URINARY TRACT INFECTIONS

Definitions

UTIs are classified according to a spectrum of dz & the predominant clinical sxs: Asymptomatic bacteriuria, uncomplicated lower UTI (cystitis), uncomplicated pyelonephritis, complicated UTI w/ or w/o pyelonephritis, recurrent UTI

Asymptomatic bacteriuria: Absence of urinary sxs w/ UA ≥10 WBC/mm³ & Ucx ≥10⁵ cfu/mL uropathogen in 2 consecutive midstream urine samples ≥24 h apart.

Acute uncomplicated UTI: Acute dysuria, urgency, frequency, suprapubic pain w/ UA ≥10 WBC/mm³ & Ucx ≥10³ cfu/mL

Acute uncomplicated pyelonephritis: Fever, chills, flank pain in the absence of alternative Dx & urologic abnlty w/ UA ≥10 WBC/mm³ & Ucx ≥10⁴ cfu/mL

Complicated UTI: Features of uncomplicated UTI/pyelonephritis AND 1 or more of the following—presence of indwelling catheter, stent or use of intermittent straight catheter, a postvoid residual >100 mL, obstructive uropathy (stones, tumor, etc.), vesicoureteric reflux or other functional abx, urinary tract modification (ie, neobladder), chemical/radiation injury to uroepithelium, & Ucx ≥10⁴ cfu/mL of uropathogen in a man

Recurrent UTI: At least 3 episodes of uncomplicated UTI documented by culture in the last 12 mo in the absence of structural/functional abx

Male urogenital tract infections: Urethritis, prostatitis, epididymitis, orchitis

Asymptomatic Bacteriuria

Definition

•  Absence of urinary sxs w/ UA ≥10 WBC/mm³ & Ucx ≥10⁵ cfu/mL of the same uropathogen in 2 consecutive midstream urine samples ≥24 h apart; however, a single positive midstream urine is generally accepted as adequate & more practical

•  USPSTF recommends screening for asymptomatic bacteriuria w/ Ucx for pregnant women at 12–16 wk gestation given increased risk of pyelonephritis, preterm labor & low birth weight

•  USPSTF recommends against screening for asymptomatic bacteriuria in men or nonpregnant women

•  The IDSA recommends against routine screening for or tx of asymptomatic bacteriuria in diabetic women, older persons >65 y/o residing in the community or institutionalized residents of long-term care facilities, spinal cord injury, & pts w/ indwelling urethral catheters

Treatment (Asymptomatic Bacteriuria in Pregnancy)

•  3–7-d course of nitrofurantoin or cephalosporin (cephalexin, cefpodoxime, cefdinir, cefaclor)

Pearl

•  Given the high PPV of leukocyte esterase & nitrites on UA for bacteriuria, a positive test result in an asymptomatic pregnant pt in the ED should be considered for tx pending culture data

Guideline: U.S. Preventive Services Task Force. Screening for Asymptomatic Bacteriuria. In Adults: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. 2008;149:43–47.

Nicolle LE, Bradley S, Colgan R, et al. Infectious Disease Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis. 2005;40:643–654.

Acute Uncomplicated Urinary Tract Infection (Acute Cystitis)

Definition

Acute dysuria, urgency, frequency, suprapubic pain w/ UA ≥10 WBC/mm³ & Ucx ≥10³ cfu/mL, but ≥10⁵ cfu/mL also used to define UTI; absence of structural/functional UG tract abnormalities

Occurs when uropathogen from bowel or vagina colonize periurethral mucosa & ascend through urethra & bladder

Predominant uropathogens: E. coli (75–95%), K. pneumoniae, P. mirabilis, E. faecalis, S. saprophyticus, & S. agalactiae (group B Strep); rarely P. aeruginosa, Ureaplasma species

Probability of dz in pts presenting w/ 1 or more UTI sxs is ∼50%

History

•  Combination of dysuria, frequency, hematuria, fever, back pain, &/or self-diagnosis all increase the probability of UTI, whereas their absence decreases its probability

•  Vaginal d/c or irritation w/o the above sxs decreases probability of UTI

•  RFs: Prior UTI, family h/o UTI, sexual intercourse, new sex partner (w/i 1 yr), use of spermicide

Physical Exam

•  ±Fever; tenderness w/ suprapubic palpation; CVA tenderness

•  GU exam if vaginal d/c or irritation present

Evaluation

•  CBC/Chemistries rarely indicated

•  Urine hCG, UA (+leukocyte esterase AND +nitrite has best diagnostic utility, where either +LE or +nitrite helpful w/ high pretest probability pts)

