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CHAPTER
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Urinary Problems in Females
35
ommon adult female urinary concerns include
C
changes in usual urination patterns (frequency,
urgency, nocturia, incontinence), changes in urine appearance (color, cloudiness), and pain (dysuria, ank
pain, or suprapubic pain).
Urinary problems in adult females can be caused
by infection, inammation, calculi (stones), congenital
malformation, or trauma. The majority of urinary tract
infections (UTIs) are caused by gram-negative bacteria,
predominantly Escherichia coli. The sexually transmit-
ted pathogens Chlamydia trachomatis, Neisseria gonor-
rhoeae, and herpes simplex are common causes of
urethritis. Vaginitis can also cause urinary symptoms in
women. Urinary stones can occur anywhere in the urinary tract and are common causes of pain, bleeding,
obstruction, and secondary infection.
UTI is the second most common clinical disorder of
childhood, following respiratory tract disorders. The
symptoms of urinary tract disorder may be vague
or absent, making the diagnosis easily overlooked.
Infection may be present without symptoms, with
symptoms that are obviously related to the urinary
system, or with symptoms that may divert attention to
another organ system problem. Abdominal masses in
the newborn are most frequently caused by renal enlargement, specically dysplastic kidney, and/or congenital hydronephrosis. Vesicoureteral reux (VUR) is
the major structural abnormality associated with UTI
and renal damage.
and Children
l
Are you positive for HIV infection? Are you receiv-
ing chemotherapy?
l
In an infant: Has the infant been irritable or had
anorexia or lethargy?
Fever and Chills
The presence of fever and chills suggests a systemic
inammatory response and indicates an acute condition that should be treated aggressively. Suspect pyelonephritis or lithiasis of the upper urinary system. UTI
is the most common bacterial infection in febrile infants and children who have no obvious source of
infection.
Nausea and Vomiting
Nausea and vomiting often accompany upper UTI,
pyelonephritis, or lithiasis. Like fever and chills, these
symptoms suggest a systemic inammatory response and
indicate that the patient may be acutely ill. In newborns
and infants, nonspecic symptoms such as vomiting,
diarrhea, and feeding difculties may indicate UTI.
Acute Pain
Acute pain in the back or abdomen suggests upper UTI
and pyelonephritis. Flank pain occurs with stretching
of the renal capsule associated with parenchymal
swelling and may indicate infection, obstruction, or
primary renal disease.
Urinary tract stones may produce localized back pain
or excruciating pain that often radiates to the thigh.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Are there systemic or upper urinary tract symptoms
present?
Key Questions
l
Have you had a fever or chills?
l
Have you had nausea or vomiting?
l
Have you had acute pain in the abdomen or back?
Immunocompromised Patients
Immunocompromised patients are susceptible to overwhelming infections by both common and atypical
organisms, and aggressive investigation is warranted.
Irritable Infant
UTI in neonates and infants is manifested in subtle
ways such as irritability, anorexia, and weight loss.
Some infants with UTI present with bacteremia.
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Chapter 35 • Urinary Problems in Females and Children
Is there hematuria?
Key Questions
l
Have you had blood in your urine? When in the
stream does it occur?
l
Do you have pain with urination?
l
Do you have bleeding without urination?
l
Have you done any strenuous exercise recently?
Hematuria
Red-to-brown discoloration is commonly caused by
infection, trauma, or urinary tract stones. It may also be
caused by parenchymal renal disease, systemic disease, medications, coagulopathies, or bladder cancer.
Pyelonephritis or urinary tract stones are common
causes of gross (macroscopic) hematuria. Neoplasm,
trauma, and some medications can also produce gross
hematuria. Gross hematuria occurs in 60% to 90% of
bladder tumors. Both bladder and renal neoplasms are
less common in women than in men. Hematuria can be
produced by local irritation in cystitis. Platelet disorders and hemophilia can cause both gross and microscopic bleeding. Urinary frequency or urgency, dysuria, or suprapubic pain suggests that the origin of
hematuria is conned to the lower urinary tract.
Initial hematuria (at the beginning of urination) sug-
gests the urethra is the source, whereas terminal hematuria (at the end of urination) suggests posterior urethra
or bladder base involvement. Total hematuria means
red blood cells are dispersed throughout the urinary
stream, characterizing origination in the kidney, ureter,
or bladder.
Pain
Hematuria without pain is usually caused by renal disease or cancer of the bladder or kidney. Other causes of
painless hematuria include stones, polycystic kidney
disease, renal cysts, sickle cell disease, and hydronephrosis. When discomfort such as renal colic accompanies hematuria, suspect a ureteral stone. Hematuria
with dysuria suggests bladder infection or lithiasis.
