Pyuria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

To view a comprehensive algorithm of common findings of urine composition and urine output, click here

Overview

Pyuria refers to urine which contains pus. Defined as the presence of 10 or more neutrophils per high power field of unspun, voided mid-stream urine. It can be a sign of a bacterial urinary tract infection. Pyuria may be present in the septic patient, or in an older patient with pneumonia. Sterile pyuria is urine which contains white blood cells (pus) while appearing sterile by standard culture techniques. Sterile pyuria is listed as a side-effect from some medications such as paracetamol (acetaminophen).

Definition

Pyuria is defined as the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase[1]

Classification

Pyuria may be classified based on the presence/absence of detectable infection as shown below:

  • Sterile pyuria: the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)[2]
  • Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine[3]== Causes==

In Alphabetical Order[4][5]

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Thalidomide
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

Pyuria Differential Diagnosis

Differentiating the diseases that can cause pyuria:

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 Edema Other CBC Electrolytes Urinalysis Ultrasound CT scan Other
Dysuria Frequency Urgency Gross hematuria Cell Cast Bacteriuria Culture Other
Infectious diseases UTI Bacterial Asymptomatic bacteriuria
Cystitis
Pyelonephritis
Viral
Tuberculosis
Fungal
Urethritis Chlamydia
Gonococcus
Prostatitis
Balanitis
PID
Appendicitis
Non-infectious diseases Urinary tract disorders Urinary catheterization
Urinary tract stone
Urinary tract neoplasm
Urinary fistula
Interstitial cystitis
Pelvic irradiation
Renal diseases Polycystic kidney disease (PCO)
Renal vein thrombosis
Interstitial nephritis
Analgesic nephropathy
Papillary necrosis
Systemic disease Systemic lupus erythematosus (SLE)
Kawasaki's disease
Graft versus host disease (GVHD)
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Edema Other CBC Electrolytes Cell Cast Bacteriuria Culture Other Ultrasound CT scan Other Gold standard for diagnosis Associated findings

Sterile Pyuria

Definition

  • Sterile pyuria is defined as the persistent finding of white cells in the urine in the absence of detectable bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)[6]
  • Note that sterile pyuria may still be caused by an infectious agent, but the inability to detect the agent on regular urine gram-stain and culture is diagnostic of sterile pyuria.

Causes

Pyuria may have either an infectious or a non-infectious etiology:[7]

  • Infectious etiologies
  • Gynecologic infection
  • Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
  • Prostatitis
  • Balanitis
  • Appendicitis
  • Viral infection of the lower genitourinary tract
  • Genitourinary tuberculosis
  • Fungal infection
  • Parasitic disease such as trichomoniasis or schistosomiasis
  • Non-infectious etiologies
  • Current use of antibiotics
  • Recently treated urinary tract infection (within past 2 weeks)
  • Presence or recent use of a urinary catheter
  • Recent cystoscopy or urologic endoscopy
  • Urinary tract stones
  • Foreign body such as surgical mesh in the urethra or a retained stent
  • Urinary tract neoplasm
  • Pelvic irradiation
  • Urinary fistula
  • Polycystic kidney
  • Rejection of a renal transplant
  • Renal-vein thrombosis
  • Interstitial nephritis or analgesic nephropathy
  • Papillary necrosis
  • Interstitial cystitis
  • Inflammatory disease such as systemic lupus erythematosus or Kawasaki’s disease===Antimicrobial regimen===

Treatment

  • Sterile pyuria
  • . Pathogen-directed antimicrobial therapy[8]
  • Renal Tuberculosis
  • Gonorrhea
  • Chlamydia
  • Mycoplasma and Ureaplasma
  • Genital herpes
  • Trichomoniasis
Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.
  • Fungal infections[9]
  • Preferred regimen, Candida albicans: Fluconazole 100 mg PO qd for 2-5 days
  • Preferred regimen, non-albicans Candida: Amphotericin B 0.1 mg/kg/day IV for 2-5 days OR Amphotericin B bladder irrigation 5-50 mg/L of sterile water qd for 2-5 days
  • Schistosomiasis
  • Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

References

  1. Horan, Teresa C.; Andrus, Mary; Dudeck, Margaret A. (2008-06). "CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting". American Journal of Infection Control. 36 (5): 309–332. doi:10.1016/j.ajic.2008.03.002. ISSN 1527-3296. PMID 18538699. Check date values in: |date= (help)
  2. Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
  3. Kwon, Jennie H.; Fausone, Maureen K.; Du, Hongyan; Robicsek, Ari; Peterson, Lance R. (2012-05). "Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients". American Journal of Clinical Pathology. 137 (5): 778–784. doi:10.1309/AJCP4KVGQZEG1YDM. ISSN 1943-7722. PMID 22523217. Check date values in: |date= (help)
  4. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  5. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  6. Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
  7. Dieter, R. S. (2000). "Sterile pyuria: a differential diagnosis". Comprehensive Therapy. 26 (3): 150–152. ISSN 0098-8243. PMID 10984817.
  8. Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
  9. Jacobs LG, Skidmore EA, Freeman K, Lipschultz D, Fox N (1996). "Oral fluconazole compared with bladder irrigation with amphotericin B for treatment of fungal urinary tract infections in elderly patients". Clin Infect Dis. 22 (1): 30–5. PMID 8824962.

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