•  Routine Ucx not needed in uncomplicated cases

Treatment

•  Spontaneous resolution observed in 25–42% of untreated women

•  Antibiotic regimens:

1st-line:

•  Nitrofurantoin monohydrate macrocrystals 100 mg BID × 5 d

•  Trimethoprim–sulfamethoxazole 160/800 mg (1 DS tablet) BID × 3 d (if <20% resistance in community)

•  Fosfomycin 3 g sachet in a single dose

•  Pivmecillinam 400 mg BID × 3–7 d (not available in US)

Alternative regimens:

•  Fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin) for 3 d

•  β-lactams (amoxicillin–clavulanate, cefdinir, cefaclor, cefpodoxime) for 3–7 d

•  Symptomatic tx: NSAIDs, phenazopyridine (variable efficacy)

Disposition

•  Home

Pearls

•  Probability of cystitis >90% in women w/ sxs of UTI in the absence of vaginal d/c or irritation, thus consider empiric tx w/o UA or w/ nl UA *(negative LE & nitrites do not reliably r/o UTI)

•  UTI in males is rare thus consider STD, prostatitis

•  Increasing E. coli resistance to amoxicillin & trimethoprim–sulfamethoxazole

Guideline: Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in woman: A 2010 update by the Infectious Disease Society of America and the European Society of Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103–e120.

Acute Uncomplicated Pyelonephritis

Definition

•  Upper UTI of renal pelvis & kidney secondary to ascending lower UTI (see acute uncomplicated UTI for pathogenesis & uropathogens)

•  Fever, chills, flank pain in absence of alternative Dx & urologic abnlty w/ UA ≥10 WBC/mm³ & Ucx ≥10⁴ cfu/mL

History

•  Highest incidence 15–29 y/o, followed by infants & elderly

•  Combination of constitutional sx (fever, chills, malaise), lower urinary tract sx (dysuria, frequency, hematuria) & upper urinary tract sx (flank pain); N/V

•  RFs: Prior UTI, sexual intercourse (esp ≥3/wk in last 30 d), new sex partner (w/i 1 yr), use of spermicide, stress incontinence in previous 30 d, diabetes mellitus

Physical Exam

•  ±Fever, tachycardia, hypotension; CVA tenderness

Evaluation

•  CBC may show leukocytosis, but can be nl (rarely guides decision making)

•  Chemistries (esp BUN/Cr) if renal impairment suspected

•  Urine hCG, UA (+leukocyte esterase AND + nitrite has best diagnostic utility, where either + LE or + nitrite helpful w/ high pretest probability pts; WBC casts)

•  Ucx & susceptibility should always be performed (usually reveals ≥10⁵ cfu/mL of single uropathogen)

•  Routine blood cultures not indicated

•  Diagnostic imaging usually not indicated; can be considered to r/o alternative Dx, if complicated dz suspected, if sxs do not improve, or if recurrence → CT abdomen/pelvis study of choice over U/S

Treatment

•  Outpt tx:

•  Ciprofloxacin 500 mg PO BID × 7 d

•  Ciprofloxacin 1 g ER PO QD × 7 d or levofloxacin 750 mg PO QD × 5 d

•  Trimethoprim–sulfamethoxazole 160/800 mg (1 DS tablet) BID × 14 d

•  Oral β-lactam (spec agent not listed) for 10–14 d

*Above regimens can be given w/ (esp if resistance in community is known to exceed 10% or Bactrim/β-lactam are used) or w/o an initial 400 mg IV dose of ciprofloxacin, 1 g IV dose ceftriaxone, or consolidated 24-h dose of aminoglycoside

•  Inpt tx:

•  IV fluoroquinolone, an aminoglycoside (w/ or w/o ampicillin), an extended spectrum cephalosporin or PCN (w/ or w/o an aminoglycoside), or a carbapenem

Disposition

•  Home: Most cases in o/w well appearing, healthy women

•  ED Obs: Persistent emesis requiring IVFs or antiemetics

•  Admit: Inability to take PO/intractable vomiting, age >65 y/o, toxic appearance, suspected sepsis, obstructive uropathy, immunocompromised (DM, sickle cell, cancer on chemotherapy, organ transplant recipient, immunosuppressives, etc.), inadequate f/u, poor social disposition (ie, homeless), pregnancy

Pearl

•  Cx: Emphysematous pyelonephritis, perinephric abscess, urosepsis, ARF, renal scarring

Guideline: Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in woman: A 2010 update by the Infectious Disease Society of America and the European Society of Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103–e120.