Bleeding Without Urination
Bladder lesions may produce bleeding independent of
micturition.
trauma to the kidneys and bladder as well as by ischemic
injury. It is caused by the shifting of blood ow from the
renal circulation to the heart, lungs, and skeletal muscles
during periods of high oxygen demand.
Can the symptoms be localized to the lower urinary
tract?
Key Questions
l
What are your primary symptoms (e.g., pain, fre-
quency, urgency, small amounts of urine, nausea,
nocturia, itching)?
l
Have you had any suprapubic pain?
l
Do you have involuntary urination?
Primary Symptoms
Dysuria suggests inammation of the bladder neck or
urethra, which is usually caused by bacterial infection
or irritation that injures the bladder mucosa and leads
to inammatory changes, inltration, and edema.
These changes, from mild stretching of the bladder to
a loss of bladder elasticity, can result in urgency and
frequency.
Dysuria is the cardinal symptom of uncomplicated
lower urinary tract infection (acute bacterial cystitis). In
children, it may also be the rst indication of an anatomical lesion such as obstruction of the urinary tract or
VUR. Other common symptoms include frequency,
mild nausea, nocturia, urgency, and voiding small
amounts. Fever is notably absent. Infants may have
strong-smelling urine and continuously damp diapers.
Dysuria also suggests urethritis, especially if accompanied by vaginal discharge. External dysuria, a
burning sensation as the urine passes the inamed
labia, suggests vulvovaginitis. Patients with vulvovaginitis may also report discharge, odor, or itching.
Women who have active herpes lesions may also experience external dysuria. Young children with pinworms
(Enterobius vermicularis) may have dysuria and vaginitis because of the abrasions that result from periurethral and perivaginal itching and scratching.
Interstitial cystitis produces diminished bladder capacity along with symptoms of frequent painful urination. Hematuria may be present. Increased frequency
can also occur as a result of stones or a tumor.
Strenuous Exercise
Transient hematuria occasionally occurs after strenuous
exercise. The amount of bleeding is proportional to the
amount of exercise and the trauma sustained by the urinary tract. Exercise-related hematuria is caused by direct
Suprapubic Discomfort and Urinary Incontinence
Discomfort in the suprapubic area is indicative of
bladder involvement and urinary incontinence and is
characteristic of bladder neck irritability caused by
inammation. Local causes of incontinence can also
Chapter 35 • Urinary Problems in Females and Children
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411
include pelvic relaxation and impaired bladder muscle
activity. Preschool-age children with UTIs frequently
have enuresis (see Chapter 34).
Could this be the result of trauma?
Key Questions
l
Have you had any recent injury?
l
Have you been hit recently?
l
If a child: Have you noticed the child putting foreign
objects in his or her genitourinary tract?
Recent Injury
An injury or a blow to the ank area can produce hematuria originating from the kidney. Straddle injury
may result in abrasions and local inammation, causing pain on urination. About 5% of childhood trauma
involves the kidney, making it a relatively uncommon
event. About 10% of the injured kidneys have underlying abnormalities, such as hydronephrosis or a horseshoe shape making them more vulnerable to injury.
Trauma
Physical injury to the trunk, including trauma from
domestic violence, may cause blood in the urine.
Trauma may or may not be associated with pain.
Active children may not remember trauma to the area.
use of a diaphragm, and use of spermicidal gel for con-
traception. Urethritis is associated with a history of a
new sexual partner, a partner with urethritis, and mul-
tiple sexual partners. Masturbation may also cause
dysuria in girls as a result of either local irritation or the
introduction of organisms that produce a lower UTI.
Organisms from sexually transmitted infections can
cause urethritis when they are present in large numbers
in the urethra, which may result in a local inammatory
response. The most common pathogen of urethritis is
C. trachomatis, but N. gonorrhoeae, Trichomonas vaginalis, and herpes simplex are also seen with urethritis.
Active herpes lesions may also produce dysuria as the
urine passes across the inamed external mucosa.
Diaphragm Use
Some women who use a diaphragm experience mechanical compression of the urethra, with subsequent
urine retention that predisposes them to the development of cystitis.
Vaginal Discharge and Hormone Therapy
Vaginal infections are a common cause of dysuria,
particularly in college-age women. Atrophic vaginitis
can also cause dysuria. Postmenopausal women who
are not on hormone therapy are more likely to have
atrophic vaginitis.
Foreign Objects
Children have a propensity to put foreign objects in
any orice. Placing foreign objects in the vagina can
cause dysuria and pyuria.
Could this be genitourinary in origin?
Key Questions
l
Are you sexually active? How frequently do you
engage in sexual activity?
l
Have you had a new sexual partner recently?
l
How many sexual partners do you have?
l
Does your sexual partner have any symptoms?
l
Do you use spermicidal gel?
l
Do you use a diaphragm?
l
Do you have any vaginal discharge?
l
If a child: Have parents noticed her masturbating?
l
If a postmenopausal woman: Are you on hormone
replacement therapy?
