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ESSENTIAL INQUIRIES

  • Fever; new back or flank pain; nausea or vomiting.

  • Vaginal discharge.

  • Pregnancy risk.

  • Structural abnormalities.

  • Instrumentation of urethra or bladder.

GENERAL CONSIDERATIONS

Dysuria (painful urination) is a common reason for adults and adolescents to seek urgent medical attention. An inflammatory process (eg, urinary tract infection [UTI], autoimmune disorder) underlies most causes of dysuria. In women, cystitis will be diagnosed in up to 50–60% of cases. Cystitis has an incidence of 0.5–0.7% per year in sexually active young women. The key objective in evaluating women with dysuria is to exclude serious upper urinary tract disease, such as acute pyelonephritis, and sexually transmitted diseases. In elderly men, dysuria may be a symptom of prostatitis. In contrast, in younger men, urethritis accounts for the vast majority of cases of dysuria. A study found a high rate of UTI in surgery patients admitted after trauma (11%).

CLINICAL FINDINGS

A. Symptoms

Well-designed cohort studies have shown that some women can be reliably diagnosed with uncomplicated cystitis without a physical examination or urinalysis, and randomized controlled trials show that telephone management of uncomplicated cystitis is safe and effective. An increased likelihood of cystitis is present when women report multiple irritative voiding symptoms (dysuria, urgency, frequency), fever, or back pain (LRs = 1.6–2.0). A cohort study found that the symptom of dysuria most reliably predicted a culture-positive UTI. Inquiring about symptoms of vulvovaginitis is imperative. When women report dysuria and urinary frequency, and deny vaginal discharge and irritation, the LR for culture-confirmed cystitis is 24.5. In contrast, when vaginal discharge or irritation is present, as well as dysuria or urinary frequency, the LR is 0.7. Gross hematuria in women with voiding symptoms usually represents hemorrhagic cystitis but can also be a sign of bladder cancer (particularly in older patients) or upper tract disease. Failure of hematuria to resolve with antibiotic treatment should prompt further evaluation of the bladder and kidneys. Chlamydial infection should be strongly considered among women aged 25 years or younger who are sexually active and seeking medical attention for a suspected UTI for the first time or who have a new partner.

Because fever and back pain, as well as nausea and vomiting, are considered harbingers of (or clinical criteria for) acute pyelonephritis, women with these symptoms should usually be examined by a clinician prior to treatment in order to exclude coexistent urosepsis, hydronephrosis, or nephrolithiasis that would affect management decisions. Risk factors for acute pyelonephritis among women 18–49 years of age relate to sexual behaviors (frequent sexual intercourse (3 times per week or more), new sexual partner in previous year, recent spermicide use), as well as diabetes mellitus and recent UTI or incontinence. Finally, pregnancy, underlying structural factors (polycystic kidney disease, nephrolithiasis, neurogenic bladder), immunosuppression, diabetes mellitus, and a history of recent bladder or urethral instrumentation usually alter the treatment regimen (antibiotic choice or duration of treatment, ...

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