Complicated Urinary Tract Infection

Definition

Features of uncomplicated UTI/pyelonephritis AND 1 or more of the following:

•  Presence of indwelling catheter

•  Stent, other FB or use of intermittent straight catheter

•  Recent urologic procedure or manipulation of GU tract

•  Postvoid residual >100 mL

•  Obstructive uropathy (stones, tumor, etc.)

•  Vesicoureteric reflux or other anatomical/functional abx of urinary tract

•  Urinary tract modification (ie, neobladder)

•  Chemical/radiation injury to uroepithelium

•  Renal insufficiency

•  Transplantation

•  Ucx ≥10⁴ cfu/mL of uropathogen in a male (any UTI in male)

•  Sxs >14 d

•  Infection w/ multidrug resistant organism (ie, ESBL-producing pathogens)

History

(See uncomplicated cystitis & pyelonephritis)

Physical Exam

(See uncomplicated cystitis & pyelonephritis)

Evaluation

•  CBC may show leukocytosis, but can be nl (rarely guides decision making)

•  Chemistries (esp BUN/Cr)

•  Urine hCG, UA (+leukocyte esterase AND + nitrite has best diagnostic utility, where either + LE or + nitrite helpful w/ high pretest probability pts; WBC casts)

•  Ucx & susceptibility should always be performed (usually reveals ≥10⁵ cfu/mL of single uropathogen when positive)

•  Routine blood cultures not indicated, but should be obtained in suspected sepsis

•  Diagnostic imaging should be considered → CT abdomen/pelvis study of choice over US

•  Urology consultation: Esp w/ known or suspected structural/functional abx, recent urologic procedure, UG tract FB, obstructive uropathy, UTI in male

Treatment

•  Empiric parenteral therapy w/ fluoroquinolone, carbapenem (ie, ertapenem, meropenem, or imipenem), or 3rd-generation cephalosporin (ie, ceftriaxone, cefotaxime), or piperacillin/tazobactam

•  Duration: 7–10 d for complicated cystitis; 10–14 d for complicated pyelonephritis

Disposition

•  Admit

Guideline: Grabe M, Bjerklund-Johansen TE, Botto H, et al. Guidelines on Urological Infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2010:1–112.

Catheter-associated UTI (CA-UTI)

Definition

•  CA-UTI: Sxs or signs compatible w/ UTI w/ no other identifiable source of infection w/ ≥10³ cfu/mL uropathogen in pts w/ indwelling urethral, suprapubic, or intermittent straight catheter in urine sample obtained w/i 48 h of removal

•  Catheter-associated asymptomatic bacteriuria (CA-ASB): Presence of ≥10⁵ cfu/mL uropathogen in a catheter urine specimen in a pt w/o sxs

•  Pt scenarios may include pts transferred from long-term care facilities w/ chronic indwelling foley/suprapubic catheters, paraplegic pts w/ chronic indwelling catheters, pts w/ urinary obstruction w/ temporary foley catheter or intermittent straight catheterization, etc.

History

•  New onset or worsening fever, rigors, AMS, malaise, or lethargy w/o identifiable cause in pt w/ catheter

•  Dysuria, frequency, urgency, suprapubic pain, flank pain, hematuria in those whose catheters were recently removed

Physical Exam

•  ±Fever, tachycardia, hypotension; CVA tenderness; suprapubic tenderness

•  Cloudy/malodorous urine should not be used to differentiate CA-UTI & CA-ASB

Evaluation

(See complicated UTI)

Treatment

(See complicated UTI for antimicrobials)

•  Screening for & tx of CA-ASB are not recommended except pregnant women

•  3-d regimen may be considered in CA-UTI pts ≤65 y/o w/o upper tract sxs

•  5-d regimen of levofloxacin may be considered in CA-UTI pts not severely ill

•  7-d regimen recommended for CA-UTI pts w/ prompt resolution of sxs

•  10–14-d regimen recommended in those w/ delayed response

Prevention

•  Strongly consider indication for catheter insertion, limit catheterization changes, aseptic technique w/ placement, among others

Disposition

•  Home in majority of cases

•  Admit: Age >65 y/o, toxic appearance, suspected sepsis, immunocompromised (DM, sickle cell, cancer on chemotherapy, organ transplant recipient, immunosuppressives), inadequate f/u, poor social disposition (ie, homeless)

Guideline: Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Disease Society of America. Clin Infect Dis. 2010;50:625–663.

