View source for Urinary tract infection

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| [[File:Siren.gif|30px|link=Urinary tract infection resident survival guide]]|| <br> || <br>
| [[Urinary tract infection resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Urinary tract infection}}
{{CMG}}{{AE}}{{USAMA}}

{{SK}} UTI

==Overview==
A urinary tract infection is an infection that involves any part of the [[urinary tract]]. It can result due to the invasion by a bacteria, virus, fungus or any other pathogen. The most common cause of a [[urinary tract infection]] is a bacterial [[infection]]. Depending on the site of the infection a [[UTI]] can be classified as either upper or lower [[UTI]]. [[UTI|Lower UTI]] includes [[urethritis]], [[prostatitis]], [[asymptomatic bacteriuria]] and [[cystitis]] (bladder infection) where as [[UTI|Upper UTI]] may include Pyelonephritis (infection of the kidney) and rarely uretritis (infection of the ureters). Each subtype of urinary tract infection can also be sub classified on the basis of [[duration]], [[etiology]] or therapeutic approach as [[acute]], [[chronic]] or recurrent and as uncomplicated or complicated infections.

The urine is normally sterile, a urinary tract infection occurs when the normally sterile [[urinary tract]] is infected by [[bacteria]], which leads to irritation and [[inflammation]]. [[Pyelonephritis]] and [[Cystitis]] result mostly from ascending infections from the urethra ([[Urethritis]]) but can also result from descending infections i.e hematogenous spread, or by the [[lymphatic system]]. The condition more often affects women, but can affect either gender and all age groups. The pathogenesis of a complicated [[UTI]] may include obstruction and stasis of urine flow.<ref name="pmid10969044">{{cite journal| author=Hooton TM| title=Pathogenesis of urinary tract infections: an update. | journal=J Antimicrob Chemother | year= 2000 | volume= 46 Suppl A | issue=  | pages= 1-7 | pmid=10969044 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10969044  }} </ref> Various factors are associated with the risk of developing a urinary tract infection. A common cause of the [[urinary tract infection]] in hospital settings is the urinary catheter placement. [[Diabetes]], [[Crohn's disease]], iatrogenic causes, [[endometriosis]], [[pelvic inflammatory disease]], [[urinary obstruction]], and [[bladder incontinence]] are some risk factors for acquiring a [[UTI]]. A thorough physical exam is very helpful in differentiating Upper from Lower [[UTI]]]s. Patients with an uncomplicated [[UTI]] are usually well-appearing. The symptoms may include abnormal urine color (cloudy), blood in the urine, [[frequent urination]] or [[urgent need to urinate]], [[dysuria]], pressure in the lower pelvis or back, [[suprapubic pain]], [[flank pain]], [[back pain]], [[fever]], [[nausea]], [[vomiting]], and [[chills]].<ref name="pmid22010614">{{cite journal| author=Colgan R, Williams M| title=Diagnosis and treatment of acute uncomplicated cystitis. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 7 | pages= 771-6 | pmid=22010614 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22010614  }} </ref> [[Urinalysis]] and [[urine culture]] are very helpful laboratory tests in diagnosing a urinary tract infection. Pyuria and either [[white blood cell]]s (WBCs) or [[red blood cells]] (RBCs) may be seen on urinalysis. ''[[Escherichia coli]] ("E. coli")'', a bacterium found in the lower gastrointestinal tract is one of the most common culprits. The individual infection must be differentiated from various causes of [[dysuria]] such as [[cystitis]], [[acute pyelonephritis]], [[urethritis]], [[prostatitis]], [[vulvovaginitis]], [[urethral stricture]]s or diverticula, [[benign prostatic hyperplasia]] and [[neoplasm]]s such as [[renal cell carcinoma]] and cancers of the bladder, prostate, and penis. Antimicrobial therapy is indicated in case of a symptomatic [[UTI]].<ref name="pmid11989635">{{cite journal| author=Bremnor JD, Sadovsky R| title=Evaluation of dysuria in adults. | journal=Am Fam Physician | year= 2002 | volume= 65 | issue= 8 | pages= 1589-96 | pmid=11989635 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11989635  }} </ref><ref name="pmid9606306">{{cite journal| author=Kurowski K| title=The woman with dysuria. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 9 | pages= 2155-64, 2169-70 | pmid=9606306 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9606306  }} </ref>A large proportion of patients with acute uncomplicated urinary infections will recover without treatment within a few days or weeks. If left untreated, some patients may progress to develop recurrent infection, involve and infect other parts of the urinary tract, [[hematuria]], and rarely [[renal failure]]. [[Prognosis]] is generally good for lower [[UTI]]s.<ref name=nid>Urinary Tract Infections in Adults. NIDDK 2016. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-tract-infections-in-adults/Pages/facts.aspx. Accessed on February 9, 2016</ref> The treatment of a [[UTI]] depends on the type of the disease, the disease course (acute uncomplicated vs. complicated), history of the individual and the rates of [[Drug resistance|resistance]] in the community. Preventative measures to avoid a [[UTI]] include abstinence from sexual activity, use of barrier contraception during sexual intercourse, urinating after intercourse, increasing fluid intake and frequency of urination, and use of [[estrogen]] (among [[Postmenopausal|post-menopausal]] women).