Sexual Activity
Factors that contribute to the development of acute
bacterial cystitis include frequent sexual intercourse,
Are there any specic risk factors to point me in the
right direction?
Key Questions
l
Have you had this or similar problems before? If yes,
when and how many times?
l
Have you had recent catheterization or urinary tract
procedures performed?
l
Is there a family history of kidney or urinary problems?
l
Do you have diabetes?
l
How much spicy food, caffeinated beverages/food,
carbonated beverages, or alcohol do you consume?
l
How much water do you drink?
l
Do you suppress the urge to urinate (postpone
urination)?
l
Do you use bubble baths, shampoos, feminine hy-
giene products, powders, and soaps?
l
Do you have constipation?
History of Similar Problems
Patients with previous urinary problems are at risk for
chronic relapsing conditions such as unresolved infections, resistant strains of organisms, or reinfection.
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Chapter 35 • Urinary Problems in Females and Children
Recent Instrumentation
Recent instrumentation in the urinary tract places the
patient at risk for infections.
Family History of Urinary Problems
A family history of renal or urinary tract problems
places the patient at increased risk for urinary tract disorders. A family history of deafness or renal insufciency suggests hereditary nephritis or Alport syndrome.
History of Diabetes Mellitus
Diabetes mellitus is associated with recurrent bacterial
cystitis.
l
Have you been diagnosed with, but not treated for, a
sexually transmitted infection?
l
Have you had excessive urination?
l
Have you had a sore throat or been treated for strep
throat recently?
Sexually Transmitted Infections
Because vaginitis can cause urinary tract symptoms in
females, a sexually transmitted vaginitis may be producing symptoms. The need for recent treatment of a
sexually transmitted infection may indicate treatment
failure, a coinfection that was not covered by the prescribed drug, or a reinfection (see Chapter 37).
Types of Food Consumed
Dysuria without pyuria can be caused by chemical
irritants such as spicy foods, caffeine, carbonated beverages, and alcohol.
Decreased Fluid Intake
Decreased uid intake and concentrated urine produce
an irritant effect on bladder mucosa and may cause
dysuria without pyuria. It can also predispose to the
development of bacterial cystitis.
Urge to Urinate
Women who ignore the urge to urinate or who postpone urination are predisposed to the development of
bacterial cystitis. Urine in the bladder for a prolonged
period promotes bacterial growth.
Girls who have a history of squatting or leg crossing
to stop urination may have a UTI. Uncontrolled bladder contractions against a closed bladder sphincter
cause the behavior. These children may develop vesicoureteral reux and infection.
Bubble Bath and Hygiene Products
Common chemical irritants can cause dysuria without
infection. The most common irritant, particularly for
children, is found in bubble baths.
Constipation
Mechanical factors related to compression of the bladder and bladder neck by a hard mass of stool from
constipation may cause UTI. There is also a relationship between constipation and dysfunctional voiding
accompanied by incomplete bladder emptying.
Excessive Urination
The presence of polyuria suggests diabetes mellitus or
diabetes insipidus. Women with diabetes mellitus are
also prone to development of UTIs.
Recent Streptococcal Infection
Poststreptococcal glomerulonephritis may develop after a 1- to 3-week latency period following pharyngeal
or skin infections with certain strains of group A
b-hemolytic streptococci. The peak incidence is at age
7 years.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Note General Appearance
A patient who appears ill or who is pacing in pain
is likely to have an upper urinary tract problem such as
pyelonephritis or urolithiasis. Patients with lower urinary tract problems usually do not present with signs
of systemic involvement, are not febrile, and generally
appear well. Neonates present with malaise, irritability,
and difculty feeding. Toddlers and preschoolers appear
ill with nausea, vomiting, and diarrhea.
Obtain Vital Signs, Height, and Weight
Failure to thrive is a common presenting sign of
urinary tract disease in neonates or young children.
Hypertension is seen in patients with nephritis.
Examine the Skin
Neonates with UTIs may present with jaundice.
What else could this be?
Key Questions
l
Have you had recent treatment for a sexually trans-
mitted infection?
Palpate and Percuss for Flank Pain and at the
Costovertebral Angle Bilaterally
Pain that is reproducible is indicative of renal capsule
distention and characterizes acute pyelonephritis or
acute ureteral obstruction.
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413
Palpate and Percuss the Abdomen
Polycystic kidneys may produce abdominal distention. A
ank mass may indicate a hydronephrotic kidney. Pain in
the lower quadrant indicates lower ureter involvement.
Suprapubic tenderness is characteristic of lower UTI.