Recurrent Urinary Tract Infection

Definition

•  At least 3 episodes of uncomplicated UTI documented by culture in the last 12 mo in the absence of structural/functional abx

•  Relapse (5–10% women) occurs w/i 2 wk of completing antimicrobial therapy & is caused by persistence of the same uropathogen, suggesting antibiotic resistance

•  Reinfection occurs >2 wk after completing antimicrobial therapy & is generally secondary to infection w/ different organism or strain

History

(See uncomplicated cystitis and pyelonephritis)

Physical Exam

(See uncomplicated cystitis and pyelonephritis)

Evaluation

•  CBC/Chemistries rarely indicated

•  Urine hCG, UA (+leukocyte esterase AND + nitrite has best diagnostic utility, where either + LE or + nitrite helpful w/ high pretest probability pts)

•  Ucx should be obtained on representation to assess for antimicrobial resistance

•  Postvoid residual if incomplete emptying suspected

•  Imaging: Renal U/S, IV pyelography, CT abdomen/pelvis if warranted although not routine needed on emergent basis

•  Further studies may include voiding cystourethrography, cystoscopy, urodynamic testing, but not routinely performed in ED

Treatment

(See uncomplicated UTI for antimicrobials)

•  Consider starting prophylactic, continuous low-dose abx for 6-mo duration:

•  Nitrofurantoin 50–100 mg PO QD

•  Fosfomycin 3 g sachet PO q10d

•  Ciprofloxacin 125 mg PO QD

•  Cephalexin 125–250 mg PO QD, cefaclor 250 mg PO QD

•  Trimethoprim–sulfamethoxazole 40/200 mg QD or 3 times weekly

•  May alternatively consider postcoital antimicrobial prophylaxis w/ a single dose w/i 2 h after intercourse (esp if UTI temporally a/w coitus):

•  Nitrofurantoin 50–100 mg

•  Trimethoprim–sulfamethoxazole 40/200 mg or 80/400 mg

•  Cephalexin 250 mg

•  Self-start antibiotic therapy is an additional option (pt must be instructed to contact a medical provider w/i 48 h if sxs do not resolve)

Disposition

•  Home w/ urology f/u to assess for anatomical/functional etiology

Guideline: Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol Assoc J. 2011;5:316–322.

Urethritis

Definition

•  Urogenital inflammatory condition characterized by urethral inflammation which can result from infectious & noninfectious etiologies

•  Infectious causes include gonococcal (N. gonorrhoeae) & nongonococcal (C. trachomatis, M. genitalium, M. hominis, U. urealyticum, U. parvum, T. vaginalis, HSV, adenovirus)

•  Rare causes include syphilis, CMV, & enteric bacteria

History

•  Highest prevalence in adolescent, sexually active men & women

•  Dysuria, urethral pruritus, mucopurulent or purulent urethral d/c; however, asymptomatic infections are common

•  Urinary frequency & urgency typically absent

•  Sexual hx: Current sexual activity, type (oral, vaginal, anal), MSM, number of sex partners, condom use, h/o STDs (esp GC/Chlamydia), sex w/ prostitutes

•  Systemic sxs? (Fever, sore throat, arthritis, rash, back pain)

Physical Exam

•  GU exam: Urethral meatus for skin lesions, erythema, d/c; milk urethra for d/c; testicular/epididymal exam in men, pelvic exam in women

Evaluation

•  First-void (“dirty”) UA (may reveal + LE & ≥10 WBC/hpf), urine hCG

•  Gram stain of urethral secretions w/ ≥5 WBC/hpf (presence of gram-negative intracellular diplococci c/w gonococcal dz) & culture

•  Urine NAAT for N. gonorrhoeae & C. trachomatis most sens

Treatment

•  GC & Chlamydia coinfection common so therapy should be geared toward both:

•  Azithromycin 1 g orally in a single dose OR doxycycline 100 mg PO BID × 7 d

-AND-

•  Ceftriaxone 250 mg in a single IM dose

*Note: Cefixime no longer recommended given increasing gonococcal resistance to oral cephalosporins. If unable to receive ceftriaxone, alternative regimens include cefixime 400 mg or azithromycin 2 g in single oral dose PLUS Test-of-cure in 1 wk

•  Abstain from intercourse for 7 d & until all sex partners (w/i previous 60 d) are evaluated or empirically treated

Disposition

•  Home w/ PCP referral for counseling & further STD testing

Pearl

•  GC & Chlamydia are reportable to state health department

Guideline: Center for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.

