History

Fact Explanation
Spectrum of presentation of urinary tract infection (UTI). Infection of the urinary tract may lead to development of acute pyelonephritis, acute cystitis/urethritis, acute prostatitis, septicaemia and asymptomatic bacteriuria.[1] UTI is diagnosed when more than 10 to the power 5 organisms/ ml is found in midstream urine.
Frequency Increased frequency of micturition is a symptom of lower tract infection.
Dysuria Burning sensation during passage of urine through the urethra is a symptom of urethritis.
Urgency Is a symptom of cystitis/ urethritis due to spasm of the inflamed bladder wall.
Abdominal pain The patient may experience suprapubic pain in acute cystitis. Loin pain characteristically occurs in acute pyelonephritis.[2]
Fever Systemic symptoms are usually mild in lower tract infections. Fever with chills & rigors are prominent symptoms of acute pyelonephritis.[2]
Asymptomatic bacteriuria Presence of more than 10 to the power 5 organisms/ ml in the urine of an asymptomatic healthy patient.
Look for risk factors for UTI Factors which lead to incomplete bladder emptying such as bladder outflow obstruction, uterine prolapse, neurogenic bladder (spinal cord dysfunction/multiple sclerosis) predispose to UTI.[3] UTI is common in diabetic and immunocompromised patients. Urethral instrumentation may also introduce organisms into the urinary tract.
References
  1. HOOTON THOMAS M.. Uncomplicated Urinary Tract Infection. N Engl J Med [online] 2012 March, 366(11):1028-1037 [viewed 09 July 2014] Available from: doi:10.1056/NEJMcp1104429
  2. RAMAKRISHNAN K, SCHEID DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician [online] 2005 Mar 1, 71(5):933-42 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15768623
  3. SHEKELLE PG, MORTON SC, CLARK KA, PATHAK M, VICKREY BG. Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction. J Spinal Cord Med [online] 1999 Winter, 22(4):258-72 [viewed 10 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10751130

Examination

Fact Explanation
General examination : Fever Fever is mild in cystitis/ urethritis while is a prominent feature in acute pyelonephritis. Patients with acute pyelonephritis appear very ill.
Cardiovascular examination : Hypo tension & tachycardia May be present in patient who develop septicaemia.
Abdominal examination Patients with acute cystitis will have suprapubic tenderness. Patients with acute pyelonephritis will have renal angle tenderness and guarding in the lumbar region.[1] A palpable bladder may be felt in patients with chronic urinary retention.
Rectal examination Benign prostatic hypertrophy may be detected in an elderly male. Rectal examination may also be performed in males patients suspected with prostatitis to detect prostatic tenderness.[2]
Vaginal examination To exclude uterine prolapse which is a risk factor for UTI.
Assessment for risk factors Examine the spine for congenital anomalies or acquired conditions - Spinal injury.[3] Perform neurological examination in suspected patients with multiple sclerosis, diabetic neuropathy which may lead to neurogenic bladder.
References
  1. MOORE KN, DAY RA, ALBERS M. Pathogenesis of urinary tract infections: a review. J Clin Nurs [online] 2002 Sep, 11(5):568-74 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12201883
  2. LIPSKY BENJAMIN A., BYREN IVOR, HOEY CHRISTOPHER T.. Treatment of Bacterial Prostatitis. CLIN INFECT DIS [online] 2010 June, 50(12):1641-1652 [viewed 09 July 2014] Available from: doi:10.1086/652861
  3. CARDENAS DD, HOOTON TM. Urinary tract infection in persons with spinal cord injury. Arch Phys Med Rehabil [online] 1995 Mar, 76(3):272-80 [viewed 10 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7717822

