Internal Medicine 14: 18-Year-Old Female For Pre-College
You will complete the Aquifer case, Internal Medicine 14: 18-year-old female for pre-college physical, focusing on the “Revisit three months later” for this assignment.
After completing the Aquifer case, you will present the case and supporting evidence in a PowerPoint presentation with the following components:
- Slide 1: Title, Student Name, Course, Date
- Slide 2: Summary or synopsis of Judy Pham’s case
- Slide 3: HPI
- Slide 4: Medical History
- Slide 5: Family History
- Slide 6: Social History
- Slide 7: ROS
- Slide 8: Examination
- Slide 9: Labs (In-house)
- Slide 10: Primary Diagnosis and 3 Differential Diagnoses – ranked in priority
Primary Diagnosis should be supported by data in the patient’s history, exam, and lab results.
- Slide 11: Management Plan: medication (dose, route, frequency), non-medication treatment, tests ordered, education, follow-up/referral.
- Slide 12-16: An evaluation of 5 evidence-based articles applicable to Ms. Pham’s case: evaluate 1 article per slide.
- Include title, author, and year of article
- Brief summary/purpose of the study
- How did the study support Ms. Pham’s case?
Course texts will not count as a scholarly source. If using data from websites you must go back to the literature source for the information; no secondary sources are allowed, e.g. Medscape, UptoDate, etc.
- Slide 17: Reference List
- You will submit the PowerPoint presentation in the Submissions Area by the due date assigned. Name your Case Study Presentation SU_NSG6430_W7_A2_lastname_firstinitial.docV
Internal Medicine 14: 18-year-old woman for pre-college physical
User: Ariana Amini
Email: aamini@gwu.edu
Date: November 11, 2019 2:19AM
Learning Objectives
The student should be able to:
Obtain a history that differentiates among etiologies of dysuria.
Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.
Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep, and KOH stain.
Describe current recommendations for cervical cancer screening.
Discuss safe sexual practices and efficacy of common methods of contraception.
Knowledge
Adolescent Interview – Safety
Violence
The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape and
school violence are all common. In many urban communities, up to one in four students report carrying a weapon to school. Family violence and
dating violence cross all economic and social boundaries.
Injuries
For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is
important to address use of a seat belt and bike helmets with every adolescent.
Even though you address the safety issues most prevalent in the patient’s community first, do not skip any part of the history based on assumptions
about the patient’s ethnic background or economic status.
Recommended Vaccinations for Adolescents and Teenagers
MMR
MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the
case of pregnant women. Pregnant women should not be vaccinated with MMR because of a risk of fetal transmission since it is a
live virus vaccine.
Hepatitis B Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and hepatic carcinoma. The
series of three injections is recommended for adolescents if they did not receive them when younger.
Meningococcal
The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12 years during the
routine preadolescent immunization visit with a booster dose at age 16 and is recommended for all previously unvaccinated
adolescents aged 11-18 years.
Human
papillomavirus
There are two different human papillomavirus vaccines available. They vary by the number of strains of HPV they protects against,
ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and women
9-26 years old.
The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or 12 years of age.
ACIP also recommends vaccination in males ages 13 through 21 who have not been vaccinated previously or who have not
completed the three-dose series. ACIP states that males aged 22 through 26 years may be vaccinated, but does not recommend
routine vaccination in this age group.
Tetanus,
diphtheria,
acellular
pertussis
The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria and pertussis. It contains acellular
pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that caused high fever and neurologic
symptoms when given to older children and adults. Tdap, which was licensed in 2005, is the first vaccine for adolescents and adults
that protects against all three diseases.
Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred timing between 11
and 12 years. If a patient has received a Td booster, then waiting at least five years between Td and Tdap is encouraged because
the incidence of side effects is lower.
The exception to this rule is the case of type III hypersensitivity reactions. Type III hypersensitivity reactions (Arthus reactions), which
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are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of tetanus toxoid or
diphtheria toxoid-containing vaccines. These reactions are characterized by severe pain, swelling, and sometimes necrosis at the
injection site and occur between 4 and 12 hours following vaccination. It is recommended that patients who have had such a type III
hypersensitivity reaction avoid receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.
