Pyuria resident survival guide

Pyuria Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ibtisam Ashraf, M.B.B.S.[2] Sahar Memar Montazerin, M.D.[3]

Synonyms and keywords: Approach to pyuria, Pyuria workup, Pyuria management

Overview

Pyuria is a urinary condition characterized by a high number of white blood cells in the urine. It is generally characterized as the presence of 10 or more white blood cells per cubic millimetre in a sample of urine, 3 or more white cells per high-power field of unspun urine, a positive result on Gram's staining of an unspun urine specimen or a urinary dipstick test that is positive for leukocyte esterase. Pyuria occurs in urinary tract infections (UTI) and/or sepsis. Other causes include sterile pyuria, STDs, pneumonia, interstitial cystitis, kidney stones, pelvic infections and urinary fistulas. Long-term usage of some medications, including aspirin, diuretics, nitrofurantoin, proton pump inhibitors and NSAIDs, induces pyuria. There may be visible changes in the urine, which may appear cloudy or thick or look like pus.

Causes

Life Threatening Causes

Life-threatening causes of pyuria include

• Sepsis

Common Causes

• Sterile Pyuria
  • Sexually transmitted disease such as chlamydia, gonorrhea, genital herpes, human papilloma virus infection, syphilis and HIV
  • Viral Infections such as adenovirus, BK polyomavirus, and cytomegalovirus
  • Genitourinary tuberculosis
  • Fungal infection such as Candida albicans
  • Parasitic infection such as Trichomonas vaginalis
• Interstitial cystitis
• Painful bladder syndrome
• Pelvic infections
• Intra-abdominal infections
• Radiation cystitis
• Pneumonia
• Foreign bodies in the urinary tract
• Transvaginal mesh
• Urinary fistulas
• Intrinsic renal diseases
• Renal transplant rejection
• Polycystic kidney disease
• Kidney stones
• Autoimmune diseases, such as Kawasaki disease

The table below demonstrates the possible causes of pyuria:

Common causes of pyuria
Non-iInfectious					Infectious
Medication side effect	Systemic disease	Accompanied with hematuria	History of surgery/radiotherapy	Accompanied with weight loss	Infections
Non-steroidal anti-inflammatory drugs Olsalazine Penicillin Proton pump inhibitors Steroids Vancomycin	Diabetes mellitus Interstitial cystitis Kawasaki disease Malignant hypertension Pregnancy Post-menopausal changes Systemic lupus erythematosus	Renal stone Urinary tract neoplasm Polycystic kidney disease Renal papillary necrosis Interstitial nephritis	Urinary catheters Ureteric stents Recent cystourethroscopy/nephroscopy Post-intrabdominal surgery Post-pelvic irradiation	Pelvic malignancy Urinary tract tuberculosis Urinary tract malignancy	Unresolved bacterial urinary infection Prostatitis Cystourethritis Balanitis Post-antibiotic pyuria Chlamydia uretritis Gonorrhoea uretritis Schistosomiasis Adenovirus cystitis

Diagnosis

The below algorithms shows primary approach to patients with pyuria:

History and Physical Eexamination Ask for urinary symptoms such as: ❑ Dysuria ❑ Hematuria Physical Examination should asses for the presence of: ❑ Hypotension ❑ Pallor ❑ Edema ❑ Muffled heart sounds ❑ Swollen joints ❑ Organomaegally ❑ Lymphadenopathy ❑ Abdominal and pelvic examination ❑ Digital rectal examination ❑ Vaginal examination (in female)

Laboratory Investigations Check for urinanalysis and urine cullture ❑ Midstream clean catch is preferred. ❑ Avoid the use of antiseptic solutions prior to collection. Check routine blood tests such as: ❑ Complete blood count ❑ Liver function test ❑ Renal function test Perform a vaginal swab in sexually active patients to rule out: ❑ Chlamydia ❑ Gonorrhoea In case of suspicion to urinary tuberculosis: ❑ Consider 3 consecutive first-void morning samples for acid-fast bacilli and polymerase chain reaction (PCR) testing In case of suspicion to schistosomiasis: ❑ Consider collecting a terminal urine sample between noon and 3 pm

Other Investigations Consider urinary tract ultrasound or computed tomography: ❑ If suspicious for renal stone ❑ If suspicious for masses ❑ If suspicious for nephritis Consider flexible cystourethroscopy and tissue biopsy: ❑ If suspicious for neoplasm

Shown below is an algorithm summarizing the diagnosis of pyuria.

