Cystitis in Females Workup

Cystitis in Females Workup
3/2/15, 3:48 PM

Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD more...
Updated: Apr 7, 2014
Approach Considerations
In the 1980s, many experts felt that urine cultures were unnecessary in young women with probable cystitis
because almost all of these were caused by pan-susceptible isolates of Escherichia coli. Since then, however,
antibiotic resistance in uropathogenic E coli has become a significant concern. Resistance has also been emerging
among other common cystitis pathogens, including Enterococcus faecalis, Staphylococcus saprophyticus,
Klebsiella pneumoniae, and Proteus mirabilis.
Trimethoprim-sulfamethoxazole (TMP-SMX) resistance has reached levels as high as 20% in some communities.
Substitution of fluoroquinolones has resulted in an increase in resistance to these drugs, as well.[14]
Nevertheless, according to guidelines from the American College of Obstetricians and Gynecologists, a urine
culture is not required for the initial treatment of women with a symptomatic lower urinary tract infection (UTI) with
pyuria or bacteriuria or both.[15] In a United Kingdom study, dipstick diagnosis proved more cost-effective than
positive midstream urine culture for targeting antibiotic therapy.[4]
Consider obtaining urine cultures in cases of cystitis in immunosuppressed patients and those with a recent history
of instrumentation, exposure to antibiotics, or recurrent infection. Obtaining cultures is also advisable in elderly
women, who have a high rate of upper tract involvement.
Microscopic hematuria is found in about half of cystitis cases; when found without symptoms or pyuria, it should
prompt a search for malignancy. Other possibilities to be considered in the differential diagnosis include calculi,
vasculitis, renal tuberculosis, and glomerulonephritis.
In a developing country, hematuria is suggestive of schistosomiasis. Retention of Schistosoma haematobium eggs
and formation of granulomas in the urinary tract can lead not only to hematuria but also to dysuria, bladder polyps
and ulcers, and even obstructive uropathies. Schistosomiasis can also be associated with salmonellosis and
squamous cell malignancies of the bladder.
Bacteremia is associated with pyelonephritis, corticomedullary abscesses, and perinephric abscesses.
Approximately 10-40% of patients with pyelonephritis or perinephric abscesses have positive results on blood
culture. Bacteremia is not necessarily associated with a higher morbidity or mortality in women with uncomplicated
UTI.
Cervical swabs may be indicated in cases of possible pelvic inflammatory disease.
Visual inspection of the urine is not helpful. Cloudiness of the urine is most often due to protein or crystal
presence, and malodorous urine may be due to diet or medication use.
No imaging studies are indicated in the routine evaluation of cystitis. Renal function testing is not indicated in most
episodes of UTI, but it may be helpful in patients with known urinary tract structural abnormality or renal
insufficiency. Renal function testing also may be helpful in older, particularly ill-appearing hosts or in hosts with
other complications.
A study of 196 women with painful and/or frequent urination found that most could be classified as having a low or
high risk for UTI by asking the following questions[16, 17] :
Does the patient think she has a UTI?
Is there at least considerable pain on urination?
Is there vaginal irritation?
History correctly classified 56% of patients as having a UTI risk of either less than 30% or more than 70%, and
adding urine dipstick results increased this correct classification rate to 73%. Correct classification increased to
83% when patients with intermediate risk (30-70%) after history alone underwent an additional test. The strongest
indicators of UTI were the patient's suspicion of having a UTI and a positive nitrite test.[16, 17]
Urinalysis
The most accurate method to measure pyuria is counting leukocytes in unspun fresh urine using a hemocytometer
chamber; greater than 10 white blood cells (WBCs)/mL is considered abnormal. Counts determined from a wet
mount of centrifuged urine are not reliable measures of pyuria. A noncontaminated specimen is suggested by a
lack of squamous epithelial cells. Pyuria is a sensitive (80-95%) but nonspecific (50-76%) sign of UTI.
White cell casts may be observed in conditions other than infection, and they may not be observed in all cases of
pyelonephritis. If the patient has evidence of acute infection and white cell casts are present, however, the infection
http://emedicine.medscape.com/article/233101-workup
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likely represents pyelonephritis. A spun sample (5 mL at 2000 revolutions per min [rpm] for 5 min) is best used for
evaluation of cellular casts.
Proteinuria is commonly observed in infections of the urinary tract, but the proteinuria usually is low grade. More
than 2 g of protein per 24 hours suggests glomerular disease.
Approximately 70% of patients with corticomedullary abscesses have abnormal urinalysis findings, whereas those
with renal cortical abscesses usually have normal findings. Two thirds of patients with perinephric abscesses have
an abnormal urinalysis.
Urine specimen collection

