Dysuria is often the 1° complaint of women in vaginitis, bacterial cystitis, subclinical pyelonephritis, acute pyelo, interstial cystitis, genital herpes, or urethritis.
Cystitis:
Sx: frequency, urgency, may have gross hematuria
Hx: recent sexual intercourse, spermacides, antibiotics, catheter, anything that disrupts normal flora or mucin layer.
PE: No CVA tenderness only 15-20% of women with cystitis have suprapubic pain.
Labs: usually positive for pyuria and sometimes positive for bacteriuria and nitrite
Other: Postcoital cystitis will present within 2-3 days of intercourse. 20% of women have recurrent episodes,
Tx: Best single dose: Trimethoprim-sulfamethoxazole, but 3 day dose is more effective.
3-day dose:1st Trim-Sulf, 2nd Fluoroquinolones. Seven day tx has offer no additional benefit.
Subclinical pyelonephritis
Sx: frequency, urgency, may have gross hematuria
Hx: sx present for more than one week, DM, immunocompromised, pregnancy, urinary tract anomaly, vesicoureteral reflux, ureteral obstruction, hx of acute pyle within 1 year, relapse after tx for acute cystitis within 3 days.
PE: may have suprapubic tenderness, no CVA tenderness
Labs:usually positive for pyuria and sometimes bacteriuria and nitrite, culture usually >10Ù5 cfus per ml, positive renal cortical scinitigraphy
Other: if patient has sx of cystitis and one of the risk factors listed in hx than suspect subclinical pyleo, renal parenchymal involvement,
Tx: requires 2 week course of broad spectrum antibiotics, organism identification and sensitivity required.
Acute pyelonephritis
Sx:Nausea, emesis, fever, sepsis, back/flank pain
Hx:may have concurrent cystitits, or hx of cystitis
PE: Fever, CVA tenderness, upper abdominal tenderness to deep palpation
Labs: pyuria usually present with WBC casts
Other:must get culture and sensitivity, E. Coli accounts for 80% of cases, some e.coli cases in young women can cause uncomplicated cystitits in their partner.
Tx: therapy for 10-14 days
Interstitial cystitis-inflammatory condition of the bladder
Sx: frequency, urgency, gross hematuria in 20% of cases, majority have dyspareunia
Hx: middle aged, longterm sx with negative cultures
PE: no CVA tenderness, may have suprapubic pain
Labs: negative for WBCs or bacteria, will have glomerulations or Hunner’s ulcers on cystoscopy, urodynamic studies will indicate reduced bladder capacity
Other: dx of exclusion, may cause depression, avg 4.5 yrs before dx, some pts urinate 60-80 times a day,
Tx: no known curative therapy, therapy is directed towards improving function and
Vaginitis
Sx: external irritation, dicharge or pruritus, dyspareunia, no hematuria
Hx: premenstrual exaggeration of sx, sexual activity, antibiotics, postmenopausal with no HRT
PE: vaginal discharge, inflamed vaginal mucosa, inflamed cervix (trichomonas)
Labs: positive potassium hydroxide or vaginal saline prep, elevated pH (bacterial vaginosis, trich)
Other: 3 days –3 week incubation, symptoms increase during menstruation due to higher pH.
Genital Herpes
Sx: dysuria, fever, headache, myalgias, neck pain, vulvar pain, photophobia
Hx: sexually active, may have vaginal discharge
PE: inguinal adenopathy, grouped painful vesicles
Labs: viral culture
Other: 80% of herpes pts have dysuria
Urethritis
Sx: usually aymptomatic, if sx they are usually delayed > 1week
Hx: unprotected sex
PE: no suprapubic pain unless associated with PID, rarely discharge
Labs: urethral swab positive for WBCs,
Other: must do gram stain and DNA probe for chlamydia and gonorrhea
Catheters
Major source of gram-negative bacteremia in hospitals.
Catheters should be replaced every 2 weeks.
For long-term caths, reduce bacteria by bladder irrigation with neomycin and polymyxin.
UTIs in Children see flow chart pg 102
Uncircumsized infants are at increased risk for UTIs
Voiding dysfunction is a common cause of UTIs.
Bathing, swimming, wiping back to front, are all myths as to why little girls get UTI’s.
Evaluate urine in a child who has fever of unknow origin for three days.