Dysuria / UTI
Dysuria
In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection.
When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.
Consider non-urinary tract infection related etiologies of dysuria (e.g., prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate.
When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (e.g., pregnancy, children, diabetes, urolithiasis).
In patients with recurrent dysuria, look for a specific underlying cause (e.g., post-coital urinary tract infection, atrophic vaginitis, retention).
UTI
Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (e.g., sepsis, pyelonephritis, impacted infected stones).
Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (e.g., ultrasound).
In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (e.g., pregnancy; immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy).
In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (e.g., pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (e.g.,pregnancy, sepsis, pyelonephritis).
Given a non-specific history (e.g., abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up.
In a patient with dysuria, exclude other causes (e.g., sexually transmitted diseases, vaginitis, stones, interstitial cystitis, prostatitis) through an appropriate history, physical examination, and investigation before diagnosing a urinary tract infection.
See Pediatric UTI.
General Overview
Anatomic
Lower: Uretheritis, cystitis
Upper: Pyelonephritis, renal/perinephric abscess, prostatitis
Clinical
Complicated - risk of treatment failure
Anatomic or functional abnormality of urinary tract (enlarged prostate, stone, diverticulum, neurogenic bladder)
Immunocompromised host
Multi-drug resistant bacteria
Pyelonephritis
Uncomplicated - Cystitis in immunocompetent nonpregnant healthy woman without anatomic/functional abnormality (regardless of her age according to INESSS 2017)
Microbiology - KEEPS
Klebsiella pneumoniae
E Coli – most common (75-95%), especially in women
Enterococci – most common in LTC facilities
Proteus mirabilis – most common in men
Staph saprophyticus
Risk Factors for UTI
Age
Female
Neurogenic bladder/urinary incontinence, vesicoureteral reflux, posterior urethral valves, prolapse, BPH
Indwelling catheter, recent surgery/instrumentation
Diabetes, other comorbidities
Sexual activity
DDx for Dysuria
Infectious
Cystitis, Pyelonephritis, Urethritis
Vulvovaginitis, Cervicitis
Prostatitis, epididiymo-orchitis
Foreign body
Urolithiasis
Dermatologic
Irritant/Contact dermatitis, lichen sclerosus, lichen planus, psoriasis, Stevens-Johnson, Behçet syndrome
BPH, urethral stricture
Neoplastic
Trauma/surgery
Interstitial cystitis (bladder pain syndrome)
History
UTI symptoms (Dysuria, frequent voiding, urgency, hematuria, suprapubic discomfort)
Pain at start of urination - Urethral
Pain at end of urination - Bladder
Complicating conditions (pregnant, co-morbidity, exposure to antibiotics in past 3 months, travel, previous drug-resistant infection)
Pyelonephritis (Fever/Chills, flank/back pain, nausea/vomiting)
STI (Vaginal discharge, sexual activity, contraception)
Diagnosis by History for Women
Highest PPV+ Self-diagnosis of cystitis (86%), absence of vaginal discharge (82%), hematuria (75%), urinary frequency (73%)
A woman with dysuria/frequency, no risk factors for complicated infection, and no vaginal discharge had a 90% probability of UTI (LR+ = 24.6)
Physical Exam
Vitals (Febrile, tachycardia, hypotension)
Abdominal exam
CVA Tenderness
Gynecological exam
Ulcers/vesicles (HSV)
Vaginal discharge (Vaginitis)
Cervical motion tenderness (PID)
Genital (male) exam
Discharge
Prostate exam (prostatitis, BPH)
Rule out prostatitis (DRE) if fever, chills, malaise, myalgias, pelvic or perineal pain, or obstructive symptoms such as dribbling and hesitancy (due to acute urinary retention)
Consider chronic prostatitis in recurrent cystitis
Testicle (Epididymo-orchitis)
Joint effusions (reactive arthritis) and polyarticular tenosynovitis (systemic gonoccocal)
Investigations
UA if history not clear
Both LE/Nitrites PPV+ 95%
LE alone consider urethritis
Urine culture indicates UTI only if accompanied by symptoms
Without indwelling catheter >10^5 cfu/mL of <2 species by void, or >10^2 by in-and-out
With indwelling catheter >10^5 cfu/mL taken from new catheter or <14d since insertion
Labs (serum creatine, electrolytes)
r/o STI in sexually active
Urine color, clarity, odor cannot be used to diagnose UTI (usually due to diet and hydration status)
Treatment
Do not treat asymptomatic bacteriuria unless pregnant or undergoing GU surgery
Women
Adjust antibiotic to C&S results
Empiric antibiotics for simple cystitis
Nitrofurantoin 100mg PO BID x 5-7d (careful in reduced creatinine clearance)
TMP-SMX DS 1 tab BID x 3d (if resistance <20%, Quebec has 15% resistance)
Fosfomycin 3g PO x 1 (appropriate but inferior efficacy)
Note: Treating with placebo 25-42% of women will clear infection spontaneously, however small risk of progression to pyelonephritis 1/38
Empiric antibiotics for cystitis in pregnancy
Amoxicillin 500mg PO TID x 7d
Amoxicillin-clavulanate 875mg PO BID x 7d
Cefixime 400mg PO daily x 7d
Nitrofurantoin 100mg PO BID x 7d (may want to avoid in first trimester)
TMP-SMX avoid in first trimester and at term
Acute Pyelonephritis or complicated cystitis
Ciprofloxacin 500mg PO BID x7d or Levofloxacin 500mg PO daily x 7d
Can consider initial intravenous dose: Ceftriaxone 1g IV or 24h dose of aminoglyocoside
If complicated pyelonephritis consider inpatient IV antibiotics initially and longer 14d course
Men
Consider r/o prostatitis, urethritis
Empiric antibiotics
Fluoroquinolones (eg. Cipro 500mg PO BID or Levofloxacin 500mg PO daily) x 7-14d
If afebrile, consider 7d course rather than 14d as per latest JAMA 2021
Consider shorter courses of fluoroquinolones for uncomplicated pyelonephritis (eg. 7d as per ACP)
Consider TMP-SMX DS 1 tab BID if culture sensitive
Urinary Catheter
Ideally remove catheter prior to antibiotics
Otherwise intermittent catheterization if possible
Otherwise replace catheter after antimicrobial therapy started
7-14 day antimicrobial treatment generally adequate
Prevention
Hydration, nutrition
Perineal hygiene
Healthy voiding habits
Avoid unnecessary urinary catheters (consider intermittent cathterization)
Aseptic technique for urinary catheters
May consider cranberry prophylaxis (eg. juice or tablet)
May consider discussing antibiotic prophylaxis (continuous x 1 year or postcoital) vs. self-treatment in recurrent UTI (eg. 2+/6mo, 3+/12mo)
May consider vaginal estrogen therapy in peri/post-menopausal women
References:
JAMA 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317010/
ACP 2021. https://www.acpjournals.org/doi/full/10.7326/M20-7355
AAFP 2011. http://www.aafp.org/afp/2011/1001/p771.html
IDSA 2010. https://academic.oup.com/cid/article-lookup/52/5/e103
Long Term Care
Pediatrics