Urine specimens may be obtained by midstream clean catch, suprapubic aspiration, or catheterization.
The midstream-voided technique is as accurate as catheterization if proper technique is followed. Instruct the
woman to remove her underwear and sit facing the back of the toilet. This promotes proper positioning of the
thighs.
Instruct the patient to spread the labia with one hand and cleanse from front to back with povidone-iodine or
soaped swabs with the other hand; then pass a small amount of urine into the toilet; and finally urinate into the
specimen cup. The use of a tampon may allow a proper specimen if heavy vaginal bleeding or discharge is
present.
Midstream urine specimens may become contaminated, particularly if the woman has difficulty spreading and
maintaining separation of the labia. The presence of squamous cells and lactobacilli on urinalysis suggests
contamination or colonization (see image below). Catheterization may be needed in some women to obtain a clean
specimen, although it poses the risk of iatrogenic infection.[18]
Lactobacilli and a squamous epithelial cell are evident on this vaginal smear. The presence of squamous cells and lactobacilli on
urinalysis suggests contamination or colonization. Source: Centers for Disease Control and Prevention, Dr. Mike Miller
Although the use of midstream urine specimens is widely advocated, one randomized trial in young women
showed that the rate of contamination was nearly identical among those who used midstream clean-catch
technique and those who urinated into a container without cleansing the perineum or discarding the first urine
output. Use of a vaginal tampon in addition to clean-catch technique had no significant effect on the contamination
rate.[19]
Dipstick testing
Dipstick testing should include glucose, protein, blood, nitrite, and leukocyte esterase. Leukocyte esterase is a
dipstick test that can rapidly screen for pyuria; it is 57-96% sensitive and 94-98% specific for identifying pyuria.
Given this broad range of sensitivity, it is important to consider the possibility of false-positive results, particularly
with asymptomatic patients undergoing evaluation for recurrent UTI.
Pyuria, as indicated by a positive result of the leukocyte esterase dipstick test, is found in the vast majority of
patients with UTI. This is an exceedingly useful screening examination that can be performed promptly in any ED
setting. If pyuria is absent, the diagnosis of UTI should be questioned until urine culture results become available.
In a United Kingdom study, dipstick diagnosis based on findings of nitrite or both leukocyte esterase and blood was
77% sensitive and 79% specific, with a positive predictive value of 81% and a negative predictive value of 65%.[4]
Diagnosis on clinical grounds proved less sensitive.
Urine microscopy
A microscopic evaluation of the urine sample for WBC counts, RBC counts, and cellular or hyaline casts should be
performed. In the office, a combination of clinical symptoms with dipstick and microscopic analysis showing pyuria
and/or positive nitrite and leukocyte esterase tests can be used as presumptive evidence of UTI.
Low-level pyuria (6-20 WBCs per high-power field [hpf] microscopy on a centrifuged specimen) may be associated
with an unacceptable level of false-negative results with the leukocyte esterase dipstick test, as Propp et al found
in an ED setting.[20]
In females with appropriate symptoms and examination findings suggestive of UTI, urine microscopy may be
indicated despite a negative result of the leukocyte esterase dipstick test. Current emphasis in the diagnosis of UTI
rests with the detection of pyuria. As noted, a positive leukocyte esterase dipstick test suffices in most instances.
According to Stamm et al, levels of pyuria as low as 2-5 WBCs/hpf in a centrifuged specimen are important in
females with appropriate symptoms. The presence of bacteriuria is significant. However, the presence of
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numerous squamous epithelial cells raises the possibility of contamination.[18] Low-level or, occasionally, frank
hematuria may be noted in otherwise typical UTI; however, its positive predictive value is poor.
Nitrate test
Nitrate tests detect the products of nitrate reductase, an enzyme produced by many bacterial species. These
products are not present normally unless a UTI exists. This test has a sensitivity and specificity of 22% and 94100%, respectively. The low sensitivity has been attributed to enzyme-deficient bacteria causing infection or lowgrade bacteriuria.
A positive result on the nitrate test is highly specific for UTI, typically because of urease-splitting organisms, such
as Proteus species and, occasionally, E coli; however, it is very insensitive as a screening tool, as only 25% of
patients with UTI have a positive nitrate test result.
Urine Culture
Urine culture remains the criterion standard for the diagnosis of UTI. Collected urine should be sent for culture
immediately; if not, it should be refrigerated at 4C. Two culture techniques (dip slide, agar) are widely used and
accurate.
The 2010 Infectious Disease Society of America (IDSA) consensus limits for cystitis and pyelonephritis in women
are more than 1000 colony-forming units (CFU)/mL and more than 10,000 CFU/mL, respectively, for clean-catch
midstream urine specimens. Historically, the definition of UTI was based on the finding at culture of 100,000
CFU/mL of a single organism. However, this misses up to 50% of symptomatic infections, so the lower colony rate
of greater than 1000 CFU/mL is now accepted.[21]
The definition of asymptomatic bacteriuria still uses the historical threshold. Asymptomatic bacteruria in a female is
defined as a urine culture (clean-catch or catheterized specimen) growing greater than 100,000 CFU/mL in an
asymptomatic individual.
Note that any amount of uropathogen grown in culture from a suprapubic aspirate should be considered evidence
of a UTI. Approximately 40% of patients with perinephric abscesses have sterile urine cultures.
An uncomplicated UTI (cystitis) does not require a urine culture unless the woman has experienced a failure of
empiric therapy. Obtain a urine culture in patients suspected of having an upper UTI or a complicated UTI, as well
in those in whom initial treatment fails.
If the patient has had a UTI within the last month, relapse is probably caused by the same organism. Relapse
represents treatment failure. Reinfection occurs in 1-6 months and usually is due to a different organism (or
serotype of the same organism). Obtain a urine culture for patients who are reinfected.
If a Gram stain of an uncentrifuged, clean-catch, midstream urine specimen reveals the presence of 1 bacterium
per oil-immersion field, it represents 10,000 bacteria/mL of urine. A specimen (5 mL) that has been centrifuged for
5 minutes at 2000 rpm and examined under high power after Gram staining will identify lower numbers. In general,
a Gram stain has a sensitivity of 90% and a specificity of 88%.
Complete Blood Cell Count