==Classification==

{{familytree/start}}
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | |A01= Urinary Tract Infections}}
{{familytree | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| }}
{{familytree | | | | B01 | | | | | | | | | | | | | | | | B02 | |B01=Upper UTI | B02 = Lower UTI}}
{{familytree | | | | |!| | | | |,|-|-|-|-|-|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|-|-|-|.| }}
{{familytree | | | | |!| | | | |!| | | | | | | | | |!| | | | | |!| | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | C01 | | | C02 | | | | | | | | C03 | | | | C04 | | | | | | C05 | C01 = [[Pyelonephritis]] | C02 = [[Cystitis]] | C03 = [[Prostatitis]] | C04 = [[Urethritis]] | C05 = [[Asymptomatic bacteriuria]]}}
{{familytree | | | | |!| | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | |!| | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | D01 | | | D02 | | | | | | | | D03 | | | | | | | | | | D01 = ❑Acute Uncomplicated<br>❑Acute Complicated <br>❑Chronic <br>❑ Emphysematous <br>❑ Xanthogranulomatous| D02 = ❑ Acute Uncomplicated<br>❑ Complicated<br>❑ Recurrent/Chronic | D03 = ❑ Acute Bacterial <br> ❑ Chronic bacterial <br>❑ Chronic Inflammatory<br>❑ Chronic non-inflammatory <br>❑ Asymptomatic }}
{{familytree/end}}

