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CMDT 2013
Chapter 2
this purpose. In a meta-analysis, the positive and negative likelihood ratios of helical CT scanning for diagnosis of nephrolithiasis were 23.2 and 0.05, respectively.
sensitive for detecting chlamydial infection. Other infectious pathogens associated with dysuria and urethritis in men include Mycoplasma genitalium and Enterobacteriaceae.
``Differential Diagnosis
``Treatment
The differential diagnosis of dysuria in women includes acute cystitis, acute pyelonephritis, vaginitis (Candida, bacterial vaginosis, Trichomonas, herpes simplex), urethritis/ cervicitis (Chlamydia, gonorrhea), and interstitial cystitis/ painful bladder syndrome. Nucleic acid amplification tests from first-void urine or vaginal swab specimens are highly
Definitive treatment is directed to the underlying cause of the dysuria. An evidence-informed algorithm for managing suspected urinary tract infection in women is shown in Figure 2–3. This algorithm supports antibiotic treatment of most women with multiple and typical symptoms of urinary tract infection without performing urinalysis or urine culture.
Woman with ≥ 1 symptom of UTI1
Risk factors for complicated infection?2
yes
no Back pain or fever?
yes
Consider urine culture to establish diagnosis Consider initiating empiric treatment Probability of UTI moderate (~60%) and probability of pyelonephritis unknown Consider urine culture to establish diagnosis Consider empiric treatment
no
Vaginal discharge?
yes
Low to intermediate probability of UTI (~20%) Pelvic examination (including cervical cultures when appropriate) and urine culture to establish diagnosis
no Most elements of the history (and physical examination3) positive?
yes
High probability of UTI (~90%) Consider empiric treatment without urine culture
yes
High probability of UTI (~80%) Consider empiric treatment without urine culture
no Perform dipstick urinalysis
Dipstick results positive? no
Low to intermediate probability of UTI (~20%) Consider urine culture or close clinical follow-up and pelvic examination (including cervical cultures when appropriate) 1In women who have risk factors for sexually transmitted diseases, consider testing for Chlamydia. The US Preventive Services Task Force recommends screening for Chlamydia for all women 25 years or younger and women of any age with more than one sexual partner, a history of sexually transmitted disease, or inconsistent use of condoms. 2A
complicated UTI is one in an individual with a functional or anatomic abnormality of the urinary tract, including a history of polycystic renal disease, nephrolithiasis, neurogenic bladder, diabetes mellitus, immunosuppression, pregnancy, indwelling urinary catheter, or recent urinary tract instrumentation.
3The only physical examination finding that increases the likelihood of UTI is costovertebral angle tenderness, and clinicians may consider not performing this test in patients with typical symptoms of acute uncomplicated UTI (as in telephone management).
▲ Figure 2–3. Proposed algorithm for evaluating women with symptoms of acute urinary tract infection (UTI). (Modified and reproduced, with permission, from Bent S et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002 May 22–29;287(20):2701–10.)