Internal Medicine

0521779407-C04 CUNY1086/Karliner 0 521 77940 7 June 14, 2007 20:37

Cystitis and Pyelonephritis 459

■Lower urinary tract infections present with dysuria, urgency, and

frequency.

■Upper urinary tract infections present with fever, nausea, rigors, and

back pain.

■In males, prostate exam should be considered to rule out prostatitis

(gently if acute prostatitis expected).

■In women, pelvic exam should be considered to rule out cervicitis,

pelvic inflammatory disease.

■Bladder palpation and percussion should be used to assess for uri-

nary retention.

tests

■Dipstick urinalysis – assess for leukocyte esterase and nitrites (leuck-

ocyte esterase is more sensitive, nitrites are more specific)

■Microscopic urinalysis – assess for white blood cells (pyuria≥ 10

wbc/hpf in a centrifuged urine sample), red blood cells, and casts

(WBC can be present in pyelonephritis)

■Urine Gram stain to guide empiric therapy

■Midstream urine and blood (if febrile) cultures – suspect Escherichia

coli, Enterococcus sp., Klebsiella sp., Enterobacater sp., Serratia sp.,

Proteus sp., Morganella sp. and Providencia sp. in outpatient setting,

Pseudomonas sp., Candida sp. in hospitalized patient

■Peripheral WBC count (normal in cystitis, elevated in pyelonephritis)

■Post void residual if urinary obstruction is suspected

■Assess for renal calculi by non-contrast CT scan if severe pain or

failure to respond to treatment (no dramatic improvement within

24 h of appropriate antibiotics, recurrence after completion of treat-

ment, or persistent bacteriuria, fever, or pain despite appropriate

antibiotic selection)

■Assess for perinephric abscess by either ultrasound or CT (same cri-

teria as for renal calculi, see above)

differential diagnosis

■Urethritis, cervicitis, pelvic inflammatory disease, prostatitis, pro-

static abscess, renal calculi, urinary obstruction, appendicitis, diver-

ticulitis, ectopic pregnancy

management

■Hydration

■Relief of urinary obstruction (catheter)

■Removal of foreign object (replace or preferably remove indwelling

bladder catheters whenever possible)