==Causes==
{| class="wikitable"
!Common Pathogens
![[Pyelonephritis]]
![[Cystitis]]
![[Urethritis]]
![[Prostatitis]]
![[Asymptomatic bacteriuria|Asymptomatic  Bacteriuria]]
|-
|[[Ecoli]]*<ref>{{Cite journal
 | author = [[R. M. Echols]], [[R. L. Tosiello]], [[D. C. Haverstock]] & [[A. D. Tice]]
 | title = Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis
 | journal = [[Clinical infectious diseases : an official publication of the Infectious Diseases Society of America]]
 | volume = 29
 | issue = 1
 | pages = 113–119
 | year = 1999
 | month = July
 | doi = 10.1086/520138
 | pmid = 10433573
}}</ref><ref>{{Cite journal
 | author = [[Manuel Etienne]], [[Pascal Chavanet]], [[Louis Sibert]], [[Frederic Michel]], [[Herve Levesque]], [[Bernard Lorcerie]], [[Jean Doucet]], [[Pierre Pfitzenmeyer]] & [[Francois Caron]]
 | title = Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis
 | journal = [[BMC infectious diseases]]
 | volume = 8
 | pages = 12
 | year = 2008
 | month = January
 | doi = 10.1186/1471-2334-8-12
 | pmid = 18234108
}}</ref><ref>{{Cite journal
 | author = [[James B. Hill]], [[Jeanne S. Sheffield]], [[Donald D. McIntire]] & [[George D. Jr Wendel]]
 | title = Acute pyelonephritis in pregnancy
 | journal = [[Obstetrics and gynecology]]
 | volume = 105
 | issue = 1
 | pages = 18–23
 | year = 2005
 | month = January
 | doi = 10.1097/01.AOG.0000149154.96285.a0
 | pmid = 15625136
}}</ref><ref>{{Cite journal
 | author = [[Rebecca E. Watts]], [[Viktoria Hancock]], [[Cheryl-Lynn Y. Ong]], [[Rebecca Munk Vejborg]], [[Amanda N. Mabbett]], [[Makrina Totsika]], [[David F. Looke]], [[Graeme R. Nimmo]], [[Per Klemm]] & [[Mark A. Schembri]]
 | title = Escherichia coli isolates causing asymptomatic bacteriuria in catheterized and noncatheterized individuals possess similar virulence properties
 | journal = [[Journal of clinical microbiology]]
 | volume = 48
 | issue = 7
 | pages = 2449–2458
 | year = 2010
 | month = July
 | doi = 10.1128/JCM.01611-09
 | pmid = 20444967
}}</ref>
|✔(70%)
|✔(78.6%)
|<nowiki>-</nowiki>
|✔(58%)
|✔(80%)
|-
|[[Klebsiella]]<ref>{{Cite journal
 | author = [[R. M. Echols]], [[R. L. Tosiello]], [[D. C. Haverstock]] & [[A. D. Tice]]
 | title = Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis
 | journal = [[Clinical infectious diseases : an official publication of the Infectious Diseases Society of America]]
 | volume = 29
 | issue = 1
 | pages = 113–119
 | year = 1999
 | month = July
 | doi = 10.1086/520138
 | pmid = 10433573
}}</ref>
|✔
|✔
|<nowiki>-</nowiki>
|✔
|✔
|-
|[[Proteus]]<ref>{{Cite journal
 | author = [[R. M. Echols]], [[R. L. Tosiello]], [[D. C. Haverstock]] & [[A. D. Tice]]
 | title = Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis
 | journal = [[Clinical infectious diseases : an official publication of the Infectious Diseases Society of America]]
 | volume = 29
 | issue = 1
 | pages = 113–119
 | year = 1999
 | month = July
 | doi = 10.1086/520138
 | pmid = 10433573
}}</ref>
|✔
|✔
|<nowiki>-</nowiki>
|✔
|✔
|-
|[[Neisseria gonorrhoeae]]<ref>{{Cite journal
 | author = [[Stephanie N. Taylor]], [[Oliver Liesenfeld]], [[Rebecca A. Lillis]], [[Barbara A. Body]], [[Melinda Nye]], [[James Williams]], [[Carol Eisenhut]], [[Edward W. 3rd Hook]] & [[Barbara Van Der Pol]]
 | title = Evaluation of the Roche cobas(R) CT/NG test for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in male urine
 | journal = [[Sexually transmitted diseases]]
 | volume = 39
 | issue = 7
 | pages = 543–549
 | year = 2012
 | month = July
 | doi = 10.1097/OLQ.0b013e31824e26ff
 | pmid = 22706217
}}</ref>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔(21.6%)
|✔
|<nowiki>-</nowiki>
|-
|[[Pseudomonas]]<ref>{{Cite journal
 | author = [[Allan Ronald]]
 | title = The etiology of urinary tract infection: traditional and emerging pathogens
 | journal = [[The American journal of medicine]]
 | volume = 113 Suppl 1A