Differential Diagnoses

Fact Explanation
Urethritis due to sexually transmitted infection Urethritis is commonly associated with gonorrhea and Chlamydia infections.[1] [2] Sexually transmitted infections(STI) of viral origin such as herpes simplex can also present with urethritis. Differentiation is based on clinical presentation and sexual history. The patient will present with a purulent discharge from the external urethral meatus. Urinary symptoms such as dysuria may be common while symptoms such as frequency, urgency may be absent. Characteristic lesions due to the STI may be present - Genital skin lesions of herpes infection, oral/rectal lesions in gonorrhea etc. Purulent samples obtained may demonstrate the pathogenic organisms.
Acute appendicitis Acute inflammation of the appendix will lead to a migratory type abdominal pain, nausea/ vomiting & anorexia. The abdominal pain is initially a diffuse dull pain located in the periumbilical area which localizes to the right iliac fossa (RIF) with involvement of the parietal peritoneum.[2] An appendix located in the pelvic position may give rise to urinary symptoms due to irritation on the bladder wall. A mild temperature (<38) may be present. Abdominal examination will reveal rebound tenderness and guarding in the RIF. A diagnosis is arrived at based on the clinical presentation supported by ultrasound scan assessment.
Acute Epididymitis Inflammation of the epididymis could be acute or chronic. Common age group of patients is 20-40 years. Organisms which cause sexually transmitted infections ascend via the urethra and vas to reach the epididymis.[4] Presenting symptoms are scrotal pain and scrotal swelling. Pain may also be present in the suprapubic region. Urinary symptoms such as dysuria may be present. Diagnosis is based on clinical history and ultrasound scan findings.
Pelvic inflammatory disease Pelvic inflammatory disease is an upper genital tract infection ascending from the endocervix. This leads to the development of endometritis, salpingitis, oophoritis, tuboovarian abcess and pelvic peritonitis.[5] Patient presents with pelvic pain, deep dyspareunia, vaginal discharge and fever. Urinary symptoms may be present. On vaginal examination adnexal tenderness, cervical motion tenderness and tender adnexal mass may be detected. Diagnosis is by clinical findings and analysis of vaginal specimens.
References
  1. NEWMAN L. M., MORAN J. S., WORKOWSKI K. A.. Update on the Management of Gonorrhea in Adults in the United States. Clinical Infectious Diseases [online] 2007 April, 44(Supplement 3):S84-S101 [viewed 09 July 2014] Available from: doi:10.1086/511422
  2. MANAVI K. A review on infection with Chlamydia trachomatis. Best Pract Res Clin Obstet Gynaecol [online] 2006 Dec, 20(6):941-51 [viewed 09 July 2014] Available from: doi:10.1016/j.bpobgyn.2006.06.003
  3. HUMES D J. Acute appendicitis. BMJ [online] 2006 September, 333(7567):530-534 [viewed 09 July 2014] Available from: doi:10.1136/bmj.38940.664363.AE
  4. HARNISCH JP, BERGER RE, ALEXANDER ER, MONDA G, HOLMES KK. Aetiology of acute epididymitis. Lancet [online] 1977 Apr 16, 1(8016):819-21 [viewed 10 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/67333
  5. BARRETT S, TAYLOR C. A review on pelvic inflammatory disease. Int J STD AIDS [online] 2005 Nov, 16(11):715-20; quiz 721 [viewed 10 July 2014] Available from: doi:10.1258/095646205774763270

Investigations - for Diagnosis

Fact Explanation
Urinalysis Samples which could be taken are mid-stream urine and s. Microscopy and culture help identify the causative pathogen. A significant result is decided according to bacterial counts. Presence of any number of organisms in a supra-pubic aspiration is significant. In a symptomatic patient with neutrophils in urine, a small number of organisms is significant.[1]
Urinalysis - cytometry Presence of pus cells in urine support the diagnosis of UTI. Microscopic haematuria may be detected.
Urine dipstick testing Urine dipstick testing can be done for nitrites and leucocyte esterase. Presence of either supports a diagnosis of UTI.[2]
Blood culture Blood culture may be indicated if the patient presents with high fever with rigors or evidence of septic shock.
References
  1. HOOTON THOMAS M.. Uncomplicated Urinary Tract Infection. N Engl J Med [online] 2012 March, 366(11):1028-1037 [viewed 09 July 2014] Available from: doi:10.1056/NEJMcp1104429
  2. SULTANA RV, ZALSTEIN S, CAMERON P, CAMPBELL D. Dipstick urinalysis and the accuracy of the clinical diagnosis of urinary tract infection. J Emerg Med [online] 2001 Jan, 20(1):13-9 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11165831

Investigations - Fitness for Management

Fact Explanation
Full blood count Neutrophilic leucocytosis will be seen due to infection. Blood picture will reveal immature white blood cells(left shift)
plasma urea, creatinine, electrolytes For assessment of renal function particularly in recurrent UTI, acute pyelonephritis etc.
References

Investigations - Followup

Fact Explanation
Renal ultrasound scan/ CT scan Imaging of the kidneys are used to rule out calculi, obstruction, cysts etc which may be the cause of UTI.[1] Follow up imaging studies are required after a single episode of UTI in male patients. In females USS is used in complicated UTIs (acute pyelonephritis, recurrent UTI, failure to respond to treatment, UTI in pregnancy etc).
Intravenous urogram (IVU) IVU is particularly useful to observe the lumen of the collecting system, ureters and bladder.[2] Lesions will be demonstrated as a filling defect. It is indicated to to exclude the possibility of urothelial malignancies, calculi and abnormalities of renal papillae.
Cystoscopy Cystoscopy is indicated when the patient presents with haematuria. Bladder carcinoma which presents with painless haematuria may predispose to recurrent UTIs.
References
  1. BROWNE RF, ZWIREWICH C, TORREGGIANI WC. Imaging of urinary tract infection in the adult. Eur Radiol [online] 2004 Mar:E168-83 [viewed 09 July 2014] Available from: doi:10.1007/s00330-003-2050-1
  2. ANDREWS SJ, BROOKS PT, HANBURY DC, KING CM, PRENDERGAST CM, BOUSTEAD GB, MCNICHOLAS TA. Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study. BMJ [online] 2002 Feb 23, 324(7335):454-6 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11859046

