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Note: This information is for preceptors only. Students are asked to not access this information and to respect this restriction as an honor code issue.
Bent S, Nallamothu BK, et al, Does this woman have an acute uncomplicated urinary tract infection? JAMA, May 22/29, 2002;287(20):2701-10.
Bergus GR, Dysuria (Chapter 30). In: Sloan PD, Slatt LM, Ebell MH, Jacques LB, eds. Essentials of Family Medicine, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002, 495 - 510. Note: This is the required text for the FM Preceptorship.
A 50 year old woman presents with 1 week of dysuria and denies vaginal or other urinary symptoms.
UTI, vaginitis, urethritis, perineal trauma, atrophic vaginosis, bacterial vaginosis, candidiasis, trichomoniasis. In men, prostatitis may present as dysuria.
1.) Physical exam: vitals, abdomen, CVA, genital, vaginal exam (if vaginal discharge reported) 2.)
3.) Possible urine CX-positive if >100 cfu/mL. not necessary in uncomplicated UTI. Consider in children, men, older women, concern of upper tract infection or recurrent infection/concern about resistant organisms 4.) Possible wet mount – if vaginal discharge
21-year-old female generally healthy presents to office with 3d h/o urinary frequency and burning on urination. She has increased her water intake without benefit. She is a college student with a new male sexual partner, and uses OCP’s. She denies fever, chills, back pain, or vaginal discharge. PMHx Neg. On physical exam, her vitals are normal and she has suprapubic tenderness, but no CVAT. UA: 1.030 / 1+LE / -blood / -nitrate / -glucose / -pro, 2-5 WBC / hpf
Yes. Frequency and dysuria in the absence of vaginal discharge predict UTI with probability of 80-90%.
No. The probability is high enough that the UA adds no predictive value. However, many physicians choose to order UA anyway.
Young, adult female; sexually active
E Coli – 70%, Staph Saprophyticus – 15%, Proteus mirabilis – 10%, S. Aureus – 5%, Enterocci – 3%, Klebsiella – 3%. \
Antibiotics (Level A rec.) Cranberry juice - push fluids (Level C rec.)
34-year-old female presents with 10 d h/o dysuria, mild urinary frequency. She note chills and aches, but has not taken her temperature. She is on Depo Provera so her LMP is unknown. She is uncertain about vaginal discharge. PMH: UTI 8 years ago. UA 1.015/ - LE/ - blood/ - nitrate. On physical exam, vitals are normal. Pelvic: mild erythema of external genitalia, no vaginal discharge or cervicitis, no CVAT or cervical motion tenderness.
High probability, complicated UTI with chills
Yes. Probable fever. Other red flags for complicated UTI include: Male gender, prepubertal or geriatric age, symptoms for more than 7 days, an immunosuppressing condition, an episode of acute pyelonephritis within the past year, known anatomic abnormality, diabetes mellitus, flank pain or tenderness.
Oral antibiotics, longer duration (7-14 days), close follow-up. Parenteral antibiotics are indicated if she cannot maintain hydration or oral intake or is medically unstable.
Urine culture. Consider pregnancy test. Consider wet prep & GC/Chlamydia testing.
78-year-old male nursing home resident has 1 week of worsening incontinence, complaints of pain in penis, and inability to sleep. His nurse reports more confusion, especially at night. His past medical history is significant for HTN, high cholesterol, new depression, and a hip fracture 2 months ago. UA 1.025 / 2 + LE / 1 + blood / 1 + glucose / + nitrate. Microscopy shows 20-50 WBC / rare bacteria / 2-5 RBC/ 10-20 Epithelial cells/ hpf. You will not be able to perform a physical until the end of the day.
Ask about prior UTIs, current meds, foley catheter use, and order urine culture.
His age, male sex, and nursing home residence all lead to higher probability of a complicated UTI.
Longer course of antibiotic therapy (7 – 10 days, if uncomplicated or 10 – 14 days if pyelonephritis). Consider using fluoroquinolone as outpatient or parenteral antibiotics. Imaging is indicated if he has a prior UTI.