Patient with Pyuria

Patient with pelvic pain, urinary symptoms and urethral symptoms

Patient with fever, systemic symptoms, urinary symptoms, abdominal or pelvic pain

Evaluate for: STDs, Prostatitis, PID

Reassess for bacterial infection by means of aerobic and anaerobic culture

If not detected, consider: Urinary stone, Foreign body, Interstitial cystitis, Bladder tumor, Schistosomiasis

No bacteria detected

Evaluate for: Tuberculosis If patient is a immigrant from tuberculosis endemic country Fungal infection If patient is immunocompromised, check for candida, aspergillus or cryptococcus infection

If no infection detected, consult with infectious disease specialist or nephrologist

Treatment

Shown below are the algorithms summarizing the treatment of pyuria. It typically depends on the specific cause of pyuria.

Gonorrhea and Chlamydia

NAAT with first-catch urine sample

Positive

Negative

Gonorrhea

Chlamydia

Evaluate for other causes

Ceftriaxone 250mg Intramuscularly and either Azithromycin 1g Orally Doxycycline 100mg Orally twice a day for 7 days

Azithromycin 1g Orally Doxycycline 100mg Orally twice a day for 7 days Alternatively Erythromycin 500mg Four times a day for 7 days

Abbreviations: NAAT: Nucleic Acid Amplification Test

Fungal Infections

Antifungal drugs: Fluconazole, Posaconazole, Echinocandins and Amphotericin B

Candida albicans: Fluconazole 100 mg PO qd for 2-5 days

If the patient has coexisting diabetes mellitus or immunosuppression

Non-albicans Candida: Amphotericin B 0.1 mg/kg/day IV for 2-5 days

More than one Antifungal drugs + Antibiotics

Renal Tuberculosis

Isoniazid 300 mg PO qd for 2 months AND Rifampicin 450-600 mg qd for 2 months AND Ethambutol 15-25 mg/kg PO qd for 2 months AND Pyrazinamide 1500 mg for 2 months THEN Isoniazid 300 mg PO qd for 4-6 months AND Rifampicin 450-600 mg qd for 4-6 months

Trichomoniasis

Preferred regimen: Metronidazole 2 g PO single dose OR Tinidazole 2 g PO single dose

Treat patient’s sex partner if trichomoniasis is diagnosed in patient

Genital herpes

Preferred regimen: Acyclovir 400 mg PO tid for 7–10 days OR Acyclovir 200 mg PO five times a day for 7–10 days OR Famciclovir 250 mg PO tid for 7–10 days OR Valacyclovir 1 g PO bid for 7 days

Mycoplasma and Ureaplasma

Preferred regimen: Azithromycin OR Levofloxacin OR Moxifloxacin

Schistosomiasis

Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

Do's

Evaluate for sexually transmitted diseases, if risk factors are present including unprotected sexual encounters.
Instruct the female patients to:

• Lose weight (if they are overweight or obese).
• Always stay hydrated.
• Urinate after sexual intercourse.
• Always wipe front to back.
• Wear cotton/comfortable underwear.
• Use menstrual cups, sanitary pads, or clean period-proof underwear.
• Maintain personal hygiene.

Don'ts

• Do not give fluoroquinolones in pregnancy.
• Don't give TMP-SMX in the first trimester or near term of pregnancy.
• Delay in urinating.
• Smoke
• Drink the following items a lot:
  • Caffeinated sodas
  • Alcohol
  • Spicy foods
  • Acidic fruits

References