Management - General Measures

Fact Explanation
Patient education Information should be provided to the patient regarding the natural course of the illness, complications, treatment available and follow-up investigations.[1]
Maintain adequate fluid intake[2] A minimum fluid intake of 2 liters per day is recommended.
Symptomatic treatment The fever may be controlled with anti-pyretics. There is limited evidence for use of potassium citrate to treat dysuria.
References
  1. STAMM WE, HOOTON TM. Management of urinary tract infections in adults. N Engl J Med [online] 1993 Oct 28, 329(18):1328-34 [viewed 09 July 2014] Available from: doi:10.1056/NEJM199310283291808
  2. NICOLLE LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North Am [online] 2008 Feb, 35(1):1-12, v [viewed 09 July 2014] Available from: doi:10.1016/j.ucl.2007.09.004

Management - Specific Treatments

Fact Explanation
Treatment of cystitis/ urethritis A 3 day oral antibiotic regime is considered adequate. Uncomplicated UTI in females may be even treated without urine culture testing. Trimethoprim is the first line treatment (200mg daily).Other antibiotics that can be used are Nitrofurantoin(50 mg 6-hourly), Ciprofloxacin(100 mg 12-hourly), cephalexin(500 mg 12-hourly). Co-amoxiclav and amoxicillin can be used if the causative organism is found to be sensitive.[1]
Management of acute pyelonephritis Depending on the severity oral or IV antibiotics are used for a period of 7-14 days. In severe cases IV cephalosporin, quinolone or gentamicin may be used. In less severe cases oral antibiotics can be used.[2]
Management of Acute prostatitis Patients should be treated with either trimethoprim or quinolones (Ciprofloxacin/ norfloxacin) for a duration of 4-6 weeks.[3]
Persistent or recurrent UTI Persistent infection and recurrent infection requires investigations to exclude an underlying cause. Men, children and patients with renal damage require prompt investigation while in females recurrent infection is common and investigations are indicated if the episodes are frequent or severe. The patient may be started on prophylactic antibiotic and monitored with routine urine cultures.[4]
Asymptomatic bacteriuria Treatment is usually not required for except when the patient is diagnosed with an abnormality of the urinary tract or if the patient is pregnant.[5]
UTI in pregnancy Penicillins and cephalosporins are safe for use during pregnancy. Antibiotics such as trimethoprim, quinolones, tetracyclins should be avoided in pregnancy.
References
  1. GUPTA K., HOOTON T. M., NABER K. G., WULLT B., COLGAN R., MILLER L. G., MORAN G. J., NICOLLE L. E., RAZ R., SCHAEFFER A. J., SOPER D. E.. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases [online] December, 52(5):e103-e120 [viewed 09 July 2014] Available from: doi:10.1093/cid/ciq257
  2. NICKEL JC. The management of acute pyelonephritis in adults. Can J Urol [online] 2001 Jun:29-38 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11442995
  3. LIPSKY BENJAMIN A., BYREN IVOR, HOEY CHRISTOPHER T.. Treatment of Bacterial Prostatitis. CLIN INFECT DIS [online] 2010 June, 50(12):1641-1652 [viewed 09 July 2014] Available from: doi:10.1086/652861
  4. EPP A, LAROCHELLE A, LOVATSIS D, WALTER JE, EASTON W, FARRELL SA, GIROUARD L, GUPTA C, HARVEY MA, ROBERT M, ROSS S, SCHACHTER J, SCHULZ JA, WILKIE D, EHMAN W, DOMB S, GAGNON A, HUGHES O, KONKIN J, LYNCH J, MARSHALL C, SOCIETY OF OBSTETRICIANS AND GYNAECOLOGISTS OF CANADA. Recurrent urinary tract infection. J Obstet Gynaecol Can [online] 2010 Nov, 32(11):1082-101 [viewed 09 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21176321
  5. SMAILL F, VAZQUEZ JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev [online] 2007 Apr 18:CD000490 [viewed 09 July 2014] Available from: doi:10.1002/14651858.CD000490.pub2