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LEARNING OBJECTIVES

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  1. Accurately identify the most likely etiology when patients present with a chief complaint of dysuria or vaginal discharge, through history, diagnostic tests, and patient findings on examination to enable the pharmacist to appropriately recommend effective self-treatment or refer the patient to an appropriate provider.

  2. Use knowledge of the pathophysiology, etiology, and common presentation of dysuria and vaginal discharge to review prescription orders for appropriateness and to accurately educate patients about their disease and its treatment.

  3. Use knowledge of the pathophysiology, etiology, and common presentation of dysuria or vaginal discharge to accurately interpret the diagnostic process to enable the pharmacist to advise providers regarding the most appropriate prescription therapy.

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Nearly 5% of patients seen in emergency departments present with complaints related to the genitourinary system. Dysuria (painful urination) and vaginal or urethral discharge are the most common complaints. There are three major causes of dysuria: vaginitis, sexually transmitted diseases (STDs), and urinary tract infections (UTIs). Pharmacists are often asked for advice regarding potential self-care of dysuria and vaginal discharge with nonprescription medication. Therefore, understanding major causes and how to determine if the patient’s symptoms are appropriate for self-care are important skills. In addition, when counseling patients on the use of medications, understanding the symptoms and complications of the disease allows the pharmacist to provide necessary information. Finally, to evaluate the appropriateness of therapy or to advise a prescriber on appropriate therapy, the pharmacist needs to understand the process of differential diagnosis for dysuria and vaginal discharge.

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GENERAL APPROACH TO THE PATIENT WITH DYSURIA

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Since dysuria is a prominent symptom of three separate disorders, providers (including pharmacists) need to take a structured approach to assessing which disorder is the most likely cause of the patient’s dysuria. There are some key initial questions that will help the provider narrow his/her diagnostic focus and make the decision whether the patient is a candidate for self-treatment or needs to be referred (Table 16.1). Unfortunately, other than vaginitis, there are few genitourinary disorders that lend themselves to self-treatment, so positive responses to most questions require referral. For example, if a patient has a vaginal discharge and dysuria, it is possible, but unlikely that they have a UTI, and further questioning as to the specific cause of the vaginal discharge is warranted. Similarly, urethral discharges are usually representative of STDs. Dysuria, plus urinary frequency or urgency point to lower tract UTIs, whereas dysuria, plus systemic signs (nausea, vomiting, fever, abdominal or flank pain, and rigors) point to an upper UTI (acute pyelonephritis). A vaginal discharge plus systemic symptoms point to possible pelvic inflammatory disease (PID). Positive answers to these questions do not automatically make the diagnosis, but point to a diagnosis more likely than a UTI. Multiple positive answers frequently force the diagnostician to do a complete workup for all three common causes to arrive at a diagnosis.

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