis area what have they tried what have
5:19
they taken for it because if they take
5:21
an over-the-counter dysuria supplement
5:23
there's like cranberry or other things
5:26
that I want to use brand names but
5:27
people don't tend to use those
5:29
over-the-counter and that can
5:30
contaminate or alter the results of your
5:32
urinalysis in your urine death and so
5:35
making sure that you always are asking
5:37
that so treatment so does it seem like
5:39
they have a really classic UTI right
5:41
they have frequency urgency no hematuria
5:44
it started yesterday they have no
5:45
vaginal symptoms they've had this before
5:47
it feels the exact same like okay they
5:49
probably have a UTI so if you're
5:51
deciding about treatment you can do a
5:53
couple of things so one is if you're in
5:55
the clinic you can do it your analysis
5:58
and a dipstick or urine dipstick at
5:59
least to start and considering sending
6:01
out of here analysis again I go into
6:03
this in the live interpretation crash
6:04
course like the full thing of how to
6:05
interpret all of those but if it seems
6:07
like they have a UTI based on the dip
6:09
you can complete reit them versus
6:11
sending over a culture and then treating
6:13
them based off the culture the things to
6:15
think about when it comes to that are do
6:16
they have any comorbidities do they have
6:19
any reasons why you would consider
6:20
reasons to think that they might have
6:22
resistance like do they live in a
6:24
skilled nursing facility where they
6:25
recently hospitalized if they recently
6:26
take antibiotics do they have other
6:29
medical comorbidities happening versus
6:31
if
6:32
a healthy 20 year old woman who comes in
6:34
and just has this right and so for those
6:36
patients you can empirically treat them
6:38
with the first-line agents without
6:39
sending out a culture again this is also
6:42
practiced preference right and if you're
6:45
a brand new grad you're probably gonna
6:46
want to text everybody and that's
6:47
totally normal that's totally fine
6:49
however if there is somebody who has
6:51
risk factors for resistance you always
6:53
want to send out that urine culture to
6:55
make sure that you're treating them with
6:57
the right antibiotic so a first-line
6:59
treatment there's there's kind of two
7:00
main options that I typically see in
7:02
primary care one is nitrile for Rancho
7:04
in and I hopefully I'm saying that right
7:06
I have a hard time pronouncing things
7:07
that is specific to cystitis though that
7:11
is not to be used for renal infections
7:13
and so if you feel like it's a simple
7:15
Sustaita it's just contained to the
7:16
bladder you can use nature for enjoyin
7:18
again it's on the cheat sheet all that
7:19
stuff hope I'm saying that right and
7:21
then the other one is my method prim
7:23
sulfamethoxazole which has a brand name
7:27
that's easier to say what I'm trying out
7:28
these brand names also on the cheat
7:30
sheet and the metro for when twin is
7:33
twice a day for five days and then the
7:35
other one is recipe for three days if
7:36
it's an uncomplicated first presentation
7:39
don't have any risk factors for
7:40
resistance three days and that's it and
7:42
depending on your comfort level and
7:44
their risk factors do you want to send
7:47
it out for culture and so if you treat
7:49
somebody they're not getting better then
7:51
you definitely do want to have them come
7:52
in giving urine sample and then send it
7:54
over culture and in terms of
7:56
telemedicine there's different levels of
7:58
comfort there as well and so for for me
8:01
personally as a clinician if I have
8:02
somebody with zero risk factors has
8:03
never had a UTI before it doesn't it
8:06
sounds a very classic UTI I'm
8:08
comfortable treating them over the phone
8:09
whereas if they have any risk factors
8:12
they're older adults things like that
8:14
and I might be more likely to have them
8:16
in some way drop off a urine sample so
8:19
that we can test it and then possibly
8:20
culture it if we need to and then I
8:22
always wrap up my mind dysuria visits
8:24
especially if I've diagnosed a UTI by
8:27
discussing urination before and after
8:30
intercourse
8:31
especially after but before if they're
8:33
getting these more often I'm talking
8:35
about panty liner use and it not
8:37
necessarily associated with UTI as much
8:39
as like a vaginitis but daily you know
8:41
daily panty liner use can be irritating
8:44
in that
8:44
general area always wiping from front to
8:46
back you might think that that's really
8:47
simple and everybody knows that but they
8:48
really don't because no more then when I
8:51
was a brand-new bread and I started to
8:52
say that more and more I felt really
8:53
stupid because obviously people know
8:55
that but they don't they really don't
8:57
and it's like revolutionary for some
8:58
people so definitely make sure that
8:59
you're talking about that so let me know
9:02
if you have any questions that's all I
9:03
have to say for today don't forget to
9:05
head over to real world in pecan slash
9:07
labs if you want to check out the lab
9:08
interpretation crash course for new
9:09
nurse practitioners it's really the best
9:11
and then also you can grab your chichi
9:12
dumble in this video thank you so much
9:14
for watching hang in there and I'll see
9:15
you soon
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