Perform deep palpation to identify kidney or other ab-
dominal masses. Normal kidneys are usually not easily
palpated. A distended bladder rises above the symphysis
pubis and is characteristic of residual urine resulting
from incomplete bladder emptying. Palpation of an en-
larged bladder may cause pain. In hypertensive patients,
auscultate at the subcostal anterior abdomen for bruits
that could indicate a renovascular cause of hypertension.
Inspect the Perirectal Area
Inspect the skin and hair for inammation, lesions,
parasites, and dermatitis. Note inammation, presence
of lesions, or vaginal discharge. Observe for the pres-
ence of labial adhesions that might predispose the
child to perineal bacterial colonization. Note personal
hygiene. External excoriation could be the cause of
burning or pain on urination. Note if there are any
abrasions, tears, or bruising present which might indi-
cate trauma and/or sexual abuse.
Perform a Pelvic Examination If Indicated
A pelvic examination is essential if you suspect vagini-
tis or vulvovaginitis as a cause of the urinary tract
symptom(s). On external examination, observe for
bladder or uterine prolapse. On internal examination,
note vaginal color, moistness, rugae of vagina, and
characteristics of discharge. Pale, dry mucosa with
lack of rugae characterizes atrophic vaginitis in an
older woman. Vaginal discharge not characteristic of
physiological discharge suggests a vaginal infection.
(For a discussion of vulvovaginitis, see Chapter 37.)
Determine rectal tone. An atonic anal sphincter sug-
gests a neurogenic bladder. Rectal examination for fe-
cal impaction is indicated if the history suggests sig-
nicant constipation or encopresis.
LABORATORY AND DIAGNOSTIC STUDIES
The extent of diagnostic investigation is determined by
the history and the ndings of the examination. The
symptoms reported by the patient are taken into ac-
count when ordering diagnostic tests to corroborate or
verify the diagnosis. General screening tests can be
used to provide additional data for patients with uri-
nary tract problems.
Urine should be freshly voided and preferably taken
midstream. If not examined immediately, the specimen
should be refrigerated because cells begin to disintegrate after 1 to 2 hours.
Urine Dipstick
Reagent strips can be used to screen urine in the clinical setting.
Specific Gravity and Urine pH
Urine specic gravity depends on the patient’s hydration. The urine pH also depends on the level of hydration, acid-base status, time of urine collection, diet, and
drugs that may affect the urine pH.
Leukocyte Esterase
A positive test is indicative of urethritis (75% to 90%
sensitivity, 95% specicity). Urine that tests positive
for leukocyte esterase may require culture for bacteria.
Vaginal infection with Trichomonas species can produce false-positive results; diets high in vitamin C can
produce false-negative results.
Nitrite
Urine that tests positive for nitrites may require culture
for bacteria. However, note that some organisms that
cause UTIs do not convert nitrates to nitrites (e.g.,
staphylococci and streptococci).
Protein
The normally small amount of protein excreted by a
healthy adult is usually not detectable by dipstick
analysis until the patient excretes 150 to 300 mg/day.
At this level, the patient will show trace amounts. In
healthy people, urine contains no protein or only trace
amounts of protein, which consists of albumin and
globulins from the plasma. Glomeruli usually prevent
the passage of protein from the blood to the glomerular
ltrate; therefore, the persistent presence of protein in
urine is a strong indication of renal disease. If more
than a trace amount of protein is found, then a quantitative 24-hour evaluation is necessary. False-positive
results can occur with alkaline urine.
If the patient has trace levels of proteinuria, then the
use of 20% sulfosalicylic acid testing for protein is appropriate. Add 8 drops of 20% sulfosalicylic acid to a
sample of fresh, concentrated urine. Protein concentration is directly proportional to the degree of white turbidity produced. The absence of white turbidity indicates a false-positive result by dipstick analysis.
A typical scale to indicate progressively increasing
amounts of protein is 11 (30 mg/dL), 21 (100 mg/
dL), 31 (300 mg/dL), and 41 (500 to 1000 mg/dL).
Peripheral edema and ascites may be present in an
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Chapter 35 • Urinary Problems in Females and Children
adult who has 31 or 41 proteinuria and is typically
excreting 3 g or more of protein per day. Proteinuria
reported for a single urinalysis is not an absolute guide
in a differential diagnosis because proteinuria may be
glomerular or tubular.
Glucose
Glucose in the urine is indicative of an elevated serum
glucose concentration greater than 200 mg/dL. If serum glucose levels are normal and the urine glucose
level is elevated, then proximal renal tubular damage
should be suspected.
Ketones
Ketones are detected earlier in the urine than in
the blood and may indicate starvation or diabetic
ketoacidosis.
Blood
The strip detects heme at 0.05 to 0.3 mg/dL of hemoglobin (see later paragraph titled Red Blood Cells).
