2. Presentation and Diagnosis
Classical symptoms: dysuria, frequency, urgency, lower abdominal pain
Assessment of a patient with recurrent UTIs includes taking a history, examination (including pelvic examination for prolapse and vaginal health assessment), urine dipstick, urine MC&S
Mid-stream urine is the gold standard for urine MC&S—minimises skin/vaginal contamination
In patients with recurrent UTIs, cystoscopy usually shows no pathology and its’ use should be in targeted patient, for example if there is a suspicion for cancer
Urine dipstick can provide a result within 2 min. The presence of leucocytes has a sensitivity of 50–95% in detecting infections. The presence of nitrites almost certainly means the presence of infection, but has a sensitivity of only 35–85% as not all bacteria’s form nitrites in urine.
2.1 Clinical Symptoms
The classical symptom of a UTI is cystitis—a group of symptoms including dysuria (pain on passing urine), frequency (urinating often), and urgency (strong sudden desires to urinate, sometimes with difficulty in reaching the toilet) with lower abdominal pain. In general systemic symptoms are mild or absent in cystitis. The urine itself may appear odorous or cloudy.
Diagnosis often is made on symptoms alone, with more symptoms associated with a higher chance of confirming an underlying infection [1, 2].
It is important when taking the patient history to determine the frequency of infections. Three or more infections in 12 months would warrant a diagnosis of recurrent UTI. Voiding patterns and behaviour (e.g. volume of urination, how much fluid intake, does it occur more commonly in the day or night, after certain activities or is associated with any incontinence) is key in assessing for evidence of voiding dysfunction.
A good past medical history is key in determining risk factors such as menopause, diabetes or stone disease. In particular, check the patient has not had previous pelvic surgery that may predispose them to infections.
Sexual history is important, vaginal itching or discharge is a positive predictor for Sexually Transmitted Infections (STIs) and actually has been shown to be a negative predictor for UTIs.
As these examinations involve intimate parts of the patient, it is good practice to offer a chaperone to your patient.
Abdominal examination is important to assess for suprapubic or flank tenderness. At the same time, it is important in the abdominal examination to feel for and exclude a palpable kidney (caused by hydronephrosis, cysts, tumours, etc.) or a full bladder.
Vaginal examination is to assess for generalised vaginal health—in particular fluid, moisture, discharge, pain and elasticity to assess for evidence of atrophy, menopause or STIs.
Pelvic organ prolapse can also be assessed at this stage, which may cause patients difficulty in fully emptying their bladder and pre-dispose them to infections.
2.4 Urine Analysis
Patients should be advised to perform a mid-stream urine “clean” catch. This involves good hand hygiene, cleaning the genitalia with water, holding open the labia (skin around the urethra which is the exit to the bladder and vagina) and catching the mid-portion of the urine having discarded the initial flow. This technique will minimise the chance of urine contamination from the skin or vagina.
Blood: Haemoglobin from the red blood cells can occur in the urine during UTIs from the inflammation of the bladder lining. In severe infections with extensive inflammation, there can even be bleeding heavy enough to turn the urine visibly red (visible haematuria). Haemoglobin reacts when it comes into contact with the indicator on the dipstick.
However the presence of menstruation, intrinsic renal disease, urinary malignancy, stones, severe exercise and dehydration can give a false positive reading when no infection is actually present.
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