Pyelonephritis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2] Syed Hassan A. Kazmi BSc, MD [3]

Overview

Pyelonephritis must be differentiated from other causes of dysuria such as cystitis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia, STDs and neoplasms such as renal cell carcinoma and from causes of abdominal pain such as ectopic pregnancy, renal stone, peritoneal or iliopsoas abscess, and rib fracture.

Differential Diagnosis

The differential diagnoses of pyelonephritis include:[1][2][3][4]

Differential Diagnosis on the basis of Urinary Symptoms

Pyelonephritis can be differentiated from other diseases that cause lower urinary tract irritation symptoms, such as: dysuria, urgency, and frequency, in addition to urethral discharge. The differential list includes: urethritis, cystitis, cervicitis, vulvovaginitis, epididimitis, prostatitis, and syphilis.[2][5][6][7]

Disease Findings
Cystitis Bladder inflammation, Features with increased frequency and urgency, dysuria, and suprapubic pain. Is more common among women. E.coli is the most common pathogen[8][9][10][11].
Urethritis Infection of the urethra,causes dysuria and urethral discharge[6][12][13]
Bacterial vulvovaginitis Presents with dysuria and pruritus, vaginal discharge and odor are almost always present, caused by Gardnerella species[14].
Cervicitis Often asymptomatic,some women have an abnormal vaginal discharge and vaginal bleeding (especially after sexual intercourse)[15]
Prostatitis Bacterial infection of the prostate, causes discomfort during ejaculation[16]
Epididymitis Presents with scrotal pain and swelling accompanied by fever and lower urinary tract irritation symptoms(dysuria and frequency)[17].
Syphilis Presents with generalized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic. It is classically described as 1) non-pruritic bilateral symmetrical mucocutaneous rash; 2) non-tender regional lymphadenopathy; 3) condylomata lata and 4) patchy alopecia.[5]

Differential Diagnosis of flank pain

Since the pain of pyelonephritis radiates to the flank, it must be differentiated from various other causes of flank pain.

Category Disease History Signs and Symptoms Physical Examination Laboratory abnormalities
Nausea/vomiting Hematuria Location of pain Fever Tachycardia Hypotension Hypertension Anorexia Constipation Rebound abdominal tenderness Urinary frequency/Urgency/Dysuria Costovetebral angle tenderness Pelvic Examination Rectal Examination Complete Blood Count (CBC) Urinalysis BUN Creatinine Stone analysis Urine Beta- hCG Abnormal Liver Function Tests (LFTs) Serum Amylase/Lipase Abdominal/Pelvic CT scan Serum Parathyroid hormone levels (PTH)

Renal Pathology

Nephrolithiasis + + - + - - +/- - - + - - - - - - -
  • Non-contrast CT scan may show stone as radiolucency
+/-
Pyelonephritis + + (microscopic) + + + - +/- - + + + - - - - -
  • Globaly decreased contrast uptake
  •  Foci from abscess pockets
-
Renal infarct + + + + - + - - - - - - - - - -
Renal papillary necrosis - + (microscopic) + +/- - + - - - + - - - - - - - -
Renal cell carcinoma + + (microscopic) - - - + + +/- - - - - -
  • Anemia
- - - -
  • Non-contrast CT:
  • Contrast-enhanced:
    • Homogenous (small lesions) to irregular (large lesions) contrast enhancement
-
Uretral stricture - +/- - - - - - - - - + - - - - - - - - - - -

Gynecological Pathology

Pelvic inflammatory disease - -
  • Right/left upper quadrant
+ + + - + - - + - - - - - -
  • Thickening of the uterosacral ligaments
  • Haziness of the pelvic fat
  • Periovarian stranding
  • Enhancement of the adjacent peritoneum
  • Thick-walled, complex fluid collection with septa formation (abscess pockets)
-
Ovarian torsion
  • Sudden acute pain
  • Sharp pain aggravated by walking
  • Intermittent/colicky pain
+ - - + - - - - - - - - - - - - - - - -
  • Twisted ovarian pedicle
  • Enlarged ovary (>4.0 cm)
  • Distended pedicle
  • Possible underlying ovarian lesion
-
Ectopic pregnancy + - - + - - + - + (if ruptured) + - -
  • Low platelet distribution width (decreased platelet activation)
  • Monocytosis
- - - - + +/- - N/A -

Prostate Pathology

Prostatitis - + + + - - - - - + - - - - - - - - -
Prostatic cancer - + - - - - - + - - + - - - - - - - -

Testicular Pathology

Testicular torsion + - - + - - +/- - - +/- - - - - - - - - - - -
Orchitis + - + + - - - - - +/- - - - - - - - - - -

Abdominal Pathology

Cholecystitis + - + + - - + - - - - - - - - - - + +/-
  • Gallbladder distention
  • Wall thickening
  • Mucosal hyperenhancement,
  • Pericholecystic fat stranding or fluid
  • Gallstones
-
Appendicitis + - + + - - + - + +/- - - -
  • Leukocytosis
- - - - - - + (if perforation) -
Diverticulitis + - + + - - + + - - - - - - - - - - + (if perforation)
  • Colonic wall thickening (wall thickness is greater than 3 mm on the short axis of the lumen)
  • Pericolic fat stranding
-
Abdominal aortic aneurysm - - - + + - - - + (if rupture) - - - - - - - - - - - -
  • Ultrasound more sensitive than CT scan
  • CT scan may accurately predict the aneurysmal size
  • Helical CT has faster scanning time (30 to 60 seconds) and the ability to obtain all images in one breath hold
-
Portal vein thrombosis + - + + + - + - + (if bowel ischemia or infarction-secondary to extension of thrombus to superior mesenteric vein) - - - - - - - - + + (if bowel infarction, perforation)
  • On non-contrast CT:
    • Hyperdense thrombus
  • On contrast CT
    • Non-enhancing defect of bland thrombus
    • Tumor thrombus exhibits enhancement
Duodenal ulcer + - + + + - - - + (if perforation) - - - - - - - + (if bowel perforation) -
Ischemic colitis + - + + + (if necrosis and sepsis) + + + + (if transmural necrosis) - - - - - - - + (if bowel perforation) -

For a detailed review of the causes of right flank pain and left flank pain please visit the page on flank pain.

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