Evaluation of Dysuria in Adults

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).

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,

autoimmune disorders

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.

NONINFECTIOUS CAUSES

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.

HISTORY

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

TABLE 2

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

replacement

Cyclic pain, premenopausal Endometriosis

status

External pain Vaginitis

Vaginal discharge (e.g., STD: with Chlamydia

amount, color, consistency) trachomatis infection,

watery, mucoid, scant

discharge; with Neisseria

gonorrhoeae infection,

yellow or gray, thick

discharge

With fungal infection

(usually candidiasis),

thick, curd-like,

white, pruritic discharge

Abnormal vaginal bleeding Cervicitis secondary to STD

Postcoital vaginal bleeding Atrophic vaginitis

Pain during intercourse Cystitis, cervicitis

secondary to STD,

vaginitis secondary

to candidiasis

Men Obstructive symptoms (e.g., Benign prostatic hyperplasia

weak stream, dribbling,

hesitancy, intermittent

stream, nocturia)

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

nocturia)

Internal pain Cystitis, urethritis

Obstructive symptoms Urethral stricture, bladder

dysfunction

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.

PHYSICAL EXAMINATION

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

TABLE 3

Possible Diagnoses Based on the Physical Findings

in Patients with Dysuria

Patients Physical findings Possible diagnosis

Women Vulval vesicles, ulcers, and Genital herpes

tender inguinal

lymphadenopathy

Vaginal satellite pustules Candidiasis

Vaginal discharge Candidiasis, STD, vaginitis

caused by hypoestrogenism

Vaginal atrophy Hypoestrogenism

Cervical erythema and STD

discharge

Cervical motion tenderness Pelvic inflammatory disease,

and adnexal tenderness in endometriosis

association with lower

abdominal tenderness

Men Penile discharge Urethritis, STD, candidiasis

Meatal inflammation Urethritis, STD, candidiasis

Penile vesicles, rashes, or Genital herpes, chancroid,

ulcers and tender neoplasm, dermatologic

lymphadenopathy condition

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

nodularity

Prostate enlargement with Neoplasm

hard consistency and

nodularity

Women or Flank tenderness Pyelonephritis, ureteral stone

men Mass on kidney palpation Renal tumor or cyst

Suprapubic tenderness Cystitis, subclinical

pyelonephritis

Bladder distention Urinary retention (e.g.,

obstruction, neurogenic

bladder)

(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)).

TABLE 4

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

smears

Vaginal cultures Must be used in cases of rape or child abuse

Ligase chain reaction Suspected STD

and polymerase

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

strictures, diverticula)

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

or mass

Evaluation of renal function

Evaluation of renal vasculature (MRA)

Cystoscopy Detection of bladder or urethral pathology

Confirmation of diagnosis of interstitial

cystitis

Diagnostic test Comments

Urinalysis Used for screening; inexpensive, easy to

perform

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

trachomatis)

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

obese patients

No misregistration artifacts with

helical CT (unlike regular

CT with or without contrast medium);

therefore, reliable

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

diagnosis

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.

REFERENCES

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(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.

The Authors

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: rsadovsky@netmail.hscbklyn.edu).

Reprints are not available from the authors.

COPYRIGHT 2002 American Academy of Family Physicians

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