Urinalysis With Microscopic Examination
Color
The urine should be clear to yellow, depending on the
concentration. The precipitation of calcium phosphate
or urates can turn the urine milky, especially when
stored in the refrigerator. Warming the urine to body
temperature causes these precipitated salts to return to
solution, removing the milky appearance. Methylene
blue and indigo blue can make the urine blue. Vegetable
dyes and paint from toys ingested by young children
can turn their urine various colors. Brown urine is often
observed in glomerulonephritis. Turbidity with a foul
odor indicates infection. Color changes of the urine
may result from various sources: hemoglobin from systemic red blood cell lysis; myoglobin from damaged
muscle cells or rhabdomyolysis; vegetable pigments
from food such as red beets; pigments from drugs such
as rifampin and phenazopyridine; or porphyrins from
porphyria.
Discoloration of the urine should be investigated
with microscopic examination to determine if red
blood cells (RBCs) or any foreign substances are present. Pyuria results from white blood cell (WBC) debris
and leukocytes in the urine, but cloudy urine can also
result from other causes.
Sediment
Sediment from casts, blood cells, and bacteria can be
detected by microscopic examination. Casts indicate
hemorrhage or various conditions of the nephron.
RBCs indicate acute inammatory or vascular disorders of the glomerulus. More than 1 or 2 RBCs per
high-power eld (HPF) is abnormal and may indicate
renal or systemic disease or trauma to the kidney.
Sediment is labeled as active when an abnormal number of cells, tubular casts, crystals, or infectious organisms are found.
A healthy person’s urinalysis usually contains no
cells, although an occasional cell per HPF is seen.
More than 1 tubular epithelial and transitional epithelial cell per HPF is suggestive of damage to the tubules
or bladder wall. More than 1 RBC or WBC per HPF is
considered abnormal. The more cells per HPF, the
more active may be the renal disease.
Microscopic examination of the urine resulting in
20 or more organisms per HPF indicates UTI. Fewer
than 20 organisms per HPF merits further study such
as culture and sensitivity (C&S).
Red Blood Cells
Hematuria is the presence of more than 3 RBCs/HPF.
Distorted, irregularly shaped cells indicate a glomerular problem. The major causes of hematuria include
acute and chronic prostatitis or urethritis, hemorrhagic
cystitis, renal stones, or tumors of the kidney, renal
pelvis, ureter, bladder, and urethra. Hematuria with
proteinuria usually suggests a renal origin. Isolated
hematuria is usually produced by sites outside the
kidneys.
White Blood Cells
Pyuria (.5 WBCs/HPF) is highly sensitive for the
presence of a UTI. However, it may occur with dehydration, renal stones, appendicitis, or other extrinsic
ureteral irritation in the absence of demonstrable
microbial infection.
Casts
Tubular casts are formed in the distal portion of the
nephron. A hyaline cast is a wispy, translucent, cylindrical replica of the tubular lumen. Red cell casts are
characteristic of glomerular origin. The presence of
abnormal cells, protein, hemoglobin, myoglobin, or
other debris with a cast helps identify the type of renal
disease.
Urine Culture and Sensitivity
A culture and sensitivity (C&S) test is indicated in
children if you are uncertain of a diagnosis of uncomplicated lower tract UTI based on clinical ndings and
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415
urinalysis, or if the patient has signs and symptoms of
an upper UTI or complicated UTI. C&S is typically not
indicated in adults suspected of having an uncomplicated lower UTI. Urine cultures are recommended for
those with suspected acute pyelonephritis, for symptoms that do not resolve or that recur within 2 to 4
weeks after the completion of treatment, and in those
with atypical symptoms.
Potassium Hydroxide and Wet Mount/Preparation
Perform these procedures if you suspect vulvovaginitis as a cause of the urinary tract symptoms (see
Chapter 37).
Vaginal Culture/DNA Testing for Infectious
Organisms
Use these testing procedures to diagnose or conrm
vaginal infection (see Chapter 37).
Ultrasonography
Ultrasonography is a noninvasive technique that can
provide information about the kidneys, ureters, bladder, and vascular structures. Renal ultrasound is a good
rst test to determine kidney size, contour, and the
presence of calculi. Urinary bladder sonogram is used
to identify tumors of the bladder, thickening of the
bladder wall, posterior masses behind the bladder, or
obstruction of the lower urinary tract showing residual
urine. Renal and bladder ultrasound is indicated in any
infant or young child with a second UTI.
Radiography
A at plate of the abdomen can be used to identify
structures of the kidney, ureters, and bladder. Urinary
calculi are usually visible on radiographs.
Computed Tomography
Noncontrast helical (spiral) CT is the gold standard for
evaluating kidney stones. It has 95% sensitivity and
98% specicity.
DIFFERENTIAL DIAGNOSIS
pediatric patients. Symptoms in neonates may include
prolonged jaundice and failure to thrive.
