Evaluation of Dysuria in Adults
Judy D. Bremnor
Dysuria, defined as pain, burning, or discomfort on urination, is more common in women than in men. Although urinary tract infection is the most frequent cause of dysuria, empiric treatment with antibiotics is not always appropriate. Dysuria occurs more often in younger women, probably because of their greater frequency of sexual activity. Older men are more likely to have dysuria because of an increased incidence of prostatic hyperplasia with accompanying inflammation and infection. A comprehensive history and physical examination can often reveal the cause of dysuria. Urinalysis may not be needed in healthier patients who have uncomplicated medical histories and symptoms. In most patients, however, urinalysis can help to determine the presence of infection and confirm a suspected diagnosis. Urine cultures and both urethral and vaginal smears and cultures can help to identify sites of infection and causative agents. Coliform organisms, notably Escherichia coli, are the most common pathogens in urinary tract infection. Dysuria can also be caused by noninfectious inflammation or trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, or psychogenic disorders. Although radiography and other forms of imaging are rarely needed, these studies may identify abnormalities in the upper urinary tract when symptoms are more complex. (Am Fam Physician 2002;65:1589-96, 1597. Copyright[C] 2002 American Academy of Family Physicians.)
Dysuria is the sensation of pain, burning, or discomfort on urination.(1,2) Although many physicians equate dysuria with urinary tract infection (UTI), it is actually a symptom that has many potential causes. Empiric treatment with antibiotics may be inappropriate, except in carefully selected patients.(3-5) Dysuria most often indicates infection or inflammation of the bladder and/or urethra. Other common causes of dysuria include prostatitis and mechanical irritation of the urethra in men, and urethrotrigonitis and vaginitis in women. Dysuria can also result from malformations of the genitourinary tract, neoplasms, neurogenic conditions, trauma, hormonal conditions, interstitial cystitis, and psychogenic disorders(6-8) (Table 1).
Selected Causes of Dysuria
Infections: pyelonephritis, cystitis, prostatitis, urethritis,
cervicitis, epididymo-orchitis, vulvovaginitis
Hormonal conditions: hypoestrogenism, endometriosis
Malformations: bladder neck obstruction (e.g., benign prostatic
hyperplasia), urethral strictures or diverticula
Neoplasms: renal cell tumor; bladder, prostate, vaginal/vulvar,
and penile cancers
Inflammatory conditions: spondyloarthropathies, drug side effects,
Trauma: catheter placement, “honeymoon” cystitis
Psychogenic conditions: somatization disorder, major depression,
stress disorders or anxiety, hysteria
Dysuria accounts for 5 to 15 percent of visits to family physicians.(9) Approximately 25 percent of American women report acute dysuria every year.(10) The symptom is most prevalent in women 25 to 54 years of age and in those who are sexually active.(11) In men, dysuria and its associated symptoms become more prevalent with increasing age.(6)
Causes of Dysuria
INFECTION AND INFLAMMATION
Infection is the most common cause of dysuria and presents as cystitis, prostatitis, pyelonephritis, or urethritis, depending on the area of the urogenital tract that is most affected. The hollow or tubular structures of the urinary system are vulnerable to infection by coliform bacteria. These bacteria are believed to gain access to the urethral meatus through sexual intercourse or local contamination and then ascend to the affected region.(1)
A community-based study10 found that about two thirds of culture-proven UTIs are caused by Escherichia coli. Other less frequent pathogens include Staphylococcus epidermidis (15 percent), Proteus mirabilis (10 percent), Staphylococcus aureus (5 percent), Enterococcus species (3 percent), and Klebsiella species (3 percent).
Abnormalities in urinary anatomy or function allow more unusual, recurrent, and persistent infections with organisms such as Proteus, Klebsiella, or Enterobacter species. Such abnormalities include bladder diverticula, renal cysts, urethral strictures, benign prostatic hyperplasia (BPH), and neurogenic bladder. Rarely, bacteria may spread hematogenously, causing pyelonephritis.
The urethra is infected preferentially by organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis. Other pathogens include Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, and herpes simplex virus.(12,13)
Rare infectious causes of dysuria include adenovirus, herpesvirus, mumps virus, and the tropical parasite Schistosoma haematobium.
