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Pyuria Differential Diagnosis

Differentiating the diseases that can cause pyuria:[1][2][3][4]

Category Disease Clinical manifestations Para−clinical findings Gold standard for diagnosis Associated findings
Symptoms Physical examination
Lab Findings Imaging
Pain Fever N/V Urinary symptoms BP Edema Other CBC Electrolytes Urinalysis Ultrasound CT scan Other
Dysuria Frequency Urgency Gross hematuria Cell Cast Bacteriuria Culture Other
Infectious diseases UTI[5] Bacterial Asymptomatic bacteriuria[6][7] − − − − − − − Nl − − Nl Nl ± − + − − − − − Urinalysis
  • Increased risk in pregnancy
  • Must be treated prior to an invasive urologic procedure
Cystitis[8] − − − + + + − Nl − − Nl Nl + − + + − − − Urinalysis
Pyelonephritis[9] + + + + + + − Nl − − WBC ↑ Nl + WBC cast + + − − − Clinical manifestation + urinalysis
Viral[10][11] − − + + + + ± Nl − − Nl Nl + − − − − − − − PCR viral load
Tuberculosis[12][13][14][15] − ± − + + + + Nl − − Nl Nl ± − − Positive mycobacterial urine culture
  • Microscopic hematuria +
 − Pulmonary TB on chest CT − Urine mycobacterial PCR
Fungal[16][17] − − − + + − − Nl − − Nl Nl ± − − + after several weeks of follow up − Hydronephrosis − − Urine culture
  • Increased risk in patients with long−term foley catheters
  • Candida as the most prevalent fungus
STD Chlamydia[18][19] Chronic pelvic pain − − + + − − Nl − Nl Nl + − − + − − − − PCR
  • Females might have concurrent chlamydial cervicitis
  • Must be considered in young, sexually active males
Gonococcus[20][21][22] Chronic pelvic pain − − + + − − Nl − Nl Nl + − − +

