A 27 -year-old construction worker consults you Friday afternoon at 4:45 P.M. because of burning on urination which started during the day.
How long have you been pierced?
For two years, what a good idea!
Hard to over looking the piercing and its possible role in urethral imitation.
Have you taken any medications recently?
I have taken a couple of NSAIDs during the past week because of back pain.
Medication history is valuable for several reasonsidentifying trigger of illness, finding associated illnesses and to guide prescribing later.
When did you last have sexual intercourse?
Three or four days ago with my girl friend.
A sexual history is essential when dealing with dysuria.
Have you ever reacted to metals, such as under a watch or blue jeans button?
This could be a clue to allergic contact dermatitis to nickel and would then fit together with the piercing.
Do you have discharge from your urethra?
Not really, maybe a drop or two of pus in my underwear this morning.
When dysuria is present, always ask about urethral or vaginal discharge and its nature.
Why did you come in now and not earlier in the day?
I had to work all day, and the burning just kept getting worse and worse. I can tell you are in a hurry. Should I go to another doctor?
Questions like this only cause hard feelings. No patient appreciates an impatient doctor.
Does your penis itch?
Maybe a little bit of itch, but it is really only a problem when I urinate.
The exact nature of the dysuria doesn't provide additional clues.
Do you have diabetes?
An important question, as diabetes mellitus can predispose to candidiasis and other infections.
Choose the right efflorescences:
There is a perforation because of the piercing, but not actually a chronic skin defect.
There is nothing to be seen; the patient has a symptomdysuria.
Even though the patient noticed a bit of pus, no pustules are present.
Choose the right diagnosis:
A fixed drug eruption can present as a blue-red genital plaque, but not with dysuria.
Artifact indicates intentional skin damage induced by the patient; it does not refer to piercing or other decorative efforts.
The presence of a foreign object in the urethra is a predisposing factor for infections.
If allergic contact dermatitis were present, the glans would be inflamed. Stainless steel rings with only trace amounts of nickel are usually used in piercing, so that nickel allergies are uncommon.
Candidiasis can cause urethritis, but a balanitis is almost invariably present. In this case, the glans is not inflamed.
Choose the right therapy(ies):
A cream is not helpful for urethritis.
This treatment covers the bacterial agents which cause nonspecific urethritis.
Designed for balanitis, not urethritis.
Designed for chronic irritant urethritis, such as that induced by repeated stripping of the urethra.