 | pages = 14S–19S
 | year = 2002
 | month = July
 | pmid = 12113867
}}</ref>
|✔
|✔
|<nowiki>-</nowiki>
|✔
|✔
|-
|[[Staphylococcus]]
|✔
|✔
|<nowiki>-</nowiki>
|✔
|✔
|-
|[[Chlamydia trachomatis]]<ref>{{Cite journal
 | author = [[J. Dimitrakov]], [[V. Ganev]], [[T. Zlatanov]], [[I. Detchev]], [[A. Horvat]], [[S. Kirov]], [[I. Vatchkova]] & [[D. Dimitrakov]]
 | title = PCR studies on the presence of Chlamydia trachomatis in the upper urinary tract of patients with obstructive pyelonephritis
 | journal = [[Folia medica]]
 | volume = 40
 | issue = 3
 | pages = 24–28
 | year = 1998
 | month = 
 | pmid = 10658351
}}</ref><ref>{{Cite journal
 | author = [[J. Dimitrakov]], [[V. Ganev]], [[T. Zlatanov]], [[I. Detchev]], [[A. Horvat]], [[S. Kirov]], [[I. Vatchkova]] & [[D. Dimitrakov]]
 | title = PCR studies on the presence of Chlamydia trachomatis in the upper urinary tract of patients with obstructive pyelonephritis
 | journal = [[Folia medica]]
 | volume = 40
 | issue = 3
 | pages = 24–28
 | year = 1998
 | month = 
 | pmid = 10658351
}}</ref><ref>{{Cite journal
 | author = [[Matthew J. Perkins]] & [[Catherine F. Decker]]
 | title = Non-gonococcal urethritis
 | journal = [[Disease-a-month : DM]]
 | volume = 62
 | issue = 8
 | pages = 274–279
 | year = 2016
 | month = August
 | doi = 10.1016/j.disamonth.2016.03.011
 | pmid = 27107783
}}</ref>
|✔
|✔
|✔(20-30%)
|✔
|<nowiki>-</nowiki>
|-
|[[Mycoplasma]]<ref>{{Cite journal
 | author = [[Iu L. Naboka]], [[L. I. Vasil'eva]], [[M. I. Kogan]], [[I. A. Gudima]] & [[I. Iu Suchkov]]
 | title = &#91;Microbial associations defecting in children with chronic pyelonephritis&#93;
 | journal = [[Zhurnal mikrobiologii, epidemiologii, i immunobiologii]]
 | issue = 5
 | pages = 8–12
 | year = 2009
 | month = September-October
 | pmid = 20063785
}}</ref><ref>{{Cite journal
 | author = [[Iu L. Naboka]], [[L. I. Vasil'eva]], [[M. I. Kogan]], [[I. A. Gudima]] & [[I. Iu Suchkov]]
 | title = &#91;Microbial associations defecting in children with chronic pyelonephritis&#93;
 | journal = [[Zhurnal mikrobiologii, epidemiologii, i immunobiologii]]
 | issue = 5
 | pages = 8–12
 | year = 2009
 | month = September-October
 | pmid = 20063785
}}</ref>
|✔
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|-
|[[Trichomonas vaginalis|Trichomonas]]<ref>{{Hoffman, David J., et al. "Urinary tract infection with Trichomonas vaginalis in a premature newborn infant and the development of chronic lung disease." Journal of perinatology 23.1 (2003): 59-61.}}</ref><ref>{{Cite journal
 | author = [[L. SYLVESTRE]], [[M. BELANGER]] & [[Z. GALLAI]]
 | title = Urogenital trichomoniasis in the male: review of the literature and report on treatment of 37 patients by a new nitroimidazole derivative (Flagyl)
 | journal = [[Canadian Medical Association journal]]
 | volume = 83
 | pages = 1195–1199
 | year = 1960
 | month = December
 | pmid = 13774369
}}</ref><ref>{{Kuberski, Tim. "Trichomonas vaginalis associated with nongonococcal urethritis and prostatitis." Sexually transmitted diseases 7.3 (1979): 135-136.}}</ref>
|✔
|✔
|✔
|✔
|<nowiki>-</nowiki>
|}
<small>*Ecoli is the most common cause of all urinary tract infections<ref>{{Cite journal
 | author = [[Matthew J. Perkins]] & [[Catherine F. Decker]]
 | title = Non-gonococcal urethritis
 | journal = [[Disease-a-month : DM]]
 | volume = 62
 | issue = 8
 | pages = 274–279
 | year = 2016
 | month = August
 | doi = 10.1016/j.disamonth.2016.03.011
 | pmid = 27107783
}}</ref></small>
*'''For more causes of [[Pyelonephritis]] [[Pyelonephritis causes|click here]].
*'''For more causes of [[Cystitis]] [[Cystitis causes|click here]].
*'''For more causes of [[Urethritis]] [[Urethritis causes|click here]].
*'''For more causes of [[Prostatitis]] [[Prostatitis causes|click here]].
*'''For more causes of [[Asymptomatic bacteriuria]] [[Asymptomatic bacteriuria#Causes|click here]].