In postmenopausal women, the marked reduction in endogenous estrogen can lead to lower urinary tract dysfunction. Atrophy, dryness, and, occasionally, inflammation of the vaginal epithelium contribute to urinary symptoms such as dysuria, frequency, and urgency.(14) Other noninfectious causes of dysuria in women include the urethral syndrome (defined as symptoms consistent with a lower UTI but without the presence of significant bacteriuria and conventional pathogens),(15) urethral trauma during sexual intercourse, and sensitivity to scented creams, sprays, soaps, or toilet paper.
More than 50 percent of men over 70 years of age have clinical symptoms of BPH, and nearly 90 percent have microscopic evidence of prostatic hyperplasia.(16) In older men, a UTI may result from obstruction and increased postresidual volume.(17) However, dysuria may be caused by inflammation of the distended urethral mucosa without superimposed infection. Obstruction and dysuria can also occur because of strictures caused by gonococcal urethritis or because of urethral instrumentation or surgery.
In both sexes, dysuria may be part of the clinical presentation of renal calculi and neoplasms of the bladder and renal tract. Spondyloarthropathies (e.g., Behcet’s syndrome, Reiter’s syndrome) can cause a general inflammatory state, including inflammation of the urothelium, that results in dysuria.
Physical activities such as horseback riding or bicycling can lead to dysuria with minimal urethral discharge. Dysuria may also be a feature of psychogenic conditions such as somatization disorder, chronic pain syndromes, major depression, and chemical dependency.(18) Sexually abused and other emotionally distressed persons can have psychogenic urinary retention and dysuria.
Evaluation of Dysuria
An algorithm for the evaluation of patients with acute dysuria is provided in Figure 1.
The timing, frequency, severity, and location of dysuria are important. In adult women, a history of external dysuria (pain as the urine passes over the inflamed vaginal labia) suggests vaginal infection or inflammation, whereas a history of internal dysuria (pain felt inside the body) suggests bacterial cystitis or urethritis.(1) Pain at the onset of urination is usually caused by urethral inflammation, but suprapubic pain after voiding is more suggestive of bladder inflammation or infection. Longer duration and more gradual onset of symptoms may suggest C. trachomatis infection, whereas sudden onset of symptoms and hematuria suggests bacterial infection.
It is important to inquire about the presence of other genitourinary symptoms. Dysuria is frequently accompanied by urinary frequency, hesitation, slowness, or urgency. Urinary frequency is most often caused by decreased bladder capacity or painful bladder distention. Other causes include overflow secondary to BPH, urethral pathology, and, rarely, a central or peripheral neurologic disorder. Urinary hesitation and slow urination are most commonly caused by urethral obstruction but may also be secondary to decreased bladder contractility. Urinary urgency occurs as a result of trigonal or posterior urethral irritation caused by inflammation, stones, or tumor and is common with cystitis. Urethral discharge is highly associated with urethritis.(19) In men, urethral discharge and dysuria are the most common symptoms of sexually transmitted urethritis.
Information should also be obtained about the patient’s sexual and general medical history. In sexually active patients, urethritis or vulvovaginitis can be a likely cause of dysuria. A history of sexually transmitted disease (STD) can point to urethral scarring or a current STD, especially in patients with high-risk sexual behaviors. Patients who have diabetes mellitus may present with vulvovaginitis secondary to candidiasis.
