Dysuria / UTI

Dysuria

1. In a patient presenting with dysuria, use history and dipstick urinalysis to determine if the patient has an uncomplicated urinary tract infection.

2. When a diagnosis of uncomplicated urinary tract infection is made, treat promptly without waiting for a culture result.

3. Consider non-urinary tract infection related etiologies of dysuria (e.g., prostatitis, vaginitis, sexually transmitted disease, chemical irritation) and look for them when appropriate.

4. When assessing patients with dysuria, identify those at higher risk of complicated urinary tract infection (e.g., pregnancy, children, diabetes, urolithiasis).

5. In patients with recurrent dysuria, look for a specific underlying cause (e.g., post-coital urinary tract infection, atrophic vaginitis, retention).

UTI

1. 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).

2. Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (e.g., ultrasound).

3. 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).

4. 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).

5. 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.

6. 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