Varicella
The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had chickenpox or have
not received the vaccine.
Varicella was added to the list of standard childhood vaccines in 1995. Two doses are required, with the first administered at 12-15
months of age and the second at 4-6 years of age. There is also a combination measles, mumps, rubella, and varicella vaccine
(MMRV) available.
Influenza
The influenza vaccine is recommended for everyone who is at least age six months. It is usually administered in September through
December when the influenza season is imminent.
The H1N1 strain, or “swine” influenza, the predominant strain circulating in the U.S. over the past several years, has high rates of
morbidity and mortality among children and adolescents.
Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.
Haemophilus
influenzae type
b
Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in infants and young
children, but it is not recommended after the age of five years.
When a Pelvic Examination Is Indicated
Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65. There is recent
evidence that screening for cervical cancer in women less than 21 years of age leads to procedures and more harm than benefit. The frequency of
cervical cancer screening with the Papanicolaou (Pap) test for immunocompetent individuals with previously normal tests is once every three years
or, for women ages 30 to 65 years, screening with a combination of cytology and human papillomavirus (HPV) testing every five years.
STI Screening Recommendations
Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.
Test results for some STIs such as gonorrhea must be reported to the public health department.
Most Common Causes of Cystitis
E. coli causes a majority of all cases of uncomplicated urinary tract infections.
Other common organisms include Staphylococcus saprophyticus, Klebsiella pneumonia, and Proteus mirabilis.
Differentiating Cystitis from Pyelonephritis
It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.
Cystitis Pyelonephritis
Clinical
manifestations
dysuria, frequency, urgency,
suprapubic pain, and/or
hematuria
may or may not have symptoms of cystitis together with fever (> 38ºC) and other systemic
symptoms such as, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting
Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)
Treatment
short-course antibiotic therapy
(three days);
hospitalization usually not
required
at least seven days of treatment;
hospitalization may be required
Dysuria in Males
Disease Presentation Diagnosis
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UTI and
cystitis
Isolated acute cystitis is rare in males because their longer urethra hinders
bacteria from reaching the bladder, and prostatic fluid has antibacterial
properties.
Most males with acute cystitis have functional or anatomic abnormalities, and
need further evaluation.
Symptoms of lower and upper tract infections are the same in males and
females.
Midstream culture and sensitivity of the urine
Urethritis
Usually sexually transmitted gonococcal and/or chlamydia infection.
Gonococcal urethritis is more likely in males with acute symptoms and
purulent urethral discharge.
Chlamydia is likely when dysuria is present alone or with minimal discharge.
Males with chlamydia infection may be asymptomatic.
Recommended that patients be treated presumptively for both gonorrhea and
chlamydia, pending results.
Herpes simplex virus is a rare cause of urethritis, but may be suggested by
the history of penile lesions.
Diagnosis can be made on a gram stain of
a urethral swab.
Leukocytes and gram-negative
intracellular diplococci confirm the
diagnosis of gonorrhea.
White cells without organisms suggest
non-gonococcal urethritis (NGU) which is
usually chlamydia but can also be
Trichomonas vaginalis.
Because many outpatient offices are not
equipped to do gram stains, NAAT testing
of the urethra or urine is becoming the
preferred diagnostic test for gonorrhea
and chlamydia.
Prostatitis
Acute prostatitis
Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy,
and is caused by gram-negative rods (Enterobacteriaceae, Pseudomonas,
Proteus), gram-positive organisms (Enterococcus, S. aureus), and sexually
transmitted agents such as Neisseria gonorrhoeae and Chlamydia
trachomatis.
Prostate is edematous and very tender on digital rectal examination.
Chronic prostatitis
Characterized by lower urinary tract symptoms, perineal discomfort, pain with
ejaculation, and occasionally deep pelvic pain that radiates to the back. The
symptoms are often subtle and sometimes may be absent, and the physical
exam may be normal.
This diagnosis should be considered in men with recurrent UTIs without risk
factors.
Diagnosis can be difficult to make and may
require submitting urine specimens gathered
following prostatic massage for microscopic
urinalysis and culture.
Epididymitis
Patients with epididymitis present with dysuria, frequency, urgency, and
unilateral testicular pain.