Questions should be asked about the use of medications, herbal remedies, and topical hygiene products. Dysuria can be caused by medications such as ticarcillin (Ticar), penicillin G, and cyclophosphamide (Cytoxan). Dysuria can also occur with the use of, among others, saw palmetto, pumpkin seeds, dopamine, or cantharidin,(6) and with the use of a number of topical hygiene products, including vaginal sprays, vaginal douches, and bubble baths.(20)
Possible diagnoses based on the findings of the history are summarized in Table 2.6
Possible Diagnoses Based on the History
in Patients with Dysuria
Patients History Possible diagnosis
Women Postmenopausal status and not Vaginitis secondary
receiving hormone to hypoestrogenism
Cyclic pain, premenopausal Endometriosis
External pain Vaginitis
Vaginal discharge (e.g., STD: with Chlamydia
amount, color, consistency) trachomatis infection,
watery, mucoid, scant
discharge; with Neisseria
yellow or gray, thick
With fungal infection
white, pruritic discharge
Abnormal vaginal bleeding Cervicitis secondary to STD
Postcoital vaginal bleeding Atrophic vaginitis
Pain during intercourse Cystitis, cervicitis
secondary to STD,
Men Obstructive symptoms (e.g., Benign prostatic hyperplasia
weak stream, dribbling,
Rectal pain Prostatitis
Pain during intercourse or Cystitis, urethritis secondary
ejaculation to STD
Women or Recent or unprotected sex STD, cystitis, urethritis
men with new partners
Irritative symptoms (e.g., Cystitis, pyelonephritis,
urgency, frequency, urethritis
Internal pain Cystitis, urethritis
Obstructive symptoms Urethral stricture, bladder
Urethral discharge STD
Systemic symptoms (e.g., Pyelonephritis
sudden fever, shaking
chills, severe fatigue,
back or flank pain, deep
right or upper left quadrant
pain, nausea, vomiting)
Other systemic symptoms Spondyloarthropathy (e.g.,
(e.g., arthralgias, oral, Reiter’s syndrome, systemic
mucosal, or ocular symptoms) lupus erythematosus)
(STD) = sexually transmitted disease.
Adapted with permission from Roberts RG, Hartlaub PP.
Evaluation of dysuria in men. Am Fam Physician 1999;60:865-72.
Although protocols have been established for telephone triage and presumptive treatment of carefully selected women with dysuria,(3-5) most patients require a physical examination with special focus on the genitourinary system.
The patient’s general condition and vital signs should be recorded. Palpation and percussion of the abdomen provide information about kidney, ureter, or bladder inflammation. Tenderness over the costovertebral angle suggests pyelonephritis. A pelvic examination in women and a perineal and penile examination in men can identify the presence of discharge, trauma, or infective lesions such as herpes or chancroid. Although a pelvic examination is often useful in patients at risk for vaginal infections, it is less of a priority when both vaginal discharge and vaginal irritation are explicitly denied and the symptoms of both internal dysuria and urinary frequency are present.
A digital rectal examination in men helps to assess the prostate gland. When prostatitis is suspected, gentle digital examination is advised because a vigorous examination can precipitate bacteremia and sepsis. An enlarged prostate can indicate an obstructive cause of dysuria; however, obstructive symptoms related to BPH can occur without palpable enlargement of the gland.(6) Mild tenderness can be present in prostatitis or prostatodynia.
Possible diagnoses based on the physical findings in patients with dysuria are provided in Table 3.6
Possible Diagnoses Based on the Physical Findings
in Patients with Dysuria
Patients Physical findings Possible diagnosis
Women Vulval vesicles, ulcers, and Genital herpes
Vaginal satellite pustules Candidiasis
Vaginal discharge Candidiasis, STD, vaginitis
caused by hypoestrogenism
Vaginal atrophy Hypoestrogenism
Cervical erythema and STD
Cervical motion tenderness Pelvic inflammatory disease,
and adnexal tenderness in endometriosis
association with lower
Men Penile discharge Urethritis, STD, candidiasis
Meatal inflammation Urethritis, STD, candidiasis
Penile vesicles, rashes, or Genital herpes, chancroid,
ulcers and tender neoplasm, dermatologic
Testicular or epididymal Epididymo-orchitis
swelling and/or tenderness
Tender, boggy prostate Prostatitis
Prostate enlargement with Benign prostatic hyperplasia
mobile mucosa, firm
consistency, and no
Prostate enlargement with Neoplasm
hard consistency and
Women or Flank tenderness Pyelonephritis, ureteral stone
men Mass on kidney palpation Renal tumor or cyst
Suprapubic tenderness Cystitis, subclinical
Bladder distention Urinary retention (e.g.,
(STD) = sexually transmitted disease.
Adapted with permission from Roberts RG, Hartlaub PP.
Evaluation of dysuria in men. Am Fam Physician 1999;60:865-72.
LABORATORY TESTS AND OTHER STUDIES
The laboratory investigation of dysuria is directed by the most probable diagnosis. Diagnostic options include urine studies, vaginal and urethral studies for STDs, radiologic studies, and invasive procedures (Table 4(4,21-24)).