==Differential Diagnosis==
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="3" |<small>Diagnostic tests</small>
! colspan="4" |<small>Physical Examination</small>
| colspan="5" |<small>Symptoms
! colspan="1" rowspan="2" |<small>Past medical history</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>Urinalysis</small> 
!<small>Urine Culture</small>
!<small>Gold Standard
!<small>Fever</small>
!<small>Tenderness</small> 
!<small>Discharge</small>
!<small>Inguinal Lymphadenopathy</small>
!<small>Hematuria</small>
!<small>Pyuria</small>
!<small>Frequency</small>
!<small>Urgency</small>
!<small>Dysuria</small>
|-
| colspan="4" |'''Differentiating amongst different types of Urinary Tract Infections:'''
| colspan="11" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Pyelonephritis
| style="background: #F5F5F5; padding: 5px; text-align:center" |
*Leukocytes

*Nitrite +ve
| style="background: #F5F5F5; padding: 5px;" |Identifies causative bacteria
| style="background: #F5F5F5; padding: 5px;" |Imaging and culture
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" |Flank or costovertebral angle
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
* History of Pyelonephritis
* Recent history of Hospitalisation
* Nephrolithiasis
* Immunosupression
| style="background: #F5F5F5; padding: 5px;" |
* Costovertebral angle tenderness
* Patient is in acute distress
* Look for obstructive causes
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Cystitis
|style="background: #F5F5F5; padding: 5px;" |
*Nitrite +ve 

*Leukocyte estrase+ve

*WBCs

*RBCs
|style="background: #F5F5F5; padding: 5px; text-align:center"|>100,000CFU/mL
| style="background: #F5F5F5; padding: 5px;" |Urinary culture
|style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
|style="background: #F5F5F5; padding: 5px; text-align:center" |Suprapubic
| style="background: #F5F5F5; padding: 5px;text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
|style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
|style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px;" |
*Recent catheterisation
*[[Pregnancy]]
*recent intercourse
*[[Diabetes]]
*Personal or Family History of [[UTI]]
*Known abnormality of the urinary tract
*[[BPH]] or [[HIV]]
|style="background: #F5F5F5; padding: 5px;" |
* Imaging studies help differentiate the type
* May company back pain, nausea, vomiting and chills
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Urethritis
|style="background: #F5F5F5; padding: 5px;" |
*Positive leukocyte esterase test or >10 WBCs
*Mucous threads in the morning urine

|style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" |
Gram stain
&
Mucoid or purulent discharge
|style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;text-align:center" | -
| style="background: #F5F5F5; padding: 5px;text-align:center" |Urethral discharge
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
|style="background: #F5F5F5; padding: 5px;" | ✔ 
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
|style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px;" |
* Prior [[STD]]s
* [[Urinary tract infection|Urinary tract infections]]
* New sexual partner
* Recent intercourse
* Recent catheterisation
|style="background: #F5F5F5; padding: 5px;" |
*Purulent discharge may suggest [[gonorrhoea]]
*Exclusive dysuria suggest [[Chlamydia]]
*Painful genital ulcers with dysuria suggest [[HSV]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Prostatitis
| style="background: #F5F5F5; padding: 5px;" |
*10-20 leukocytes for acute and chronic bacterial subtypes
| style="background: #F5F5F5; padding: 5px; text-align:center" | Identifies causative bacteria (in bacterial subtypes)
| style="background: #F5F5F5; padding: 5px;" | 
Urine Culture 
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;text-align:center" | -
| style="background: #F5F5F5; padding: 5px;text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" |
* Urogenital disorders
* Recent [[catheterization]] or other genitourinary instrumentation
* History of [[UTI|UTIs]]
| style="background: #F5F5F5; padding: 5px;" |
* In acute prostatitis, palpation reveals a tender and enlarged prostate<sup>[[Prostatitis physical examination|[1][3]]]</sup>
* In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate<sup>[[Prostatitis physical examination|[1]]]</sup>
* A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce [[sepsis]]
|-
| colspan="3" |'''Differentiating UTIs from Other Diseases:'''
| colspan="12" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | Bacterial Vulvovagintis

|style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px; text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" |
Gram Stain
&
Culture of discharge
|style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;text-align:center" |-
|style="background: #F5F5F5; padding: 5px;text-align:center" | Vaginal discharge 
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px; text-align:center" |-
| style="background: #F5F5F5; padding: 5px; text-align:center" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
* Number and type of sexual partners (new, casual, or regular)
* Prior [[STDs]]
* Previous history of symptomatic BV in female partner (in homosexual women)
| style="background: #F5F5F5; padding: 5px;" |
* Fishy odor from the [[vagina]] (Whiff test)
* Thin, white/gray homogeneous [[vaginal discharge]]
* Microscopy (wet prep) and vaginal pH 
* Clue cells

|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" | Cervicitis
|style="background: #F5F5F5; padding: 5px; text-align:center"|-
|style="background: #F5F5F5; padding: 5px; text-align:center"|-
|style="background: #F5F5F5; padding: 5px; text-align:center" |culture for [[gonococcal]] cervicitis
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |Cervical
|style="background: #F5F5F5; padding: 5px; text-align:center"|

endocervical exudate
| style="background: #F5F5F5; padding: 5px; text-align:center" |-
|style="background: #F5F5F5; padding: 5px; text-align:center" |-
|style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px; text-align:center"|-
| style="background: #F5F5F5; padding: 5px; text-align:center" |-
|style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" |
* Abnormal vaginal bleeding after intercourse or after [[menopause]]
* Abnormal vaginal discharge
* Painful sexual intercourse
* Pressure or heaviness in the pelvis
| style="background: #F5F5F5; padding: 5px; text-align:center" |
*Purulent or mucopurulent endocervical exudate