Fever and rigors may be present and there may be redness and tenderness
of the entire affected testicle.
Testicular torsion should be considered in all cases, especially when the
patient is an adolescent and the onset is sudden.
Epididymitis in men < 35 years is usually caused by Chlamydia trachomatis
or Neisseria gonorrhoeae; in those > 35, enteric gram-negative rods
(Escherichia coli) are the most common causes.
If the diagnosis is questionable, color duplex
doppler scanning should be obtained
immediately.
Factors that Contribute to Complicated Urinary Tract Infections
Hospital-acquired Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing
infections with antibiotic-resistant organisms that are found in the hospital environment.
Pregnant Urinary tract infections in pregnant females can progress to and can induce preterm labor so are thus considered complicated.
Urinary catheter or
recent
instrumentation
Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they
introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial
growth.
Immunosuppressed Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated
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or recently treated
with antibiotics
infections.
Anatomic or
functional
abnormalities of the
urinary tract
Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial
growth and causing complicated infections.
Male
Urinary tract infections in men are complicated because they are commonly associated with bladder outlet obstruction,
instrumentation, or other urologic abnormalities. However, a small number of adult men can develop uncomplicated UTIs. Risk
factors associated with these infections are homosexuality, intercourse with a urinary tract-infected female partner, and lack of
circumcision.
Birth Control Options
Percentage of women experiencing an unintended pregnancy within the first year of use: United States
Method Typical use Perfect use
No method 85 85
Spermicides 29 18
Withdrawal 27 4
Fertility awareness-based methods 25
Standard days method 5
Two day method 4
Ovulation method 3
Sponge
Parous women 32 20
Nulliparous women 16 9
Diaphragm 16 6
Condom
Female (Reality) 21 5
Male 15 2
Combined pill and progestogen-only pill 8 0.3
Evra patch 8 0.3
NuvaRing 8 0.3
Depo-Provera 3 0.3
Combined injectable (Lunelle) 3 0.05
IUD
ParaGard (copper T) 0.8 0.6
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Mirena (LNG-IUS) 0.2 0.2
Implanon 0.05 0.05
Female sterilization 0.5 0.5
Male sterilization 0.15 0.10
Adapted from WHO Medical eligibility criteria for contraceptive use (2009)
Male latex condoms: when correctly used with each episode of intercourse, are the best protection against sexually transmitted infections.
IUDs: can be considered for women at low risk of acquiring sexually transmitted infections, since sexually transmitted infections may require
removal of the IUD. Women with a history of PID can safely use the IUD with appropriate counseling. IUDs can be used as long as the woman
is not planning a pregnancy for at least one year, since attempting a pregnancy would require IUD removal. Women who have never been
pregnant can safely use the IUD.
Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the risk of pregnancy by at
least 75%.
Management
First-Line Empiric Therapy for Cystitis
In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.
In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a poor choice for
empiric therapy.
In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%. Therefore, these
have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these antibiotics vary by geographic
region and can exceed 20% in some areas.
Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas resistance rates
exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant resistant organisms (sometimes referred
to as “collateral damage”). Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are
not eligible to receive recommended first-line agents.
Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there are less data with these agents.
The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate,
2nd-generation cephalosporins (cefaclor), 3rd-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances 1st-generation
cephalosporins (cephalexin and cefadroxil).
In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug-
drug interactions, recent antibiotic use, and renal function, among others.
Recommended Dosing and Duration for Cystitis Therapy
Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has similar efficacy to
that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other recommended first-line agents have
different recommended durations. See the table below for recommended durations of first-line agents.
First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.
Drug Dose and interval Duration
Trimethoprim-sulfamethoxazole 160/800 mg q 12 hours 3 days
Nitrofurantoin monohydrate macrocrystals 100 mg q 12 hours 5 days
Fosfomycin trometamol 3 gm in a single dose 1 dose
Recommended Therapy for Pyelonephritis
In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic urinalysis. Definitive
antibiotic choice should be based on the results of the urine culture.
For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the local resistance rates
are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be
given for pyelonephritis.
