CCFP priority topic 33 of 105
Dysuria on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Dysuria. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Is it simple cystitis?
Use the story and a urine dipstick to tell whether this is simple cystitis.
CFPC skill Clinical reasoning, selectivityPhase DiagnosisSources Choosing Wisely Canada
On the exam
A 17-year-old woman with burning, frequency and a nitrite-positive dipstick. Expect a short menu (pick several from a list) of tests.
Pick the tests that change the plan.
Common mistakes
Ordering a blood count, an inflammatory marker, kidney tests or imaging for trace blood. Simple cystitis can be diagnosed and treated on the story alone, and nothing here points past the bladder.
Approach
- Ask about burning, urgency, going often and pain over the bladder. These point to the bladder.
- Ask about fever, flank pain, vaginal discharge or itch, and a new partner. Each one changes the diagnosis.
- Classic symptoms in a healthy woman can be enough on their own to diagnose and treat simple cystitis.
- A nitrite-positive dipstick supports the diagnosis. It does not need a culture to back it in a simple case.
- Cloudy or smelly urine is not a sign of infection on its own. It is no reason to culture.
- Fever, flank pain or tenderness over the kidney in the back. Then the work-up changes.
Key feature 2 of 5
Treat today
Once simple cystitis is clear, start the antibiotic the same day instead of holding for the lab.
CFPC skill Clinical reasoning, selectivityPhase TreatmentSources Choosing Wisely Canada, Health Canada
On the exam
The same young woman, clearly with cystitis, worried about antibiotics. Expect one best answer for the drug and plan.
Pick the best first treatment.
Common mistakes
Sending a culture and waiting days to treat. Or picking ciprofloxacin because it feels stronger. Holding antibiotics altogether is wrong too: symptoms last and infection can climb.
Approach
- Treat on the story, plus the dipstick if done. A healthy woman with simple cystitis needs no culture first.
- Choose a drug that suits the bladder (table below).
- Nitrofurantoin works in the urine only. Blood levels are too low to treat infection outside the bladder, such as the kidney or prostate.
- Fosfomycin is one 3 g dose for simple cystitis in women 18 and older. More doses add side effects, not cures.
- Keep ciprofloxacin for simple cystitis when no other drug will do. Its label asks for a urine culture first.
| Drug | Use for | Know this |
|---|---|---|
| Nitrofurantoin | Simple bladder infection | Not for kidney infection or prostatitis. Label: avoid if creatinine clearance is under 60 mL/min, in labour, or under 1 month. |
| Fosfomycin | Simple cystitis in women 18 and older | One 3 g dose. Not for kidney infection. No approved use under 18. |
| Ciprofloxacin | Simple cystitis only when nothing else will do | Can cause lasting tendon rupture, nerve damage and mental effects. Not advised under 18. Culture first. |
Key feature 3 of 5
Not every burn is infection
Look past the bladder: vaginitis, sexually transmitted infections, prostatitis and irritating products all burn.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Public Health Agency of Canada, Choosing Wisely Canada, Health Canada
On the exam
A 17-year-old woman with burning, itch and thick white discharge after a new partner. Expect a short menu (pick several from a list) of causes and tests.
Pick the causes that fit, and the tests.
Common mistakes
Calling a thick, curd-like discharge bacterial vaginosis, trichomonas or soap irritation. Or dropping her chlamydia test because yeast explains the itch.
Approach
- Ask about discharge, itch, sores, a new partner, condom use and new soaps or sprays.
- Burning on the skin as urine passes points to the vulva. Burning deep inside points to the bladder. Both can happen at once.
- Choose sexually transmitted and blood-borne infection tests by her history and the sites exposed. Swab more than one site if needed.
- If one sexually transmitted infection is suspected, screen for the others too.
- A Pap test does not explain burning. Cervical screening starts at 25.
- In a man, fever with pain in the pelvis or between the scrotum and anus suggests prostatitis. Nitrofurantoin does not treat it.
| Cause | What you see |
|---|---|
| Yeast | Thick, white, curd-like discharge; itchy red vulva |
| Bacterial vaginosis | Thin, grey, fishy discharge; little itch |
| Trichomonas | Frothy, yellow-green, bad-smelling discharge |
| Chlamydia or gonorrhea | Often little to see; burning, sometimes an inflamed cervix |
| Soap or spray irritation | Red skin, no curd-like discharge, clean urine |
Key feature 4 of 5
Who carries more risk
Pick out the patients whose urine infection is more likely to be serious or hard to treat.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generationSources Choosing Wisely Canada, Health Canada
On the exam
A 7-month-old girl with a fever of 39.4 °C, a runny nose and crying when she pees. Expect a short menu (pick several from a list) of next steps.