Diagnostic Testing in Patients with Dysuria
Diagnostic test Indication
Urinalysis History of internal dysuria
Urine culture Patients in whom covert bacteriuria can cause
complications, such as pregnant women and
patients with disorders that affect immune
status (e.g., diabetes mellitus)(21)
All male patients with suspected UTI(4)
Urine cytology Gold standard for bladder cancer screening(22)
Vaginal and urethral Vaginal and urethral discharge
Vaginal cultures Must be used in cases of rape or child abuse
Ligase chain reaction Suspected STD
chain reaction tests
Ultrasonography Suspected upper urinary tract pathology
(e.g., abscess, hydroureter, hydronephrosis)
Suspected stones or diverticula in the bladder,
suspected stones in the urethra
Plain-film radiography Unusual gas patterns (e.g., emphysematous
of kidneys, ureters, pyelonephritis)
and bladder Suspected stones (if radiopaque)
Intravenous pyelography Recurrent UTI
Voiding Assessment for causes of chronic dysuria,
cystourethrography such as congenital abnormalities
of lower urinary tract and abnormal bladder
(e.g., vesicoureteric reflux,
neurogenic bladder, BPH, urethral
CT with and without Discrimination of different types of solid
contrast medium, tissue (noncontrast study)
helical CT(23,24) Detection of calcifications in renal
parenchyma or ureter
Improved visualization of avascular structures
such as cysts, abscesses, necrotic tumors,
and infarcts (contrast study)
Measurement of concentrating ability of kidneys
MRI(23) Identification of urinary tract obstruction
Evaluation of renal function
Evaluation of renal vasculature (MRA)
Cystoscopy Detection of bladder or urethral pathology
Confirmation of diagnosis of interstitial
Diagnostic test Comments
Urinalysis Used for screening; inexpensive, easy to
Urine culture Accurate diagnosis of infection;
helpful for determining antimicrobial
susceptibility of infecting bacteria(21)
Urine cytology Poor sensitivity but excellent specificity;
can detect high-grade malignant
cells before cystoscopically
distinguishable gross lesion is present
Vaginal and urethral Easy to perform; wet-mount preparation can
smears detect Trichomonas vaginalis
and Candida species; Gram
staining can detect Neisseria gonorrhoeae
Vaginal cultures Gold standard (specificity close to 100
percent for N. gonorrhoeae and Chlamydia
Ligase chain reaction Detects N. gonorrhoeae and C. trachomatis;
and polymerase results available sooner than with cultures
chain reaction tests
Ultrasonography Noninvasive, relatively inexpensive, and
rapid in emergencies; no exposure
to radiation or contrast medium
Limitations: user dependent;
poor visualization in obese
patients and patients with
open wounds, and dressings or
other devices overlying pertinent area
Plain-film radiography Inexpensive
of kidneys, ureters, Limitations: lack of visualization if
and bladder urinary tract is obscured by gas,
feces, contrast medium, or foreign bodies
in intestine; clear visualization
prevented by uterine fibroids,
ovarian lesions, obesity, and ascites
Intravenous pyelography Visualization of renal parenchyma,
calyces pelvis, ureters, bladder,
and, occasionally, urethra; therefore,
can identify extent of urinary obstruction
Voiding Highly accurate in determining extent
cystourethrography of vesicoureteric reflux
CT with and without Contrast-enhanced CT is radiologic test
contrast medium, of choice; easy to perform and easily
helical CT(23,24) accessible; improved visualization in
No misregistration artifacts with
helical CT (unlike regular
CT with or without contrast medium);
demonstration of small lesions
MRI(23) Useful in patients with renal
insufficiency or allergy to
iodinated contrast media, because
gadolinium contrast agents are
non-nephrotoxic and hypoallergenic
Without contrast medium, MRI is not the
screening method for renal
masses; when contrast medium and
fat suppression are used,
sensitivity of MRI is comparable
to that of CT with contrast medium.
Cystoscopy Direct visualization, allowing
for biopsy and histologic
UTI = urinary tract infection; STD = sexually transmitted disease;
BPH = benign prostatic hyperplasia; CT = computed tomographic scanning;
MRI = magnetic resonance imagine; MRA = magnetic resonance angiography.
Information from references 4 and 21 through 24.