A CBC is not helpful in differentiating upper from lower UTI or in making decisions regarding admission. However,
significant leukopenia in hosts who are older or immunocompromised may be an ominous finding.
The WBC count may or may not be elevated in patients with uncomplicated UTI, but it is usually elevated in
patients with complicated UTIs. Patients with complicated UTIs may have anemia; for example, anemia is
observed in 40% of patients with perinephric abscesses.
Diagnostic Catheterization
Catheterization is indicated if the patient cannot void spontaneously, if the patient is too debilitated or immobilized,
or if obesity prevents the patient from obtaining a suitable specimen. Measurement of postvoiding residual urine
volume by catheterization may reveal urinary retention in a host with a defective bladder-emptying mechanism.
Measurement of the postvoid residual volume should be strongly considered in all patients who require hospitallevel care. Handheld portable bladder scans may also be used as a noninvasive alternative.
Guidelines from the Centers for Disease Control and Prevention (CDC) advise that in acute care hospital settings,
aseptic technique and sterile equipment for catheter insertion must be used to minimize the risk of catheterassociated UTI. Only properly trained individuals who are skilled in the correct technique of aseptic catheter
insertion and maintenance should take on this task.[22]
For more information on this procedure, see the Medscape Reference article Urethral Catheterization in Women.
Infection in Patients with Spinal Cord Injury

