Sterile pyuria differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Pyuria Differential Diagnosis

Differentiating the diseases that can cause sterile pyuria:[1][2][3][4]

To review differential diagnosis of pyuria, click here.

Category Disease Clinical manifestations Para−clinical findings Gold standard for diagnosis Associated findings
Symptoms Physical examination
Lab Findings Imaging
Pain Fever N/V Urinary symptoms BP Other CBC Electrolytes Urinalysis
Dysuria Frequency Urgency Gross hematuria Cell Cast Bacteriuria Culture Other
Infectious diseases UTI[5] Viral[6][7] − − + + + + ± Nl − Nl Nl + − − − NA NA PCR viral load
Tuberculosis[8][9][10][11] − ± − + + + + Nl − Nl Nl ± − − Positive mycobacterial urine culture Pulmonary TB on chest CT Urine mycobacterial PCR
Fungal[12][13] − − − + + − − Nl − Nl Nl ± − − + after several weeks of follow up NA Hydronephrosis on ultrasound Urine culture
  • Increased risk in patients with long−term foley catheters
  • Candida as the most prevalent fungus
STD Chlamydia[14][15] Chronic pelvic pain − − + + − − Nl Nl Nl + − − + NA NA PCR
  • Females might have concurrent chlamydial cervicitis
  • Must be considered in young, sexually active males
Gonococcus[16][17][18] Chronic pelvic pain − − + + − − Nl Nl Nl + − − +

High false negative result

NA Nucleic acid amplification testing (NAAT)
  • Females might have concurrent cervical gonococcal infection
  • Must be considered in young, sexually active males
Ureaplasma urealyticum[19] − − − + + − − Nl − Nl Nl + − − −
  • Gram stain −
 NA PCR
  • Associated with complications of pregnancy
Herpes simplex virus[20] + + − + + − − Nl Nl Nl + − − Viral culture + NA NA Clinical manifestation + PCR
  • Associated with extragenital complications, like aseptic meningitis
  • High risk of recurrence 
Herpes zoster[21] − − − + + − − Nl Nl Nl + − − − NA Clinical manifestation + PCR
  • Associated with lumbosacral dermatome involvement
HPV[22] − − − + − − − Nl Nl Nl + − − − NA NA Clinical manifestation + PCR
HIV[23] − + + + + − − Nl Nl + − − − NA NA Combination antigen/antibody immunoassay + PCR HIV viral load test
Appendicitis[24][25] Right lower abdominal pain + + + + + − Nl Nl + − − − Enlarged appendiceal diameter on CT scan or ultrasound Clinical manifestation NA
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
Non−infectious diseases Urinary tract disorders Urinary tract stone[26][27] Colicky pain − + + + + ± Nl − Nl Nl + − − − Visible stone on CT scan Clinical manifestation
  • Might cause renal obstruction
Urinary tract neoplasm[28] + + + + + + + Nl − Nl Nl + − − − Visible tumor on CT scan Cystoscopy  + biopsy
Urinary fistula[29] − − − + + − − Nl Nl Nl + − − − NA Fistula on cystoscopy or IVP Physical examination
  • History of recent surgery
Interstitial cystitis[30] Chronic bladder pain − − + + + − Nl Nl Nl + − − − NA NA Clinical manifestation Associated with other chronic pain syndromes
Vesicoureteral reflux[31] + − − + − − − Nl Nl Nl + − − − Imaging
Hydronephrosis[32] − − − + − − − Nl Nl Nl + − − − Imaging
Renal diseases Polycystic kidney disease[33]  Flank or back pain − − + + − + ↑ Nl Nl + − − − Multiple cysts on ultrasound Imaging
Renal vein thrombosis[34] Flank pain + + + + + + Nl or ↑ + − − − Thrombosis on CT scan Renal venography
Interstitial nephritis[35] Lower back pain − − + + − − Nl or ↑ + + − − Nl Clinical manifestation + urinalysis
IgA nephropathy[36] − − − − − − + Nl or ↑
  • Might be asymptomatic
 Nl Nl + − − − Nl Biopsy
Renal transplant rejection[37] Flank pain + + + + + + ↑ Nl + + − − Increased graft size on ultrasound Renal allograft biopsy
Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
Systemic disease Diabetic nephropathy[38] − − − − − − ± ↑
  • Might be asymptomatic
 Nl Nl + − − − Nl Clinical manifestation + laboratory tests
Lupus nephritis[39] − + − + + + + ↑ Nl + + − − Enlarged kidneys on CT scan Biopsy
  •  Abnormal results of specific serologic tests
Sjögren’s syndrome[40] − − − + + − − ↑ Nl + + − − Abnormal diffuse fat tissue deposition and diffuse punctate calcification on parotid gland CT scan Clinical manifestation + laboratory tests
  •  Abnormal results of specific serologic tests
Kawasaki's disease[41] − + − + + + − Nl + − − − − Vessels involvement on angiography Clinical manifestation Associated with multiple organ involvement including heart
Medication/toxin Analgesic nephropathy[42] Flank pain + + + + + + ↑ + + − − Renal impairment on CT scan Imaging
Contrast−induced nephropathy[43] + − + + − − − Nl Nl + + − − NA Clinical manifestation + exclusion of other causes of AKI
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
  1. ↑ Wise, Gilbert J.; Longo, Dan L.; Schlegel, Peter N. (2015). "Sterile Pyuria". New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 0028-4793.