Urinalysis and Urine Cultures. Because UTI is the most common cause of dysuria, urinalysis is often helpful. When UTI is unlikely based on the history and physical findings, urine studies may be deferred.
The specificity of the dipstick test makes it useful for identifying hematuria, pyuria, or bacteriuria. Leukocyte esterase is a marker for white blood cells and has a sensitivity of 75 percent for the detection of UTI. Pyuria has a sensitivity of 96 percent.(20,25) A dipstick test that is positive for nitrite suggests a probable UTI; however, a negative test does not rule out the diagnosis.
The gold standard for evaluating dysuria is microscopic examination of spun, clean-catch, midstream urine sediment. Pyuria is diagnosed by the presence of three to five white blood cells per high-power field, and hematuria is diagnosed by the presence of three to five red blood cells per high-power field. Pyuria detected on urinalysis is associated not only with bacterial UTI, but also with T. vaginalis, C. trachomatis and other infections. Therefore, the finding of pyuria on urinalysis does not eliminate the need for a gynecologic evaluation. Sterile pyuria may be present in patients with prostatitis, nephrolithiasis, urologic neoplasms, and fungal or mycobacterial infections.(2,26)
Many physicians depend on urine Gram staining to identify a UTI. Achieving the best correlation between the Gram stain and significant bacteriuria by culture requires good collection techniques, appropriate methods of observation by a skilled observer, and use of an appropriate stain. Urine Gram stains may demonstrate urinary pathogens, most commonly coliform organisms, or sexually transmitted organisms such as T. vaginalis or N. gonorrhoeae.
Urine culture is also commonly used to investigate dysuria. Cultures are not essential in selected young women when clear-cut signs and symptoms of acute dysuria indicate a high probability of uncomplicated cystitis.(21) If STDs are excluded, these patients are most likely to have uropathogenic coliform infection. Urine cultures can be deferred when dysuria is described as largely external and a probable urethral or vaginal cause is identified.
When symptoms are present, a count of 103 colony-forming units (CFU) per mL of urine is generally diagnostic of infection. Some authorities suggest that a pure colony count of 102 CFU per mL for a known pathogen from a scrupulously collected urine sample is sufficient to diagnose a UTI when dysuria is present.(2)
Vaginal or Urethral Smears and Cultures. If a patient with dysuria has a vaginal or urethral discharge or is sexually active, vaginal or urethral specimens should be obtained for wet-mount preparation and Gram staining, along with appropriate cultures. Although cultures for C. trachomatis and N. gonorrhoeae are the gold standard, other methods, including ligase chain reaction and polymerase chain reaction tests, are often used. Only in cases of sexual assault and child abuse are cultures absolutely necessary (because of their 100 percent specificity).(27) Vaginal pH measurements, potassium hydroxide microscopy, and yeast culture are required in women with chronic or recurrent dysuria of unknown cause.
Radiology and Other Studies. Imaging studies and other diagnostic tests are indicated when the diagnosis is in doubt, when patients are severely ill or immunocompromised and do not respond to antibiotic therapy, and when complications are suspected (Table 44,21-24).(23) Cystoscopy, with or without a voiding urologic study, is an invasive test that can be used to rule out bladder or urethral pathology.
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
(1.) Seller RH. Differential diagnosis of common complaints. 3d ed. Philadelphia: Saunders, 1996:341-52.
(2.) Hoffman RF. Acute dysuria or pyuria in men. In: Greene HL II, Johnson WP, Lemcke DP, eds. Decision making in medicine: an algorithmic approach. 2d ed. St. Louis: Mosby, 1998:506-7.
(3.) Stuart ME, Macuiba J, Heidrich F, Farrell RG, Braddick M, Etchison S. Successful implementation of an evidence-based clinical practice guideline: acute dysuria/urgency in adult women. HMO Pract 1997;11:150-7.
(4.) Campbell J, Felver M, Kamarei S. ‘Telephone treatment’ of uncomplicated acute cystitis. Cleve Clin J Med 1999;66:495-501.
(5.) Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Am J Med 1999; 106:636-41.
(6.) Roberts RG, Hartlaub PP. Evaluation of dysuria in men. Am Fam Physician 1999;60:865-72.
(7.) Margolis S, ed. Johns Hopkins symptoms and remedies: the complete home medical reference. New York: Rebus, 1995:288-9.