High false negative result

Intracellular gram−negative diplococci on gram stain − − − Nucleic acid amplification testing (NAAT)
  • Females might have concurrent cervical gonococcal infection
  • Must be considered in young, sexually active males
Ureaplasma urealyticum[23] − − − + + − − Nl − − Nl Nl + − − − Gram stain − − − − PCR
  • Associated with complications of pregnancy
Herpes simplex virus[24] + + − + + − − Nl − Nl Nl + − − Viral culture + − − − − Clinical manifestation + PCR
  • Associated with extragenital complications, like aseptic meningitis
  • High risk of recurrence 
Herpes zoster
HPV
HIV
Prostatitis
Balanitis
Appendicitis
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Edema Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Ultrasound CT scan Other imaging Gold standard for diagnosis Associated findings
Non−infectious diseases Urinary tract disorders Urinary catheterization[25] − − − + + − − Nl − − Nl ↑ − + + − − − Clinical manifestation + urinalysis
Urinary tract stone
Urinary tract neoplasm
Urinary fistula
Interstitial cystitis
Vesicoureteral reflux
Hydronephrosis
Renal diseases Polycystic kidney disease
Renal vein thrombosis
Interstitial nephritis
Papillary necrosis
IgA nephropathy
Renal transplant rejection
Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Edema Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Ultrasound CT scan Other imaging Gold standard for diagnosis Associated findings
Systemic disease Malignant hypertension
Diabetic nephropathy
Sickle cell disease
Sarcoidosis
Systemic lupus erythematosus
Sjögren’s syndrome
Kawasaki's disease[26] − + − + + + − Nl − + − − − − − − − Clinical manifestation
Henoch−Schönlein purpura + + + +
  • Proteinuria
Graft versus host disease (GVHD)
Medication/toxin Analgesic nephropathy
Contrast−induced nephropathy
Glucocorticoids
Toluene
Lead poisoning
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Edema Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Ultrasound CT scan Other imaging Gold standard for diagnosis Associated findings
  1. ↑ Wise, Gilbert J.; Longo, Dan L.; Schlegel, Peter N. (2015). "Sterile Pyuria". New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 0028-4793.
  2. ↑ Stamm, Walter E. (1983). "Measurement of pyuria and its relation to bacteriuria". The American Journal of Medicine. 75 (1): 53–58. doi:10.1016/0002-9343(83)90073-6. ISSN 0002-9343.
  3. ↑ Groah, Suzanne; Perez-Losada, Marcos; Caldovic, Ljubica; Ljungberg, Inger; Sprague, Bruce; Castro-Nallar, Eduardo; Shah, Neel; Hsieh, Michael; Pohl, Hans (2015). "MP20-08 PYURIA AND ASYMPTOMATIC BACTERIURIA IS ASSOCIATED WITH NOVEL AND SPECIFIC URINE MICROBIOMES". The Journal of Urology. 193 (4): e226. doi:10.1016/j.juro.2015.02.980. ISSN 0022-5347.
  4. ↑ Shaikh, N.; Shope, T. R.; Hoberman, A.; Vigliotti, A.; Kurs-Lasky, M.; Martin, J. M. (2016). "Association Between Uropathogen and Pyuria". PEDIATRICS. 138 (1): e20160087–e20160087. doi:10.1542/peds.2016-0087. ISSN 0031-4005.
  5. ↑ Neal DE (February 2008). "Complicated urinary tract infections". Urol. Clin. North Am. 35 (1): 13–22, v. doi:10.1016/j.ucl.2007.09.010. PMID 18061020.
  6. ↑ Nicolle, Lindsay E. (2014). "Asymptomatic bacteriuria". Current Opinion in Infectious Diseases. 27 (1): 90–96. doi:10.1097/QCO.0000000000000019. ISSN 0951-7375.
  7. ↑ Nicolle, Lindsay E. (2015). "Asymptomatic Bacteriuria and Bacterial Interference". Microbiology Spectrum. 3 (5). doi:10.1128/microbiolspec.UTI-0001-2012. ISSN 2165-0497.
  8. ↑ Sabih A, Leslie SW. PMID 28613784. Missing or empty |title= (help)
  9. ↑ Pietrucha-Dilanchian P, Hooton TM (December 2016). "Diagnosis, Treatment, and Prevention of Urinary Tract Infection". Microbiol Spectr. 4 (6). doi:10.1128/microbiolspec.UTI-0021-2015. PMID 28087935.
  10. ↑ Aboumohamed A, Flechner SM, Chiesa-Vottero A, Srinivas TR, Mossad SB (November 2014). "Disseminated adenoviral infection masquerading as lower urinary tract voiding dysfunction in a kidney transplant recipient". Clin. Nephrol. 82 (5): 332–6. doi:10.5414/CN107977. PMID 23816478.
  11. ↑ Santiago-Rodriguez TM, Ly M, Bonilla N, Pride DT (2015). "The human urine virome in association with urinary tract infections". Front Microbiol. 6: 14. doi:10.3389/fmicb.2015.00014. PMC 4304238. PMID 25667584.
  12. ↑ Altiparmak MR, Trabulus S, Balkan II, Yalin SF, Denizli N, Aslan G, Doruk HE, Engin A, Tekin R, Birengel S, Cetin BD, Arslan F, Turhan V, Mert A (August 2015). "Urinary tuberculosis: a cohort of 79 adult cases". Ren Fail. 37 (7): 1157–63. doi:10.3109/0886022X.2015.1057460. PMID 26123266.
  13. ↑ Verma AK, Mishra AK, Kumar M, Kant S, Singh A, Singh A (July 2016). "Renal tuberculosis presenting as acute pyelonephritis - A rarity". Indian J Tuberc. 63 (3): 210–213. doi:10.1016/j.ijtb.2015.07.010. PMID 27865246.
  14. ↑ Daher Ede F, da Silva GB, Barros EJ (January 2013). "Renal tuberculosis in the modern era". Am. J. Trop. Med. Hyg. 88 (1): 54–64. doi:10.4269/ajtmh.2013.12-0413. PMC 3541747. PMID 23303798.
  15. ↑ Czapka M, Shukla S, Slosar-Cheah M (August 2017). "Urine trouble: genitourinary tuberculosis and subsequent DRESS syndrome". BMJ Case Rep. 2017. doi:10.1136/bcr-2017-220440. PMID 28784884.
  16. ↑ Kim J, Kim DS, Lee YS, Choi NG (September 2011). "Fungal urinary tract infection in burn patients with long-term foley catheterization". Korean J Urol. 52 (9): 626–31. doi:10.4111/kju.2011.52.9.626. PMC 3198237. PMID 22025959.
  17. ↑ Carvalho M, Guimarães CM, Mayer JR, Bordignon GP, Queiroz-Telles F (December 2001). "Hospital-associated funguria: analysis of risk factors, clinical presentation and outcome". Braz J Infect Dis. 5 (6): 313–8. PMID 11980593.
  18. ↑ Matthews, R.S.; Bonigal, S.D.; Wise, R. (1990). "Sterile pyuria and Chlamydia trachomatis". The Lancet. 336 (8711): 385. doi:10.1016/0140-6736(90)91936-5. ISSN 0140-6736.
  19. ↑ Tayal SC, Pattman RS (1996). "Sterile pyuria: consider chlamydial infection". Br J Clin Pract. 50 (3): 166–7. PMID 8733337.
  20. ↑ Clarke M, Maskell R (December 1981). "Gonorrhoea presenting as "sterile" pyuria". Br Med J (Clin Res Ed). 283 (6305): 1546. PMC 1507898. PMID 6799059.
  21. ↑ Jephcott AE (August 1997). "Microbiological diagnosis of gonorrhoea". Genitourin Med. 73 (4): 245–52. PMC 1195851. PMID 9389943.
  22. ↑ Tomas ME, Getman D, Donskey CJ, Hecker MT (August 2015). "Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department". J. Clin. Microbiol. 53 (8): 2686–92. doi:10.1128/JCM.00670-15. PMC 4508438. PMID 26063863.
  23. ↑ Nassar FA, Abu-Elamreen FH, Shubair ME, Sharif FA (2008). "Detection of Chlamydia trachomatis and Mycoplasma hominis, genitalium and Ureaplasma urealyticum by polymerase chain reaction in patients with sterile pyuria". Adv Med Sci. 53 (1): 80–6. doi:10.2478/v10039-008-0020-1. PMID 18614434.
  24. ↑ Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, Berman SM, Markowitz LE (August 2006). "Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States". JAMA. 296 (8): 964–73. doi:10.1001/jama.296.8.964. PMID 16926356.
  25. ↑ Forster, C.S.; Haslam, D.B.; Jackson, E.; Goldstein, S.L. (2017). "Utility of a routine urinalysis in children who require clean intermittent catheterization". Journal of Pediatric Urology. 13 (5): 488.e1–488.e5. doi:10.1016/j.jpurol.2017.01.016. ISSN 1477-5131.
  26. ↑ Wirojanan J, Sopontammarak S, Vachvanichsanong P (March 2004). "Sterile pyuria in Kawasaki disease". Pediatr. Nephrol. 19 (3): 363. doi:10.1007/s00467-003-1394-8. PMID 14745638.
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