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Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism
is known to be susceptible. Two-week regimens are generally advised when using trimethoprim-sulfamethoxazole. If trimethoprim-sulfamethoxazole
is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be
given before starting the course of trimethoprim-sulfamethoxazole.
Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained.
Who Should Be Hospitalized For Pyelonephritis
Patients who cannot maintain oral hydration or cannot take oral medicines should be hospitalized, as should those who have social
circumstances or other factors that hinder adherence to therapy.
Patients who appear septic, who are hemodynamically unstable and who have any complicating factors should also be hospitalized.
In many cases, people with diabetes should be hospitalized for parenteral therapy because they have worse outcomes, and diabetics have an
increased risk of complications such as emphysematous pyelonephritis or abscess.
Pregnant women should be hospitalized because pyelonephritis is associated with an increased incidence of fetal complications and
premature delivery.
Preventing Recurrent UTIs
1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis and urine culture.
Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical irritation, or urethritis.
2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating infections. These
predisposing factors should be treated if present.
3. In patients without predisposing factors, some physicians attempt behavioral and lifestyle modification. Because sexual activity is associated
with recurrent infections, doctors often recommend that women void before and after sexual intercourse. This, and advice to wipe “front to
back,” increase fluid intake (including cranberry juice), and avoid full bladders, have not been proven to reduce the recurrence of infection, but
they are benign maneuvers, and still make sense to many clinicians.
4. For post-menopausal women, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection.
5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at least two in six
months, antibiotic prophylaxis may be considered.
Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do not differ
significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than continuous prophylaxis with
similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise, patient-initiated treatment upon developing
symptoms can represent a cost-effective management strategy if infections are not severe and not frequent.
The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns of the patient’s
prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by observation for reinfection.
Recommended Chlamydia Therapy
First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline 100 mg twice daily . The
one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin are considered alternative treatment agents
and require seven days of therapy.
Studies
Cervical Cancer Screening Guidelines
Age Recommendation
Under
21 Women under the age of 21 should not be tested, regardless of sexual activity.
21-29 Women between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique. HPV testing
should not be used in this age range unless it is prompted by an abnormal Pap result.
30-65 There are three options for screening women between the ages of 30 to 65: 1. “Co-testing” with the Pap test and a high-risk HPV test every
five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years.
Over
65
Women older than 65 who have had negative Pap tests are unlikely to have abnormal Pap tests with repeat testing so should no longer be
screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing continues after the age of 65.
Women in the following groups should be screened yearly:
those with HIV infection
those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids)
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those with diethylstilbestrol (DES) exposure before birth
HPV vaccines target only certain genotypes of HPV. The 9-valent Gardasil-9 includes 7 genotypes that cause cervical cancer (types 16, 18, 31, 33,
45, 52 and 58) and 2 genotypes that most commonly cause genital warts (types 6 and 11), the quadrivalent Gardasil includes the most common
genotypes to cause cervical cancer (types 16 and 18) and the 2 genotypes that most commonly cause genital warts (types 6 and 11). But recipients
of either vaccine are still at risk of developing cervical cancer. Therefore, they should receive age-appropriate screening as discussed above.
However, they are at a decreased risk because types 16 and 18 are the cause of cervical cancer in a majority of cases.
Liquid-based cytology is a method where cervical cells are suspended in a vial of liquid preservative instead of spread from a brush and spatula onto
a glass slide. There are fewer unsatisfactory specimens with liquid Paps, and testing for HPV can be done on fluid from the vial, if warranted.
However, there are more false-positive results with liquid Pap, which can result in needless referrals for colposcopy.
Recommended Pelvic Exam Tests in the Setting of Suspected STIs
Nucleic acid amplification testing
(NAAT) for N. gonorrhea and C.
trachomatis
The best way to test for chlamydia and gonorrhea during a pelvic exam is nucleic acid amplification testing
(NAAT) for N. gonorrhea and C. trachomatis. NAAT is a sensitive and specific assay and has replaced
culture methods. It can be used on urine specimens as well.
Microscopic examination of slide
with drop of vaginal discharge and
potassium hydroxide
The potassium hydroxide slide is used to visualize budding yeast and hyphae that are seen with candida
vaginal infections.