The adult patient appears well on physical examination and may or may not have costovertebral angle
(CVA) tenderness. Clinical diagnosis is supported by
urine dipstick ndings which may include the presence
of blood, leukocyte esterase, and nitrites. However, a
negative dipstick result does not rule out UTI. Microscopic analysis may show the presence of RBCs and
WBCs. No casts will be present. Urine C&S will conrm the diagnosis. See the Evidence-Based Practice
boxes for evidence supporting the diagnosis of UTI in
adults or children.
UTIs in the elderly are sometimes mistaken as the
early stages of dementia or Alzheimer disease because
the symptoms may be confusion, delirium, agitation,
hallucinations, behavioral changes, poor motor skills
or dizziness, and falling.
Urethritis
Dysuria suggests urethritis, especially if accompanied
by vaginal discharge. The history often includes a new
sex partner, frequent sexual activity, a partner with urethritis, or multiple sex partners. As with uncomplicated
UTI, the patient appears well and on physical examination has no CVA tenderness or fever. On urinalysis using a dipstick, ndings may include the presence of
blood, leukocyte esterase, and nitrites, although the
patient may have urethritis in the absence of these ndings. Urine culture or DNA testing conrms the presence of the offending pathogens, usually Chlamydia,
N. gonorrhoeae, Trichomonas species, and herpes.
Vulvovaginitis
Vulvovaginitis is a common cause of dysuria. The patient
often describes the dysuria as “external”—a burning
sensation as the urine passes inamed labia. The patient
usually has a history of vaginal discharge, odor, and/or
itching. On physical examination, discharge is usually
present in the vagina or from the cervix. Wet mount,
KOH, and vaginal culture or DNA testing for infectious
organisms can conrm the diagnosis (see Chapter 37).
Uncomplicated Urinary Tract Infection
Uncomplicated lower UTIs (or bacterial cystitis) are
common in women. Uncomplicated UTIs occur in
individuals with normal urinary tract anatomy and
function. Patients present with symptoms of dysuria,
urinary frequency, hematuria, back pain, mild nausea,
nocturia, urgency, and voiding of small amounts. Fever
is notably absent in adults, but may be present in
Atrophic Vaginitis
In older women, atrophic vaginitis may produce urinary
tract symptoms. These women may be perimenopausal
or postmenopausal. Women with atrophic vaginitis may
report vaginal dryness or discomfort during sexual intercourse. On physical examination, the vaginal mucosa
is thin, pale, and dry with fewer rugae. Diagnosis is
made on the basis of clinical ndings.
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Chapter 35 • Urinary Problems in Females and Children
EVIDENCE-BASED PRACTICE
In this systematic review the authors report that the symptoms of dysuria, frequency, hematuria, and back pain along
with costovertebral angle tenderness significantly increase
the probability of uncomplicated UTI. Women with one of
more of the symptoms have about a 50% probability of having a UTI. The probability increases to more than 90% in
women with specific combinations of symptoms, such as
dysuria and frequency without vaginal discharge and irritation. A urine dipstick that has positive results for both
nitrites and leukocyte esterase has a sensitivity of 75% and
Reference: Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S: Does this woman have an acute uncomplicated urinary tract infection? JAMA 287:
2701, 2002.
EVIDENCE-BASED PRACTICE
This meta-analysis offers insight into the diagnosis of UTI in
infants and children based on clinical examination and urine
dipstick. Although certain signs and symptoms (high fever,
fever for 24 hours, history of a previous UTI, abdominal pain,
nonblack race, lack of circumcision, back pain, dysuria, frequency, new-onset urinary incontinence, suprapubic tenderness, and absence of another source of fever on examination)
increase the probability of UTI, no single sign or symptom has
a sufficiently high likelihood ratio to definitively diagnose UTI
Reference: Shaikh N, Morone NE, Lopez J, et al: Does this child have a urinary tract infection? JAMA 298:2895, 2007.
Diagnosing Uncomplicated UTI in Adults
a specificity of 82% in determining UTI. However, a urine
dipstick with negative results does not rule out UTI. The absence of dysuria and back pain, with the presence of vaginal
discharge and irritation significantly decrease the probability
of UTI.
Their conclusion: History alone may effectively rule in the
diagnosis of uncomplicated UTI, and the likelihood of a correct
diagnosis is improved when the urine dipstick has positive results. However, the history, physical examination, and a dipstick
urinalysis with negative results cannot reliably rule out UTI.
Diagnosing UTI in Infants and Children
or a sufficiently small likelihood ratio to rule out UTI. A urine
dip that is positive for both nitrites and leukocyte esterase
substantially increases the likelihood of a UTI. A positive
dipstick test should always be followed up with a confirmatory
urine culture.