(8.) O’Brien DP III. Dysuria. In: Hurst JW, et al., eds. Medicine for the practicing physician. 4th ed. Stamford, Conn.: Appleton & Lange, 1996:1450-1.
(9.) Schwiebert LP. Dysuria in women. In: Mengel MB, Schwiebert LP, eds. Ambulatory medicine: the primary care of families. Stamford, Conn.: Appleton & Lange, 1993:118-22.
(10.) Richardson DA. Dysuria and urinary tract infections. Obstet Gynecol Clin North Am 1990;17:881-8.
(11.) Jolleys JV. Factors associated with regular episodes of dysuria among women in one rural general practice. Br J Gen Pract 1991;41:241-3.
(12.) Madeb R, Nativ O, Benilevi D, Feldman PA, Halachmi S, Srugo I. Need for diagnostic screening of herpes simplex virus in patients with nongonococcal urethritis. Clin Infect Dis 2000;30:982-3.
(13.) Schwartz MA, Hooton TM. Etiology of nongonococcal nonchlamydial urethritis. Dermatol Clin 1998;16:727-33,xi.
(14.) Pandit L, Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci 1997;314:228-31.
(15.) Hamilton-Miller JM. The urethral syndrome and its management. J Antimicrob Chemother 1994;33 (suppl A):63-73.
(16.) Chute CG, Panser LA, Girman CJ, Oesterling JE, Guess HA, Jacobsen SJ, et al. The prevalence of prostatism: a population-based survey of urinary symptoms. J Urol 1993;150:85-9.
(17.) Lipsky BA. Urinary tract infection and prostatitis in men. Hosp Med 1996;59 (June; suppl):9-17.
(18.) Schover LR. Psychological factors in men with genital pain. Cleve Clin J Med 1990;57:697-700.
(19.) Ainsworth JG, Weaver T, Murphy S, Renton A. General practitioners’ immediate management of men presenting with urethral symptoms. Genitourin Med 1996;72:427-30.
(20.) Kurowski K. The women with dysuria. Am Fam Physician 1998;57:2155-64,2169-70.
(21.) Andriole VT. When to do culture in urinary tract infections. Int J Antimicrob Agents 1999;11:253-5.
(22.) Brown FM. Urine cytology. It is still the gold standard for screening? Urol Clin North Am 2000;27:25-37.
(23.) Kaplan DM, Rosenfield AT, Smith RC. Advances in the imaging of renal infection. Helical CT and modern coordinated imaging. Infect Dis Clin North Am 1997;11:681-705.
(24.) Smith RC, Levine J, Rosenfeld AT. Helical CT of urinary tract stones. Epidemiology, origin, pathophysiology, diagnosis, and management. Radiol Clin North Am 1999;37:911-52.
(25.) Claudius H. Dysuria in adolescents. West J Med 2000;172:201-5.
(26.) Barger M, Woolner B. Primary care for women. J Nurse Midwifery 1995;40:231-45.
(27.) Lappa S, Moscicki AB. The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases. Pediatr Clin North Am 1997;44:1405-45.
Members of various family practice departments develop articles for “Problem-Oriented Diagnosis.” This article is one in a series from the Department of Family Practice at SUNY Health Science Center at Brooklyn College of Medicine. Guest coordinator of the series is Miriam Vincent, M.D.
JUDY D. BREMNOR, M.D., is clinical assistant instructor at the State University of New York (SUNY) Health Science Center at Brooklyn College of Medicine. Dr. Bremnor received her medical degree from the University of the West Indies Faculty of Medical Sciences, Mona, Jamaica.
RICHARD SADOVSKY, M.D., is associate professor of family practice at the SUNY Health Science Center at Brooklyn College of Medicine, where he earned his medical degree, completed a family practice residency, and served as residency director for 10 years. Dr. Sadovsky has served as president of the New York chapter of the American Academy of Family Physicians. He is presently an associate editor for American Family Physician.
Address correspondence to Richard Sadovsky, M.D., Department of Family Practice, State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 67, Brooklyn, NY 11203 (e-mail: email@example.com).
Reprints are not available from the authors.
COPYRIGHT 2002 American Academy of Family Physicians
COPYRIGHT 2002 Gale Group