Diagnosing a UTI in a patient with a spinal cord injury is difficult. In patients with SCI, signs and symptoms
suggestive of a UTI are malodorous and cloudy urine, muscular spasticity, fatigue, fevers, chills, and autonomic
instability.
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In these patients, suprapubic aspiration of the bladder is the criterion standard for diagnosing a UTI, although it is
not performed often in clinical practice.
For more information on this topic, see the Medscape Reference article Urinary Tract Infections in Patients with
Spinal Cord Injury.
Infection in Patients with Diabetes Mellitus

Patients with diabetes are at risk for complicated UTIs, which may include renal and perirenal abscess,
emphysematous pyelonephritis, emphysematous cystitis, fungal infections, xanthogranulomatous pyelonephritis,
and papillary necrosis.
For more information, see the Medscape Reference topic Urinary Tract Infections in Diabetes Mellitus.
Cystitis Caused by Candida

Cystitis caused by Candida is clinically similar to cystitis from other pathogens. The presence of fungus in the urine
should be verified by repeating the urinalysis and urine culture. Other features of diagnosis are as follows[23] :
Pyuria is a nonspecific finding
C glabrata may be differentiated from other species by morphology
Candida casts in the urine indicate renal candidiasis but are rarely seen
Colony counts have not proved diagnostically useful
Ultrasonography of the kidneys and collecting systems is the preferred initial study in symptomatic or critically ill
patients with candiduria, but computed tomography is better for detecting pyelonephritis or perinephric abscess.[23]
Contributor Information and Disclosures

Author
John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff,
Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and
Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Coauthor(s)
Mary F Bavaro, MD Fellowship Director, Division of Infectious Disease, Navy Medical Center, San Diego
Mary F Bavaro, MD is a member of the following medical societies: American College of Physicians and
Infectious Diseases Society of America
Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook;
Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians,
American College of Physicians, and Infectious Diseases Society of America
Jeffrey M Tessier, MD Assistant Professor, Division of Infectious Diseases, Department of Internal Medicine,
Virginia Commonwealth University School of Medicine
Jeffrey M Tessier, MD is a member of the following medical societies: American College of Physicians-American
Society of Internal Medicine
Chief Editor
Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G
Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science
Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American
College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious
Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical
Investigation
Additional Contributors
Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities
College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center
Page 4 of 8
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Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of
Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS
Physicians, and Society for Academic Emergency Medicine
Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles,
David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA
Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency
Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, American College of Physicians-American Society of
Internal Medicine, and Society for Academic Emergency Medicine
Elicia S Kennedy, MD Clinical Assistant Professor, Department of Emergency Medicine, University of Arkansas
for Medical Sciences
Elicia S Kennedy, MD is a member of the following medical societies: American College of Emergency
Physicians and Society for Academic Emergency Medicine
Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of
Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine,
Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest
Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and
Society of Critical Care Medicine
Disclosure: Sepracor None None
Allison M Loynd, DO Resident Physician, Department of Emergency Medicine, Wayne State University School
of Medicine, Detroit Receiving Hospital
Allison M Loynd, DO is a member of the following medical societies: American College of Emergency
Physicians, American Medical Association, and Emergency Medicine Residents Association
Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons,
American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of
University Urologists, and Southwest Oncology Group
Adam J Rosh, MD Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne
State University School of Medicine
Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine,
American College of Emergency Physicians, and Society for Academic Emergency Medicine
Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of
Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri
Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency
Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine,
Research Director, State University of New York College of Medicine; Consulting Staff, Department of
Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and
Society for Academic Emergency Medicine
Page 5 of 8
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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College
of Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, and American Medical Association
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