eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Urinary Tract Infections in Pregnancy: Differential Diagnoses & Workup

Author: Leticia A Jones, MD, Clinical Instructor, Department of Obstetrics and Gynecology, Indiana University Hospital, Clarian Health Partners
Coauthor(s): Patrick J Woodman, DO, Assistant Director, Urogynecology (FPMRS) Fellowship, Associate Clinical Professor, Indiana University School of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Methodist Hospital; Henry E Ruiz, MD, Chief, Reconstructive Urology and Urodynamics, Urology Associates of South Texas, PA and Radiation Oncology Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Differential Diagnoses

Bladder Cancer
Ureteral Stricture
Bladder Stones
Ureteral Trauma
Bladder Trauma
Ureterocele
Candidiasis
Urethral Cancer
Chlamydial Genitourinary Infections
Urethral Caruncle
Cystitis, Nonbacterial
Urethral Diverticula
Ectopic Pregnancy
Urethral Prolapse
Gardnerella
Urethral Strictures
Interstitial Cystitis
Urethral Syndrome
Nephrolithiasis
Urethral Trauma
Trichomoniasis
Urethral Warts
Trigonitis
Urethritis

Other Problems to Be Considered

Bacteriuria
Glomerulonephritis
Group B streptococci colonization
Threatened or incomplete miscarriage
Urge incontinence

Workup

Laboratory Studies

  • Urine specimen collection
    • Obtain a midstream, clean-catch urine specimen from all patients with urinary tract symptoms. Collect a catheterized specimen from patients who are unable to provide a clean-catch specimen. Routine catheterization is not recommended because of the risks of introducing bacteria into the urinary tract.
    • Several methods are available for specimen evaluation; all have benefits and limitations. The clean-catch specimen reduces, but does not eliminate, the possibility of cross-contamination from the urethra and vagina. The presence of more than one organism in a culture usually indicates a contaminated specimen.
    • Send the specimen for evaluation as soon as possible. Specimens that are allowed to sit at room temperature may have falsely elevated colony counts. Refrigerate the specimen at 4°C if it cannot be transported immediately.
  • Urine culture
    • This is the criterion standard for evaluation of a urinary tract infection (UTI) during pregnancy. A urine culture should be obtained upon admission from patients with pyelonephritis and from those with recurrent infection or those who are not responding to initial treatment regimens.
    • A colony count of 100,000 colony-forming units (CFUs) per milliliter has historically been used to define a positive culture result. Powers has reported a true positive result on culture may have as low as 100 CFUs per milliliter of bacteria.
    • Culture results can be used to identify specific organisms and antibiotic sensitivities.
    • Urine culture has an average cost of approximately $40.
    • Results are often unavailable at the time of treatment.
  • Urinalysis
    • Positive results for nitrites, leukocyte esterase, WBCs, RBCs, and protein suggest UTI. Bacteria found in the specimen can help with the diagnosis.
    • Urinalysis has a specificity of 97-100%, but its sensitivity ranges from 25-67% when compared to culture in the diagnosis of asymptomatic bacteriuria (ASB).
    • Millar and Cox (1997) indicate that 1-2 bacteria in an unspun catheterized specimen or more than 20 bacteria per high-power field in spun urine correlate closely with more than 100,000 CFUs per milliliter of bacteria on a urine culture.5
  • Urine dip
    • Several reports describe the use of urine dip for nitrites and leukocyte esterase in the evaluation of ASB.
    • Sensitivities range from 50-92%, and specificity is 86-97% when compared with culture in the diagnosis of ASB.
    • In the evaluation of symptomatic patients, this is a useful and inexpensive test.
    • The addition of protein and blood increases the sensitivity and specificity of the test in the evaluation of UTI.

Imaging Studies

Routine imaging studies are not indicated in the evaluation of pregnancy-related UTI.