The bottom line: Although no sign or symptom is diagnostic
of UTI in children by itself, the absence of several key signs
and symptoms in combination can be used to identify infants
at low risk for UTI.
Interstitial Cystitis
Interstitial cystitis produces diminished bladder capacity along with symptoms of frequent, painful urination.
Hematuria may be present. The cause is unknown but
may be related to collagen disease, an autoimmune
disorder, an allergic manifestation, or may occur secondary to an unidentied infectious agent. The bladder
wall becomes inamed, with mucosal ulceration and
scarring that produce contraction of the smooth
muscle and cause the symptoms. Middle-age women
are most often affected. Typically, the patient appears
well and has no physical ndings. Symptoms include
bladder discomfort and suprapubic/pelvic tenderness.
Urinalysis ndings are usually negative. This is a diagnosis of exclusion, and the patient is often frustrated
because no cause will have been found for her longstanding and persistent symptoms. The patient has no
evidence of urological disease on radiographic and
cystometric studies. Cystoscopic evidence of interstitial disease includes focal ulceration, edema, and perivascular inltrates.
Pyelonephritis
The patient presents with fever and chills, appears
toxic, and reports back pain. Nausea and vomiting may
be present. Some patients also report lower urinary
tract symptoms including frequency and dysuria. The
patient feels and looks ill. On physical examination,
CVA tenderness is usually present. The abdomen may
also be tender. On microscopic examination, WBCs
are usually present. White cell casts suggest pyelonephritis. Bacterial casts, although rare, are pathognomonic of pyelonephritis. Urine C&S or DNA testing
conrms the diagnosis and identies the pathogen—
usually E. coli, Klebsiella, Proteus mirabilis, or
Enterobacter.
Urolithiasis
Urinary stones can occur anywhere in the urinary tract
and may produce symptoms of acute pain, hematuria,
and secondary infection. Many calculi are “silent” and
may cause only hematuria, either microscopic or gross.
Renal calculi may occur when a stone obstructs the
Chapter 35 • Urinary Problems in Females and Children
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417
urinary tract. Typical symptoms of renal colic include
severe ank pain that radiates along the pathway of the
ureter to the inner thigh. Chills, fever, and urinary frequency are common. The patient may have nausea,
vomiting, and abdominal distention.
The clinical diagnosis is supported by urinalysis
and imaging ndings. The urine may be normal;
however, gross or microscopic hematuria is common.
Pyuria (WBCs) with or without bacteria may be pres-
and lethargy. On physical examination, periorbital
edema is usually present, as is hypertension. Other
presenting symptoms are orthopnea, dyspnea, cough,
rales, hematuria, and proteinuria. A positive serum
ASO titer conrms recent infection. Low serum complement levels are indicative of an antigen-antibody
interaction. A depressed serum concentration of complement component 3 (C3) is found in the rst few
days of the disease.
ent. Crystalline structures may be present. Noncontrast
helical (spiral) CT is the gold standard for evaluating
kidney stones.
Chemical Irritation
There is a history of the use of bubble baths, body lo-
tions, soaps, and sprays. The patient experiences fre-
Poststreptococcal Glomerulonephritis
This condition is an immune-mediated nephritis following a streptococcal skin or pharyngeal infection in
the previous 1 to 3 weeks. It occurs most commonly in
elementary school children. The patient reports anorexia, vomiting, fever, abdominal pain, headache,
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Urinary Problems in Females
quency, burning, and urgency with small volumes of
voided urine. Children will frequently suppress void-
ing because of pain. Physical examination may reveal
erythema of the labia and urethral outlet. Laboratory
examination may reveal pyuria and bacteriuria as a
result of local infection and denudation.
and Children
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Uncomplicated UTI Dysuria, frequency, mild nausea,
nocturia, urgency, voiding
small amounts; neonates and
young infants present with
anorexia and irritability
Urethritis Dysuria; vaginal discharge;
history of new sex partner,
frequent sex, partner with
urethritis, multiple sex
partners
Vulvovaginitis History of vaginal itching,
discharge, burning
Atrophic vaginitis Vaginal dryness; dyspareunia;
postmenopausal
Interstitial cystitis Frequent painful urination;
hematuria; most often
middle-age women; often
frustrated because no cause
has been previously found for
long-standing and persistent
symptoms
No fever in adults; appears well;
no CVA tenderness; may
have suprapubic tenderness;
neonates and young infants
may present with failure to
thrive, bacteremia, and fever
Appears well; has no CVA
tenderness or fever
Inflamed or atrophic labia;
vaginal or cervical discharge
Thin, pale, dry vaginal mucosa
with loss of rugae
Appears well and has no
physical findings; suprapubic
tenderness may be present
Urine dipstick: may be
positive for blood,
leukocyte esterase, nitrites;
microscopic analysis: RBCs,
WBCs, no casts; urine C&S;
renal and bladder ultrasound
in any infant, young child
with a second UTI
Urine dipstick: may be
positive for blood, leukocyte
esterase, nitrites; urine
culture; DNA testing
Microscopic examination,
vaginal cultures, molecular
testing
None
Urinalysis usually negative;
x-ray and cystometric
studies to rule out other
urological disease;
cystoscopy to diagnose
Continued
418
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Chapter 35 • Urinary Problems in Females and Children
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Urinary Problems in Females
and Children—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pyelonephritis Fever, chills, back pain,
nausea and vomiting, toxic
appearance; some patients
also have frequency and
dysuria
Urolithiasis Pain, hematuria; may have
symptoms of secondary
infection; renal colic: pain
that radiates to inner thigh;
nausea, vomiting
Poststreptococcal
glomerulonephritis
Chemical irritation History of bubble baths, soaps,
C&S, Culture and sensitivity; CT, computed tomography; CVA, costovertebral angle; RBC, red blood cell; U/A, urinalysis; UTI, urinary tract infection;
WBC, white blood cell.