  2. ↑ Stamm, Walter E. (1983). "Measurement of pyuria and its relation to bacteriuria". The American Journal of Medicine. 75 (1): 53–58. doi:10.1016/0002-9343(83)90073-6. ISSN 0002-9343.
  3. ↑ Groah, Suzanne; Perez-Losada, Marcos; Caldovic, Ljubica; Ljungberg, Inger; Sprague, Bruce; Castro-Nallar, Eduardo; Shah, Neel; Hsieh, Michael; Pohl, Hans (2015). "MP20-08 PYURIA AND ASYMPTOMATIC BACTERIURIA IS ASSOCIATED WITH NOVEL AND SPECIFIC URINE MICROBIOMES". The Journal of Urology. 193 (4): e226. doi:10.1016/j.juro.2015.02.980. ISSN 0022-5347.
  4. ↑ Shaikh, N.; Shope, T. R.; Hoberman, A.; Vigliotti, A.; Kurs-Lasky, M.; Martin, J. M. (2016). "Association Between Uropathogen and Pyuria". PEDIATRICS. 138 (1): e20160087–e20160087. doi:10.1542/peds.2016-0087. ISSN 0031-4005.
  5. ↑ Neal DE (February 2008). "Complicated urinary tract infections". Urol. Clin. North Am. 35 (1): 13–22, v. doi:10.1016/j.ucl.2007.09.010. PMID 18061020.
  6. ↑ Aboumohamed A, Flechner SM, Chiesa-Vottero A, Srinivas TR, Mossad SB (November 2014). "Disseminated adenoviral infection masquerading as lower urinary tract voiding dysfunction in a kidney transplant recipient". Clin. Nephrol. 82 (5): 332–6. doi:10.5414/CN107977. PMID 23816478.
  7. ↑ Santiago-Rodriguez TM, Ly M, Bonilla N, Pride DT (2015). "The human urine virome in association with urinary tract infections". Front Microbiol. 6: 14. doi:10.3389/fmicb.2015.00014. PMC 4304238. PMID 25667584.
  8. ↑ Altiparmak MR, Trabulus S, Balkan II, Yalin SF, Denizli N, Aslan G, Doruk HE, Engin A, Tekin R, Birengel S, Cetin BD, Arslan F, Turhan V, Mert A (August 2015). "Urinary tuberculosis: a cohort of 79 adult cases". Ren Fail. 37 (7): 1157–63. doi:10.3109/0886022X.2015.1057460. PMID 26123266.
  9. ↑ Verma AK, Mishra AK, Kumar M, Kant S, Singh A, Singh A (July 2016). "Renal tuberculosis presenting as acute pyelonephritis - A rarity". Indian J Tuberc. 63 (3): 210–213. doi:10.1016/j.ijtb.2015.07.010. PMID 27865246.
  10. ↑ Daher Ede F, da Silva GB, Barros EJ (January 2013). "Renal tuberculosis in the modern era". Am. J. Trop. Med. Hyg. 88 (1): 54–64. doi:10.4269/ajtmh.2013.12-0413. PMC 3541747. PMID 23303798.
  11. ↑ Czapka M, Shukla S, Slosar-Cheah M (August 2017). "Urine trouble: genitourinary tuberculosis and subsequent DRESS syndrome". BMJ Case Rep. 2017. doi:10.1136/bcr-2017-220440. PMID 28784884.
  12. ↑ Kim J, Kim DS, Lee YS, Choi NG (September 2011). "Fungal urinary tract infection in burn patients with long-term foley catheterization". Korean J Urol. 52 (9): 626–31. doi:10.4111/kju.2011.52.9.626. PMC 3198237. PMID 22025959.
