Dysuria and Abdominal pain

A 15-year-old girl complains of dysuria and abdominal pain for 2 days. She denies nausea, vomiting, flank pain, and vaginal discharge. Menarche occurred 2 years ago, and menses have been irregular. Physical examination reveals Sexual Maturity Rating (Tanner) stage 4 genitalia, mild suprapubic tenderness, and otherwise normal findings.

There are many causes of dysuria, including vaginitis, chemical irritation, urethritis, urinary tract infection (UTI), and trauma. Depending on the age and gender of the patient, some etiologies may be more common than others. In addition, specific historical points may aid in the diagnosis. For example, because UTI is much more common in the young child, general information regarding a previous history of UTIs is especially important, as is a family history of renal disease. In the adolescent who has urethritis or cystitis, a sexual history must be obtained because sexually transmitted infections, as well as UTIs, are part of the differential diagnosis in this age group. The incidence of UTI increases with the onset of sexual activity.

The adolescent girl described in the vignette has some of the classic signs and symptoms of a lower UTI (eg, dysuria and acute lower abdominal pain). Although she denies nausea, vomiting, and flank pain, the mild suprapubic pain on physical examination also is consistent with the diagnosis.

Although sexually transmitted infections must be considered in the adolescent patient, their likelihood depends on a history of sexual activity and findings on physical examination, such as vaginal discharge or cervical motion tenderness. A homogeneous grayish vaginal discharge with a pH of greater than 4.5 is seen with bacterial vaginosis. A saline wet mount of the discharge reveals greater than 20 % clue cells and an absence of lactobacilli. An isolated Gardnerella vaginalis infection usually does not cause dysuria and lower abdominal pain.

Bacterial vaginosis is characterized by elevated vaginal pH and clue cells. (Courtesy of M Rimsza)

Chlamydia trachomatis infection can cause dysuria if the urethra is involved. However, it typically is not accompanied by lower abdominal pain unless the infection has ascended beyond the urethra and cervix to the upper genital tract (ie, pelvic inflammatory disease). Of note, many chlamydial infections are asymptomatic and do not present with vaginal or urethral symptoms. Retaining a high index of suspicion among high-risk individuals (eg, patients >25 years of age, history of multiple partners in the past 12 months) is necessary to diagnose and treat many chlamydial infections.

Symptoms and signs of pelvic inflammatory disease recently published by the Centers for Disease Control and Prevention include lower abdominal pain, cervical motion tenderness, and adnexal tenderness. Additional symptoms are fever, vomiting, diarrhea, irregular vaginal bleeding, and increased vaginal discharge. Dysuria and lower abdominal pain are not characteristic of candidal vulvovaginitis.

References:
Gittes EB, Irwin CE Jr. Sexually transmitted diseases in adolescents. Pediatr Rev. 1993;14:180-189
Lappa S, Moscicki AB. The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases. Pediatr Clin North Am. 1997;44:1405-1445
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent. Pediatr Rev. 1993;14:141-147