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A 22-year-old female presents to the ED with 3 days of increased urinary frequency and suprapubic pain after micturition. She has no fevers, chills, or flank pain, nausea or vomiting, and urethral discharge. There have been no similar complaints in the past. She is sexually active and uses a barrier mode of contraception. She has no history of sexually transmitted diseases. She has no allergies to medications or food. Physical examination is unremarkable. Spot urinary pregnancy test is negative. Urinalysis is significant for 12 white blood cells (WBCs) and 3 red blood cells (RBCs), and the urine is nitrite positive. She has no primary care physician.

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1. What is the diagnosis and the next step of action?

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Answer

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  1. Simple or uncomplicated urinary tract infection. Prescribing short course (3 days) of Bactrim or ciprofloxacin is the next step as she has an uncomplicated lower urinary tract infection that can be managed as an outpatient. She does not need admission to the hospital or need imaging as she has a simple UTI.

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Urinary tract infection is one of the commonest infections encountered by a physician. Clinical presentation could range from annoying urinary symptoms to severe sepsis and death. Further management depends on the severity of the infection. In the above case, the patient is a sexually active young female with no systemic symptoms or comorbid conditions. Lower urinary tract infections are common among sexually active women due to the anatomy of the female urinary tract. Short antibiotic therapy without further imaging is the best course of management for this patient.

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Urinary Tract Infections

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Simple or uncomplicated UTIs are urinary tract infections occurring in healthy premenopausal women without structural or neurological abnormalities. Rest of the UTIs are classified as complicated (males, pregnancy, immunosuppression, diabetes, structural abnormalities including stones, strictures, neurogenic bladder, tumors, etc).

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Urinary tract infections are classified on an anatomical basis into lower and upper UTIs. Lower urinary tract infections include urethritis, cystitis, prostatitis, and epididymitis. Upper urinary tract infections include pyelonephritis. We will discuss topics related to cystitis and pyelonephritis in this section.

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Common Organisms Causing UTIs

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E. coli, Proteus, Klebsiella, Pseudomonas, Staphylococcus saprophyticus, Chlamydia (suspect in patients with history of STDs), and Candida (in patients with indwelling Foley catheter or immunosuppression).

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Cystitis

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Cystitis is the infection/inflammation of the urinary bladder and patients present with urinary frequency, urgency, dysuria, suprapubic discomfort/pain, and hematuria. Physical examination may be positive for suprapubic tenderness.

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Cystitis is a clinical diagnosis, and routine urinalysis or reflex cultures are not required unless there is a recurrence. Urinalysis is considered positive if any of the following are present; nitrite positive or LE positive or >10 WBC/hpf. Men are treated for longer duration due to ...

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