  13. ↑ Carvalho M, Guimarães CM, Mayer JR, Bordignon GP, Queiroz-Telles F (December 2001). "Hospital-associated funguria: analysis of risk factors, clinical presentation and outcome". Braz J Infect Dis. 5 (6): 313–8. PMID 11980593.
  14. ↑ Matthews, R.S.; Bonigal, S.D.; Wise, R. (1990). "Sterile pyuria and Chlamydia trachomatis". The Lancet. 336 (8711): 385. doi:10.1016/0140-6736(90)91936-5. ISSN 0140-6736.
  15. ↑ Tayal SC, Pattman RS (1996). "Sterile pyuria: consider chlamydial infection". Br J Clin Pract. 50 (3): 166–7. PMID 8733337.
  16. ↑ Clarke M, Maskell R (December 1981). "Gonorrhoea presenting as "sterile" pyuria". Br Med J (Clin Res Ed). 283 (6305): 1546. PMC 1507898. PMID 6799059.
  17. ↑ Jephcott AE (August 1997). "Microbiological diagnosis of gonorrhoea". Genitourin Med. 73 (4): 245–52. PMC 1195851. PMID 9389943.
  18. ↑ Tomas ME, Getman D, Donskey CJ, Hecker MT (August 2015). "Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department". J. Clin. Microbiol. 53 (8): 2686–92. doi:10.1128/JCM.00670-15. PMC 4508438. PMID 26063863.
  19. ↑ Nassar FA, Abu-Elamreen FH, Shubair ME, Sharif FA (2008). "Detection of Chlamydia trachomatis and Mycoplasma hominis, genitalium and Ureaplasma urealyticum by polymerase chain reaction in patients with sterile pyuria". Adv Med Sci. 53 (1): 80–6. doi:10.2478/v10039-008-0020-1. PMID 18614434.
  20. ↑ Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, Berman SM, Markowitz LE (August 2006). "Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States". JAMA. 296 (8): 964–73. doi:10.1001/jama.296.8.964. PMID 16926356.
  21. ↑ Chen, Po-Hong; Hsueh, Hsiu-Fang; Hong, Chang-Zern (2002). "Herpes zoster–associated voiding dysfunction: A retrospective study and literature review". Archives of Physical Medicine and Rehabilitation. 83 (11): 1624–1628. doi:10.1053/apmr.2002.34602. ISSN 0003-9993.
  22. ↑ Guo CC, Fine SW, Epstein JI (July 2006). "Noninvasive squamous lesions in the urinary bladder: a clinicopathologic analysis of 29 cases". Am. J. Surg. Pathol. 30 (7): 883–91. doi:10.1097/01.pas.0000213283.20166.5a. PMID 16819332.
  23. ↑ Parkhie SM, Fine DM, Lucas GM, Atta MG (May 2010). "Characteristics of patients with HIV and biopsy-proven acute interstitial nephritis". Clin J Am Soc Nephrol. 5 (5): 798–804. doi:10.2215/CJN.08211109. PMC 2863972. PMID 20338962.
  24. ↑ Lee SL, Walsh AJ, Ho HS (May 2001). "Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis". Arch Surg. 136 (5): 556–62. PMID 11343547.
  25. ↑ Mahattanobon S, Samphao S, Pruekprasert P (August 2014). "Clinical features of complicated acute appendicitis". J Med Assoc Thai. 97 (8): 835–40. PMID 25345259.
  26. ↑ Fwu CW, Eggers PW, Kimmel PL, Kusek JW, Kirkali Z (March 2013). "Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States". Kidney Int. 83 (3): 479–86. doi:10.1038/ki.2012.419. PMC 3587650. PMID 23283137.
  27. ↑ Singh P, Enders FT, Vaughan LE, Bergstralh EJ, Knoedler JJ, Krambeck AE, Lieske JC, Rule AD (October 2015). "Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community". Mayo Clin. Proc. 90 (10): 1356–65. doi:10.1016/j.mayocp.2015.07.016. PMC 4593754. PMID 26349951.
  28. ↑ Azuma T, Nagase Y, Oshi M (September 2013). "Pyuria predicts poor prognosis in patients with non-muscle-invasive bladder cancer". Clin Genitourin Cancer. 11 (3): 331–6. doi:10.1016/j.clgc.2013.04.002. PMID 23664207.