Microscopic examination of slide
with drop of vaginal discharge and
normal saline
The saline-prepped or “wet mount” slide allows for diagnosis of Trichomonas and bacterial vaginosis.
Smelling a slide with a drop of
vaginal discharge and potassium
hydroxide
Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test. The production
of a fishy odor indicates a positive test. A positive whiff-amine test is seen in bacterial vaginosis.
Tests not indicated:
Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of Neisseria
gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid testing.
Smelling a slide with normal saline is not useful.
What to Look for on Wet Mount Slides
In the case of trichomoniasis, wet mount slides reveal trichomonads, which are flagellated protozoans. The treatment is a single dose of 2
grams of metronidazole.
Clue cells can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of a vaginal
discharge in women of childbearing age, is a condition characterized by reduced numbers of normal vaginal lactobacilli and overgrowth of
other vaginal bacteria. Clue cells are epithelial cells entirely covered with these bacteria giving the perimeter a “furlike” appearance. The
treatment of BV is a course of metronidazole 500 mg twice daily for seven days.
It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis, and atrophic
vaginitis.
Diagnostic Tests for Cystitis
Microscopic urinalysis
Pyuria, defined as at least two to five leukocytes per high-powered field in a spun urine specimen, is present in almost all women with cystitis, and
evaluation of midstream urine for white blood cells is the most valuable lab test for urinary tract infection. If white cells are not present in the urine, an
alternative diagnosis should be considered.
Urine dip stick
In ambulatory settings, urine dipstick testing has largely replaced microscopy to confirm the diagnosis of urinary tract infection (UTI), because it is
cheaper, faster and more convenient. Dipsticks detect the presence of leukocyte esterase and nitrite and have comparable accuracy to microscopic
urinalysis in the diagnosis of cystitis. However, they may be negative in low-colony count infections (less than 104 colonies/mL). Therefore, patients
should also have a microscopic urinalysis performed.
Tests not indicated for diagnosis of cystitis
Microscopic evaluation of the urine for bacteriuria is generally not recommended for acute cystitis because bacteria in low quantities (less
than 104 colonies/mL) are difficult to find, even with gram stain.
Urine culture is not cost-effective and not necessary in women with cystitis, because the causative organisms and antibiotic sensitivities are
predictable, and the results of the culture are not immediately available. There are certain situations when obtaining a urine culture is useful,
such as in patients with refractory symptoms or those with history of urinary tract infections with antibiotic-resistant organisms.
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Indications for Imaging or Urologic Evaluation in a Patient with a UTI
Imaging studies and urologic referral are not indicated in the routine evaluation of young women with cystitis or pyelonephritis because they rarely
uncover abnormalities that require treatment. However, in certain groups, further evaluation is recommended to exclude anatomic abnormalities and
complications of pyelonephritis.
Isolation of Proteus can be associated with urologic (struvite) stones so may require imaging, especially in patients with recurrent or refractory
infections despite adequate antibiotic treatment.
Recurrent pyelonephritis should prompt imaging to rule out nephrolithiasis or other urologic anomalies.
Patients with pyelonephritis who remain febrile and show no clinical improvement within 72 hours on appropriate antibiotic therapy should
have imaging to rule out obstruction or renal or perinephric abscesses. The presence of these complications often requires drainage and
longer courses of antibiotics.
Patients with suspected abnormality of the urinary tract.
CT scan or renal ultrasound is recommended as a first step to rule out nephrolithiasis or obstruction prior to urologic evaluation in these
circumstances.
Urologic evaluation, including cystoscopy, should also be performed in those with persistent hematuria after infection has been eradicated.
Clinical Reasoning
Differential of Dysuria, Urinary Frequency, and Hematuria
Most Likely Diagnoses
Gonorrhea
Several sexually transmitted infections, such as chlamydia, gonorrhea, trichomoniasis, and herpes simplex virus can cause
urethritis and dysuria similar to that seen here.
Symptoms that occur gradually over several weeks are more likely with a sexually transmitted urethritis.
Cystitis
Cystitis is an inflammation of the bladder caused most commonly by bacterial infection.
A non-specific term often used interchangeably with cystitis is “urinary tract infection”. Urinary tract infection can denote
infection of any portion of the urinary tract including the kidneys (pyelonephritis) or urethra (urethritis).