Pick how to collect urine, and what to avoid.
Common mistakes
Blaming the cold or teething. Or sending a bag sample for culture: skin germs make bag cultures falsely positive, and a positive one needs confirming anyway.
Approach
- More risk: pregnancy, infants and children, men, diabetes, stones, a catheter, or a blocked or abnormal urinary tract. Expect more work-up.
- Child in diapers: get urine by catheter, or by a needle through the skin into the bladder. A bag sample cannot make the diagnosis.
- Toilet-trained child: a clean-catch sample is the standard. In infants it is often contaminated.
- An infant's diagnosis rests on a catheter or needle sample, not a bag.
- Fever means the kidney may be involved. Nitrofurantoin does not reach useful levels there.
- Vomiting, drowsy or not keeping medicine down: assess today, in hospital if needed. Not imaging next week.
- Older adult with new confusion but no fever or urinary symptoms: do not test or treat the urine.
| Who | What changes | Why |
|---|---|---|
| Pregnant woman | Culture urine even without symptoms | An exception to the no-symptoms, no-culture rule (the other is a urinary procedure that will cause bleeding) |
| Infant in diapers | Catheter or needle sample | Bag samples are contaminated by skin germs |
| Older adult | Test only with urinary symptoms or fever | Bacteria without symptoms is common and treating it does not help |
| Man | Think of the prostate | Nitrofurantoin does not treat prostatitis |
Key feature 5 of 5
Burning that keeps coming back
When burning returns again and again, hunt for what keeps setting it off.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Choosing Wisely Canada, Health Canada
On the exam
A 26-year-old woman with three bladder infections in 8 months, each after sex with spermicide. Expect one best answer.
Pick the best next step.
Common mistakes
Starting nightly or after-sex antibiotics while the spermicide stays. Ask what sets each episode off, and remove that cause first.
Approach
- Ask how episodes link to sex, spermicide or a diaphragm, and to menopause.
- Count only episodes with urinary symptoms. Bacteria in the urine without symptoms is not a recurrence.
- Stop the spermicide and see whether the infections stop.
- After menopause, ask about vaginal dryness and soreness. Thin vaginal tissue can drive repeat infections.
- Think of leftover urine after voiding in older adults, men with a weak stream, and anyone with nerve disease.
- Long preventive courses carry harms. Nitrofurantoin taken for 6 months or more can cause lung reactions.
Flashcards
Answer it first, then check.
KF 1Cloudy, smelly urine but no urinary symptoms. Do you send a culture?
No. Cloudy or smelly urine alone is not infection. Culture only with urinary symptoms or fever, unless she is pregnant. Source: Choosing Wisely Canada
KF 2A healthy woman has burning and frequency. Must you wait for a culture?
No. Simple cystitis can be diagnosed and treated on the history alone, with no extra urine test. Source: Choosing Wisely Canada
KF 2When does ciprofloxacin fit simple cystitis?
Only when no other drug will do. Get a urine culture first to confirm it will work. Source: Health Canada
KF 3Burning and a new partner at 17. Does she need a Pap test?
No. Cervical screening starts at 25. Test for sexually transmitted infections, and screen for the others if one is suspected. Source: Choosing Wisely Canada, Public Health Agency of Canada
KF 4A febrile 7-month-old needs a urine culture. How do you collect it?
By catheter, or by a needle into the bladder. A bag sample gives false positives from skin germs. Source: Choosing Wisely Canada
KF 4Which adults need a urine culture when they have no symptoms?
Pregnant women. Also anyone due for a procedure on the urine tract that may cause bleeding. Source: Choosing Wisely Canada
KF 4An 85-year-old is newly confused, with a positive dipstick and no fever. Treat?
No. Confusion alone is not a bladder infection, and treating bacteria without symptoms does not help. Source: Choosing Wisely Canada
KF 5Why not keep her on nitrofurantoin prevention for years?
Taken for 6 months or more, it can cause lung reactions that may not fully go away. Source: Health Canada
FAQ
Is bacteria in the urine without symptoms ever treated?
Yes, in pregnancy and before urinary procedures that will make the lining bleed. Otherwise leave it alone in adults, older adults included. Treating it brings side effects and no benefit.
Is a bag urine sample ever useful in a baby?
A negative bag culture rules infection out. A positive one must be confirmed by catheter or needle sample, which delays the diagnosis. In a sick infant, start with the catheter.
Does burning in a man always mean the prostate?
No. A sexually transmitted infection or a bladder infection also burns. Fever with pain in the pelvis or between the scrotum and anus points to prostatitis, which needs a drug that reaches the prostate.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada
- STBBI screening and diagnostic testingPublic Health Agency of Canada