  29. ↑ Hampton BS, Kay A, Pilzek A (January 2015). "Urinary fistula and incontinence". Semin. Reprod. Med. 33 (1): 47–52. doi:10.1055/s-0034-1395279. PMID 25565512.
  30. ↑ Konkle KS, Berry SH, Elliott MN, Hilton L, Suttorp MJ, Clauw DJ, Clemens JQ (February 2012). "Comparison of an interstitial cystitis/bladder pain syndrome clinical cohort with symptomatic community women from the RAND Interstitial Cystitis Epidemiology study". J. Urol. 187 (2): 508–12. doi:10.1016/j.juro.2011.10.040. PMC 3894739. PMID 22177158.
  31. ↑ Hubert KC, Kokorowski PJ, Huang L, Prasad MM, Rosoklija I, Retik AB, Nelson CP (February 2014). "New contralateral vesicoureteral reflux after unilateral ureteral reimplantation: predictive factors and clinical outcomes". J. Urol. 191 (2): 451–7. doi:10.1016/j.juro.2013.08.076. PMC 4123205. PMID 24012582.
  32. ↑ Dancz CE, Walker D, Thomas D, Özel B (August 2015). "Prevalence of Hydronephrosis in Women With Advanced Pelvic Organ Prolapse". Urology. 86 (2): 250–4. doi:10.1016/j.urology.2015.05.005. PMID 26194290.
  33. ↑ Paul BM, Vanden Heuvel GB (2014). "Kidney: polycystic kidney disease". Wiley Interdiscip Rev Dev Biol. 3 (6): 465–87. doi:10.1002/wdev.152. PMC 4423807. PMID 25186187.
  34. ↑ Mahmoodi BK, ten Kate MK, Waanders F, Veeger NJ, Brouwer JL, Vogt L, Navis G, van der Meer J (January 2008). "High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: results from a large retrospective cohort study". Circulation. 117 (2): 224–30. doi:10.1161/CIRCULATIONAHA.107.716951. PMID 18158362.
  35. ↑ Raghavan R, Eknoyan G (September 2014). "Acute interstitial nephritis - a reappraisal and update". Clin. Nephrol. 82 (3): 149–62. PMC 4928030. PMID 25079860.
  36. ↑ Roberts IS (August 2014). "Pathology of IgA nephropathy". Nat Rev Nephrol. 10 (8): 445–54. doi:10.1038/nrneph.2014.92. PMID 24861083.
  37. ↑ Martin-Moreno PL, Tripathi S, Chandraker A (May 2018). "Regulatory T Cells and Kidney Transplantation". Clin J Am Soc Nephrol. doi:10.2215/CJN.01750218. PMID 29789350.
  38. ↑ Bjornstad P, Cherney D, Maahs DM (August 2014). "Early diabetic nephropathy in type 1 diabetes: new insights". Curr Opin Endocrinol Diabetes Obes. 21 (4): 279–86. doi:10.1097/MED.0000000000000074. PMC 4138314. PMID 24983394.
  39. ↑ Schwartz, Noa; Goilav, Beatrice; Putterman, Chaim (2014). "The pathogenesis, diagnosis and treatment of lupus nephritis". Current Opinion in Rheumatology. 26 (5): 502–509. doi:10.1097/BOR.0000000000000089. ISSN 1040-8711.
  40. ↑ de Paiva, Cintia S.; Rocha, Eduardo Melani (2015). "Sjögren syndrome". Current Opinion in Ophthalmology. 26 (6): 517–525. doi:10.1097/ICU.0000000000000208. ISSN 1040-8738.
  41. ↑ Wirojanan J, Sopontammarak S, Vachvanichsanong P (March 2004). "Sterile pyuria in Kawasaki disease". Pediatr. Nephrol. 19 (3): 363. doi:10.1007/s00467-003-1394-8. PMID 14745638.
  42. ↑ Henderickx M, Brits T, De Baets K, Seghers M, Maes P, Trouet D, De Wachter S, De Win G (June 2017). "Renal papillary necrosis in patients with sickle cell disease: How to recognize this 'forgotten' diagnosis". J Pediatr Urol. 13 (3): 250–256. doi:10.1016/j.jpurol.2017.01.020. PMID 28341428. Vancouver style error: initials (help)
  43. ↑ Patschan, D.; Buschmann, I.; Ritter, O. (2018). "Contrast-Induced Nephropathy: Update on the Use of Crystalloids and Pharmacological Measures". International Journal of Nephrology. 2018: 1–8. doi:10.1155/2018/5727309. ISSN 2090-214X.
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