Hematuria, urinary frequency, and dysuria are all common features of cystitis.
Urinary frequency and dysuria can also be seen with urethritis, but hematuria is rarely seen with that condition. The
presence of hematuria points to cystitis rather than urethritis in this patient.
Note that fever is not seen with cystitis. When fever is present in the setting of urinary symptoms, pyelonephritis should be
considered.
Pelvic
inflammatory
disease
Pelvic inflammatory disease, often called PID, is the name for a spectrum of disorders of the upper female genital tract,
including endometritis, tubo-ovarian abscess and salpingitis.
Often sexually transmitted infections are the source of PID, which can lead to infertility if not treated.
Women with PID may have subtle symptoms, and physical exam findings of cervical motion tenderness, and uterine or
adnexal tenderness are important diagnostic features of PID.
In addition to vaginal discharge, abdominal and pelvic pain are common in PID-more so than with the other diagnoses.
Fever is variably present in PID, and is more likely in severe cases.
Less Likely Diagnoses
Pyelonephritis
Pyelonephritis is an infection of the kidney, or upper urinary tract.
Dysuria may be present, but is rarely the only symptom.
Symptoms that suggest the diagnosis of pyelonephritis are flank pain, fever, chills, nausea, vomiting, and prostration none of
which are present here.
Fever is usually present with pyelonephritis, but not always, so a lack of fever argues against this diagnosis.
Candidiasis
Candidiasis is an often-neglected cause of dysuria, and is perceived as pain or burning when urine comes in contact with an
inflamed perineum or labia.
A vaginal yeast infection may cause inflammation of the perineum and the urethral orifice, called “vaginitis” that leads to
dysuria. This so-called “external dysuria” is most common with candida and trichomonas vaginitis, but is also present in
patients with genital ulcers from herpes simplex, and in irritant vaginitis from soaps, hygiene products, condoms, and
spermicides.
Urinary frequency, urgency or hematuria are symptoms related to the bladder and urethra. When present, they speak against
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the diagnosis of vaginitis.
Bacterial
vaginosis
Bacterial vaginosis is a condition marked increased malodorous vaginal discharge.
It is caused by an imbalance of naturally occurring vaginal flora.
It is not an inflammatory condition, therefore pain and burning are rarely seen.
Sexual activity is a risk factor for bacterial vaginosis, but there is no clear evidence that it is transmitted sexually.
Interstitial
cystitis
Interstitial cystitis, also known as painful bladder syndrome, is a chronic pain syndrome characterized by frequency, urgency
and dysuria.
However, it is less likely to present with hematuria and is less likely to have such an acute onset.
Nephrolithiasis Although nephrolithiasis can cause hematuria, it usually does not present with dysuria or urinary frequency.
References
Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women.
Cochrane Database Syst Rev. 2004;(3):CD001209.
Goldring J, Rosen D. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21:64.
Gupta K, Hooton TM, Naber KG, Wullt B, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious
Diseases. Clin Infect Dis 2011;52:e103-20. DOI: 10.1093/cid/ciq257.
Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med
2007;167:2207-12. DOI: 10.1001/archinte.167.20.2207.
Hooton TM. Recurrent urinary tract infection in women. Int J Antimicrob Agents 2001;17(4):259-68.
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Rep. 2011;60(2):1-60.
Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for cervical cancer: a decision analysis for the U.S. Preventive Services Task Force.
https://www.ncbi.nlm.nih.gov/books/NBK92546/. Agency for Healthcare Research and Quality, Publication No. 11-05157-EF-1. Published May 2011.
Accessed August 21, 2019.
Qaseem A, Snow V, Shekelle P, Hopkins R Jr, et al. Screening for HIV in health care settings: a guidance statement from the American College of
Physicians and HIV Medicine Association. Ann Intern Med. 2009 Jan 20;150(2):125-31. DOI: 10.7326/0003-4819-150-2-200901200-00300.
U.S. Preventive Services Task Force. Final Recommendation Statement: Cervical Cancer: Screening.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2. Accessed August 21,
2019.
WHO Medical eligibility criteria for contraceptive use. 2009.
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