History of skin or throat
infection 1 to 3 wk prior;
lethargy, anorexia, vomiting,
abdominal pain
lotions, sprays; urgency,
dysuria
Feels and looks ill; fever; CVA
tenderness; abdomen may be
tender
May have CVA tenderness; looks
ill during periods of acute
pain; may have abdominal
distention
Hypertension, periorbital
edema, CVA tenderness; may
have dyspnea, cough, pallor
No fever; erythematous labia,
urethral opening
Urine dipstick: may be
positive for blood,
leukocyte esterase, nitrites;
microscopic examination:
WBCs may have white cell
casts or bacterial casts;
urine C&S: E. coli,
Klebsiella, Proteus
mirabilis, Enterobacter;
blood cultures
Urinalysis: gross or
microscopic hematuria;
WBCs with or without
bacteria; crystalline
structures may be present;
noncontrast helical CT
U/A: proteinuria, hematuria;
ASO titer; serum C3 is low,
early in disease
Hematuria common, gross
hematuria unusual and
casts never seen
References and Readings
American Urological Association: Diagnosis, evaluation and follow-
up of asymptomatic micro-hematuria (AMH) in adults: AUA
guideline, J Urol 188:2473, 2012.
Colgan R, Lindsay E, Nicolle LE, et al: Asymptomatic bacteriuria in
adults, Am Fam Physician 74:985, 2006.
Colgan R, Williams M, Johnson JR: Diagnosis and treatment of
acute pyelonephritis in women, Am Fam Physician 84:519, 2011.
Ebell MH: Treating adult women with suspected UTI, Am Fam
Physician 73:293, 2006.
Feld L, Matto T: Urinary tract infections and vesicoureteral reux in
infants and children, Pediatr Rev 31:451, 2010.
Frassetto L, Kohlstadt I: Treatment and prevention of kidney stones:
An update, Am Fam Physician 84:1234, 2011.
Giesen LG, Cousins G, Dimitrov BD, et al: Predicting acute uncom-
plicated urinary tract infection in women: A systematic review of
the diagnostic accuracy of symptoms and signs, BMC Fam Pract
11:78, 2010.
Grabe M, Bjerklund-Johansen TE, Botto H, et al (eds.): Uncomplicated
UTIs in adults. In Guidelines on urological infections, Arnhem, The
Netherlands, 2011, European Association of Urology (EAU), p 15.
Retrieved from www.guidelines.gov/content.aspx?id534098.
Graham K, Levy J: Enuresis, Pediatr Rev 30:165, 2009.
Heffner V, Gorelick M: Pediatric urinary tract infection, Clin Ped
Emerg Med 9:233, 2008.
Kodner CM, Thomas Gupton EK: Recurrent urinary tract infections
in women: Diagnosis and management, Am Fam Physician
82:638, 2010.
Medina-Bombardó D, Jover-Palmer A: Does clinical examination
aid in the diagnosis of urinary tract infections in women?
A systematic review and meta-analysis, BMC Fam Pract
12:111, 2011.
Meister L, Morley EJ, Scheer D, Sinert R: History and physical ex-
amination plus laboratory testing for the diagnosis of adult female
urinary tract infection, Acad Emerg Med 20:631, 2013.
Roberts KB: Urinary tract infection: Clinical practice guideline for
the diagnosis and management of the initial UTI in febrile infants
and children 2 to 24 months, Pediatrics 128:595, 2011.
Türk C, Knoll T, Petrik A, et al: Guidelines on urolithiasis, Arnhem,
Netherland, 2013, European Association of Urology (EAU). Retrieved
from www.guideline.gov/content.aspx?id5
45324&sea rch5urolithiasis.
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