  • Renal ultrasonography (or limited intravenous pyelography [IVP] if the benefits of a definitive diagnosis outweigh the minor risk of radiation) may be helpful in patients with recurrent UTI or symptoms that suggest nephrolithiasis (see Images 1-4). Urolithiasis and pyelonephritis share many common symptoms (ie, hematuria, flank pain, shaking chills, anorexia). Urolithiasis is usually unassociated with fever except in patients with concomitant pyelonephritis.
  • Confusion about the diagnosis of urolithiasis, pyelonephritis, or both is an indication for obtaining imaging studies.
    • Urolithiasis offers a unique problem in the pregnant female. The presence of a stone should initially be treated conservatively because 50-67% of stones diagnosed during pregnancy pass spontaneously. Conservative therapy includes appropriate antibiotic coverage, adequate hydration, and systemic analgesics (usually narcotics, which are class C in pregnancy). Anti-inflammatory medications may cause oligohydramnios and/or premature closure of the patent ductus arteriosus and should be avoided, if possible.
    • If ultrasonography reveals a stone, then ultrasound-guided cystoscopic passage of a ureteral stent may relieve ureteral colic. In some cases (ie, pyonephrosis with an obstructing stone), percutaneous nephrostomy can be useful. Cystoscopic extraction (with fluoroscopic guidance) of a distal ureteral stone should be used sparingly because of the risk of ionizing radiation to the fetus.
    • The total dosage of ionizing radiation should not exceed 3-5 rads during the course of pregnancy. Of particular concern is radiation delivered during the first trimester, during organogenesis (especially days 11-56). A limited IVP can deliver 0.4-1 rad. Doses of more than 5 rads have been associated with an increase in benign and malignant tumors in the child after birth. No patient should receive more than 10-14 rads.
    • Renal ultrasonography is often performed initially, but the findings are often inconclusive. A limited IVP (ie, kidneys, ureters, and bladder [KUB] and a 30-min shot following injection of contrast) can be helpful in delineating the site of obstruction.

Other Tests

  • Other tests are rarely indicated in the diagnosis of UTI during pregnancy.
  • Urine cytology may be useful in detecting rare upper urinary tract lesions. An antistreptolysin-O (ASO) titer greater than 200 Todd units suggests recent group A streptococcal infection; however, as many as 20% of patients with acute glomerulonephritis have ASO titers within the reference range.
  • The sulfosalicylic acid (SSA) test measures urine turbidity when a small amount of aspirin is added to the urine specimen. A finding of +2 to +4 suggests bacteriuria.

Procedures

  • Evaluation of fetal status
    • Obtain fetal heart tones, if possible. This depends on the gestational age of the fetus.
    • Evaluation of fetal status may help to narrow the differential diagnoses.

Histologic Findings

Histological findings can be described for urine cytology. Clumping WBCs and WBC casts are consistent with pyelonephritis. RBC casts are characteristic of acute glomerulonephritis and should be suspected after a recent or concurrent streptococcal infection.

Renal involvement usually leads to proteinuria. Nephrotic syndrome includes high proteinuria (>3.5 g/24 h), edema, hypercholesterolemia, and hypoalbuminemia; however, this can be confused with preeclampsia. Oval fat bodies and fatty casts can suggest membranous glomerulonephritis.

More on Urinary Tract Infections in Pregnancy

Overview: Urinary Tract Infections in Pregnancy
Differential Diagnoses & Workup: Urinary Tract Infections in Pregnancy
Treatment & Medication: Urinary Tract Infections in Pregnancy
Follow-up: Urinary Tract Infections in Pregnancy
Multimedia: Urinary Tract Infections in Pregnancy
References
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Further Reading

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Keywords

urinary tract infection, UTI, upper urinary tract infection, lower urinary tract infection, upper UTI, lower UTI, asymptomatic bacteriuria, ASB, bacteriuria, cystitis, urethritis, pyelonephritis, Escherichia coli, E coli, urinary stasis, ureterovesical reflux, vesicoureteral reflux, pyuria, acute cystitis, upper urinary tract disease, acute pyelonephritis, group B Streptococcus, GBS, Klebsiella pneumoniae, K pneumoniae, Proteus mirabilis, P mirabilis, Enterobacter species, Staphylococcus saprophyticus, S saprophyticus, group B beta-hemolytic Streptococcus, group B beta-hemolytic streptococci

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Contributor Information and Disclosures

Author

Leticia A Jones, MD, Clinical Instructor, Department of Obstetrics and Gynecology, Indiana University Hospital, Clarian Health Partners
Leticia A Jones, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick J Woodman, DO, Assistant Director, Urogynecology (FPMRS) Fellowship, Associate Clinical Professor, Indiana University School of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Methodist Hospital
Patrick J Woodman, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Osteopathic Association, American Urogynecologic Society, Association of Professors of Gynecology and Obstetrics, Indiana State Medical Association, and International Continence Society
Disclosure: Glaxo-Smith-Klein Beechum Honoraria Speaking and teaching

Henry E Ruiz, MD, Chief, Reconstructive Urology and Urodynamics, Urology Associates of South Texas, PA and Radiation Oncology Center
Henry E Ruiz, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida
Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Society for Urology and Engineering, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting

 
 
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