*Sustained endocervical bleeding easily induced by a cotton swab 

*>10 [[WBC]] in vaginal fluid, in the absence of [[trichomoniasis]], may indicate endocervical [[inflammation]] caused specifically by [[C. trachomatis]] or [[N. gonorrhea]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Epididymitis
|style="background: #F5F5F5; padding: 5px;" |
*Hematuria may be seen
|style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | Culture
|style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;text-align:center" | 
Testicular
&
Suprapubic
|style="background: #F5F5F5; padding: 5px;" | +/- urethral discharge
| style="background: #F5F5F5; padding: 5px;" |✔  
| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
| style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" | 
*Scrotal pain:  starts gradually, is usually unilateral and localized posterior to the testis
*Scrotal swelling
*Scrotal wall erythema
*Constitutional symptoms: feeling of hotness, chills, nausea and vomiting

| style="background: #F5F5F5; padding: 5px;" | 
*Ultrasound in patients with acute testicular pain to assess for testicular torsion
*If equivocal do surgical exploration
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Syphilis (STD)
|style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |Darkfield Microscopy
| style="background: #F5F5F5; padding: 5px;" | +/-
| style="background: #F5F5F5; padding: 5px;" |-
|style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" | ✔
|style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
|style="background: #F5F5F5; padding: 5px;" |
* History of STD
* HIV
* Immunosupression
* Previous history of chancre
| style="background: #F5F5F5; padding: 5px;" |
* May be asymptomatic
* Painless chancre in primary syphilis
* Secondary syphilis may have generalised features and condylomata late
* Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |BPH
| style="background: #F5F5F5; padding: 5px;" |
*Hematuria may be seen
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
DRE
&
Serum PSA
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px;" |
* Sudden inability to [[urinate]]
* [[Urinary tract infection|Urinary tract infections]]
* [[Urinary stone|Urinary stones]]
* Damage to the [[Kidney|kidneys]]
* [[Hematuria|Blood in the urine]]
| style="background: #F5F5F5; padding: 5px;" |
* Involves mainly central or transitional zone 
* [[Hyperplasia]] rather than [[Organ hypertrophy|hypertrophy]]
* Obstruction of the [[urethra]]
* Nocturia
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Neoplasms 
| style="background: #F5F5F5; padding: 5px;" |
*Hematuria may be seen
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |Imaging and biopsy
| style="background: #F5F5F5; padding: 5px; text-align:center" | +-
| style="background: #F5F5F5; padding: 5px;text-align:center" |-
| style="background: #F5F5F5; padding: 5px;text-align:center" |-
| style="background: #F5F5F5; padding: 5px;" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
* Sudden inability to [[urinate]]
* Recurrent [[Urinary tract infection|urinary tract infections]]
* Weight loss and other constitutional symptoms
| style="background: #F5F5F5; padding: 5px;" |
* [[Cachexia]]
* Gradual progression
|}

