Diagnostic Considerations

Occult pyelonephritis occurs in 15% to 50% (or more) of all UTIs. This usually occurs in older women. It appears that these patients are unable to mount a fever or develop an elevated white count or costovertebral angle (CVA) tenderness. These patients may present with an unexplained fall or a change in mental status.

Postmenopausal women also may experience senile urethritis. In addition to urinary burning, frequency, and urgency, these patients may complain of vaginal and vulvar itching and discharge. Physical examination reveals a dry, pale vaginal epithelium and eversion of the urethral mucosa. Senile urethritis responds to topical estrogen therapy.

The differential diagnosis for infectious causes of sterile pyuria includes perinephric abscess, urethral syndrome, renal tuberculosis, and fungal infections of the urinary tract system. Noninfectious causes of pyuria include the following:

Uric acid and hypercalcemic nephropathy
Lithium and heavy metal toxicity
Sarcoidosis and other granulomatous diseases (eg, tuberculosis)
Interstitial cystitis
Polycystic kidney disease
Genitourinary malignancy
Renal transplant rejection
Any periurethral process

Consider UTI in any condition involving pain in the flank and back or pain in the abdomen and pelvis. Also consider cervicitis and Chlamydia infection. Do not assume that a sexually active female with dysuria has a UTI without first excluding the possibility of sexually transmitted disease–related cervicitis, vaginitis, or pelvic inflammatory disease.

UTIs in pregnancy have potentially adverse outcomes for both the mother and the fetus. Obtain a urine culture in all pregnant patients with suspected UTI. Pyuria and bacteriuria always are treated during pregnancy, regardless of whether symptoms are present.

Patients with diabetes mellitus are at increased risk for complicated UTIs. Diagnostic considerations include the following:

Renal and perirenal abscess
Emphysematous pyelonephritis
Emphysematous cystitis
Fungal infections
Xanthogranulomatous pyelonephritis
Papillary necrosis

Older patients who appear toxic are more likely to have obstruction complicating their UTI. Obtain a structural study to rule out this possibility.

Differential Diagnoses

Acute Pyelonephritis
Bladder Cancer
Chlamydia (Chlamydial Genitourinary Infections)
Cystitis, Nonbacterial
Herpes Simplex
Interstitial Cystitis
Pelvic Inflammatory Disease
Urethritis
Vaginitis

Workup

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Media Gallery

Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.
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

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Author

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, 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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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; Fellow of the Royal College of Physicians, London

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, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

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