Pyuria dysuria

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

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Differential Diagnosis

Urinary tract infections should be differentiated from one another and from various other diseases:

Diseases	Diagnostic tests			Physical Examination				Symptoms					Past medical history	Other Findings
	Urinalysis	Urine Culture	Gold Standard	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Hematuria	Pyuria	Frequency	Urgency	Dysuria
Differentiating amongst different types of Urinary Tract Infections:
Pyelonephritis	Leukocytes Nitrite +ve	Identifies causative bacteria	Imaging and culture	✔	Flank or costovertebral angle	✔	✔	✔	✔	-	-	✔	History of pyelonephritis Recent history of hospitalisation Nephrolithiasis Immunosupression	Costovertebral angle tenderness Patient is in acute distress Look for obstructive causes
Cystitis	Nitrite +ve Leukocyte esterase+ve WBCs RBCs	>100,000CFU/mL	Urine culture	✔	Suprapubic	-	✔	✔	✔	✔	✔	✔	Recent catheterisation Pregnancy recent intercourse Diabetes Personal or family history of UTI Known abnormality of the urinary tract BPH or HIV	Imaging studies help differentiate the various types May acompany back pain, nausea, vomiting and chills
Urethritis	Positive leukocyte esterase test or >10 WBCs Mucous threads in the morning urine	-	Gram stain & Mucoid or purulent discharge	✔	-	Urethral discharge	✔	-	✔	-	-	✔	Prior STDs Urinary tract infections New sexual partner Recent intercourse Recent catheterization	Purulent discharge may suggest gonorrhoea Exclusive dysuria suggest Chlamydia Painful genital ulcers with dysuria suggest HSV
Prostatitis	10-20 leukocytes for acute and chronic bacterial subtypes	Identifies causative bacteria (in bacterial subtypes)	Urine culture	✔	-	-	-	-	✔	✔	✔	✔	Urogenital disorders Recent catheterization or other genitourinary instrumentation History of UTIs	In acute prostatitis, palpation reveals a tender and enlarged prostate[1][3] In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate[1] A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis
Differentiating UTIs from Other Diseases:
Vulvovagintis	-	-	Gram stain & Culture of discharge	✔	-	Vaginal discharge	✔	-	-	-	-	✔	Number and type of sexual partners (new, casual, or regular) Prior STDs Previous history of symptomatic BV in female partner (in homosexual women)	Fishy odor from the vagina (Whiff test) Thin, white/gray homogeneous vaginal discharge Microscopy (wet prep) and vaginal pH  Clue cells
Cervicitis	-	-	culture for gonococcal cervicitis	✔	Cervical	endocervical exudate	-	-	✔	-	-	✔	Abnormal vaginal bleeding after intercourse or after menopause Abnormal vaginal discharge Painful sexual intercourse Pressure or heaviness in the pelvis	Purulent or mucopurulent endocervical exudate Sustained endocervical bleeding easily induced by a cotton swab >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea
Epididymitis	Hematuria may be seen	✔	Culture	✔	Testicular & Suprapubic	+/- urethral discharge	✔	✔	-	✔	✔	✔	Scrotal pain: starts gradually, is usually unilateral and localized posterior to the testis Scrotal swelling Scrotal wall erythema Constitutional symptoms: feeling warm, chills, nausea and vomiting	Ultrasound in patients with acute testicular pain to assess for testicular torsion If equivocal do surgical exploration
Syphilis (STD)	-	-	Darkfield microscopy	+/-	-	-	✔	-	-	-	-	-	History of STD HIV Immunosupression Previous history of chancre	May be asymptomatic Painless chancre in primary syphilis Secondary syphilis may have generalised features and condylomata lata Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas
BPH	Hematuria may be seen	-	DRE & Serum PSA	-	-	-	-	✔	-	✔	✔	✔	Sudden inability to urinate Urinary tract infections Urinary stones Damage to the kidneys Blood in the urine	Involves mainly central or transitional zone Hyperplasia rather than hypertrophy Obstruction of the urethra Nocturia
Neoplasms	Hematuria may be seen	-	Imaging and biopsy	+-	-	-	✔	✔	-	✔	✔	-	Sudden inability to urinate Recurrent urinary tract infections Weight loss and other constitutional symptoms	Cachexia Gradual progression