==Management==
{{familytree/start}}
{{familytree | | | | | | | | | A01 | |A01=[[UTI]] confirmed with [[urine culture]] <br> (≥ 10<sup>5</sup> CFU/mL) + [[Pyuria]]}}
{{familytree | | | | | | | | | |!| |}}
{{familytree | | | | | | | | | B01 | |B01=Is there [[abdominal pain|suprapubic pain]]?}}
{{familytree | | | | | | |,|-|-|^|-|-|.| |}}
{{familytree | | | | | | C01 | | | | C02 | |C01=Yes|C02=No}}
{{familytree | | | | | | |!| | | | | |!| | |}}
{{familytree | | | | | | D01 | | | | D02 | |D01=Consider [[Cystitis]]|D02=Is there flank or back pain?}}
{{familytree | |,|-|-|-|v|^|-|-|.| | |!| |}}
{{familytree | E01 | | E02 | | E03 | |!| | |E01=Acute uncomplicated cystitis <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> [[TMP-SMX]] 160/800mg bid x 3 days <br> OR <br> [[nitrofurantoin|Nitrofurantoin monohydrate/macrocrystals]] 100mg bid x 5-7 days <br> OR <br> [[fosfomycin|Fosfomycin trometamol]] 3g once (single dose) <br> OR <br> [[Pivmecillinam]] 400mg bid x 5 days <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E02=Complicated/Catheter-Associated Cystitis <br> '''''Preferred regimen''''' <br> For those who can tolerate '''ORALLY''' <br> [[Ciprofloxacin]] 500mg PO bid x 5-14 days <br> OR <br> [[Ciprofloxacin]] Extended Release 1000mg daily x 5-14 days <br> OR <br> '''PARENTERALLY''' <br> IV [[Levofloxacin]] 500mg <br> OR <br> IV [[Ceftriaxone]] 1g <br> OR <br> IV [[Ertapenem]] 1g <br> '''''Catheter-Associated UTI''''' <br> Remove catheter or intermittent catheterization <br> Use same antibiotic therapy as above for CA-Cystitis <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E03= Acute Cystitis in Pregnancy <br> '''''Preferred regimen''''' <br> [[Nitrofurantoin]] 100mg PO q12h x 5 days <br> OR <br> [[Amoxicillin-clavulanate]] 500mg PO q12h 3-7 days <br> OR <br> [[Fosfomycin]] 3g PO single dose <br> '''''Alternative regimen''''': <br> [[TMP-SMX]] DS PO bid x 3 days only in 2nd trimester <br> {{See main|Cystitis medical therapy}}}}
{{familytree | | | | | | | | | | |,|-|^|-|-|.| |}}
{{familytree | | | | | | | | | | F01 | | | F02 | |F01=Yes|F02=No}}
{{familytree | | | | | | | | | | |!| | | | |!| |}}
{{familytree | | | | | | | | | | G01 | | | G02 | |G01=Consider [[pyelonephritis]]|G02=Consider alternative diagnosis such as; <br> [[Prostatitis]] <br> [[Urethritis]] <br> [[Renal abscess]]}}
{{familytree | | | |,|-|-|-|v|-|-|^|.| | | |!| |}}
{{familytree | | | H01 | | H02 | | H03 | | H04 | |H01=Acute uncomplicated pyelonephritis (Outpatient) <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> [[Ciprofloxacin]] (immediate release) 500mg bid x 7 days <br> [[Ciprofloxacin]] (extended release) 1000mg once daily x 7 days <br> OR <br> [[Levofloxacin]] 750mg once daily x 5 days OR <br> [[TMP-SMX]] 160/800mg bid x 14 days <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H02=Complicated [[pyelonephritis]] (Inpatient) <br> '''''Preferred regimen''''' <br> IV [[Ceftriaxone]] 1g q24h <br> OR <br> IV [[Ciprofloxacin]] 400mg q12h <br> OR <br> IV [[Levofloxacin]] 750mg q24h <br> OR <br> IV [[Cefepime]] q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H03=Acute [[pyelonephritis]] in Pregnancy <br> '''''Preferred regimen''''' <br> IV [[Ceftriaxone]] 1g q24h <br> OR <br> IV [[Ampicillin]] 1-2g q6h <br> OR <br> IV [[Cefepime]] 1g q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H04=Is there [[urethral discharge]]?}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | | | | | I01 | | I02 | |I01=Yes|I02=No}}
{{familytree | | | | | | | | | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | | | J01 | | J02 | |J01=Consider [[Urethritis]] <br> For treatment of [[urethritis]]: <br> {{See main|Urethritis medical therapy}}|J02=[[Weak urine stream]] or [[hesitancy]]?}}
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | | | | | | | | | | K01 | | K02 | |K01=Yes|K02=No}}
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | | | L01 | | L02 | |L01=Consider [[Prostatitis]]|L02=Renal USS to rule out [[renal abscess]] (drainage + antibiotics for renal abscess) <br> Other investigations (Abdominal CT, VSUG, for anatomic abnormality or obstructions}}
{{familytree/end}}

==References==
{{Reflist|2}}


[[Category:Infectious disease]]
[[Category:Urology]]
[[Category:Nephrology]]


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