Male Urogenital Tract infections
Acute Bacterial Prostatitis

Definition

•  The NIH consensus classification of prostatitis syndromes includes 4 categories:

•  I. Acute bacterial prostatitis

•  II. Chronic bacterial prostatitis (≥3 mo of sxs)

•  III. Chronic bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS)

A. Inflammatory

B. Noninflammatory

•  IV. Asymptomatic inflammatory prostatitis

•  Acute bacterial prostatitis is an acute bacterial infection of prostate w/ + Ucx, lower urinary tract sxs, obstructive voiding sxs, & systemic sxs

•  Bacterial prostatitis can be spontaneous or secondary to urologic intervention

•  Bacterial spectrum similar to uropathogens seen in other UTIs (see uncomplicated UTI); however, uropathogens of prostatitis carry greater number of virulence factors. Also, C. trachomatis, T. vaginalis, U. urealyticum, N. gonorrhoeae, & viruses rare causes

History

•  Typical age 20–45 y/o; most common urologic Dx in men <50 y/o

•  Acute onset fevers, chills, malaise, frequency, dysuria, poor urine stream, feeling of incomplete bladder emptying, & lower back/abdominal/pelvic pain

•  Sexual Dysfxn (ejaculatory discomfort & hematospermia) may be present

•  RFs: Recent urologic intervention/instrumentation, urethral stricture, urethritis

Physical Exam

•  ±Fever; suprapubic abdominal discomfort

•  Testicular exam should be performed to r/o epididymitis/orchitis

•  DRE w/ warm, tender, swollen prostate

Evaluation

•  Consider CBC & Bcx, esp if toxic appearing

•  UA (+nitrites & LE, PPV 95%, NPV ∼70%), Ucx

•  Meares–Stamey four-glass test: Collection of initial void urine (urethral sample) → midstream urine (bladder sample) → prostate massage, then collection of urine (prostate sample) → wet mount/microscopy of expressed prostate secretions (*Not practical in ED)

•  Pre- & postmassage test (PPMT): Urine sample collected before & after vigorous prostate massage (greater number of bacteria & WBCs postmassage suggests acute bacterial prostatitis)

•  Consider transrectal U/S if prostate abscess suspected (poor response to abx)

•  Prostate biopsy as an outpt

Treatment

•  Systemically ill pts should receive parenteral abx:, piperacillin/tazobactam, cephalosporins (ie, ceftriaxone, cefotaxime, ceftazidime) w/ or w/o an aminoglycoside, carbapenem (ie, imipenem, ertapenem)

•  Clinically stable pts may be treated w/ oral therapy (usually fluoroquinolone)

•  Ciprofloxacin 500 mg PO BID or levofloxacin 500–750 mg PO QD × 14 d

•  Trimethoprim–sulfamethoxazole 160/800 mg (1 DS tablet) BID × 14 d

•  Sexually transmitted: Ceftriaxone 250 mg IM × 1 AND doxycycline 100 mg BID × 14 d

•  Duration of therapy 2–4 wk

Disposition

•  Home w/ urology f/u

•  Admit if systemically ill, known antibiotic resistant pathogen, etc.

Pearls

•  10% men w/ acute bacterial prostatitis go on to suffer chronic prostatitis, & 10% progress to chronic prostatitis/chronic pelvic pain syndrome

•  Cx: Chronic prostatitis (10%), acute urinary retention, prostatic abscess (∼2%), sepsis

Epididymitis/Orchitis

Definition

•  Epididymitis & orchitis are inflammation of the epididymis & testes, respectively, w/ or w/o infection

•  Can be acute (<6 wk), subacute (6 wk–3 mo), or chronic (>3 mo) based on symptom duration

•  Orchitis usually occurs when inflammation spreads from epididymis to adjacent testicle (epididymo-orchitis), but isolated orchitis w/o epididymitis can be seen w/ mumps

•  Epididymitis can be sexually transmitted, caused by N. gonorrhoeae or C. trachomatis, or by ascending lower UTI by common uropathogens (see uncomplicated UTI); M. tuberculosis should be considered in high-risk pts, & fungal or viral causes found in pts w/ immunodeficiency

•  Noninfectious causes of epididymitis include postinfectious inflammatory rxn to pathogens (ie, M. pneumoniae, adenoviruses), vasculitides, meds (ie, amiodarone)

History

•  Primarily affects young men aged 18–35 y/o, bimodal distribution 16–30 y/o & 50–70 y/o

•  Testicular pain, swelling usually beginning posteriorly overlying epididymis; lower urinary tract sxs may be present

•  RFs: Unprotected intercourse (esp anal), MSM, increased number of sex partners, h/o STDs (esp GC/Chlamydia), sex w/ prostitutes, structural/functional GU abnlty, urinary tract instrumentation

Physical Exam

•  ±Fever; assess for CVA tenderness, suprapubic pain as e/o other urinary tract dz

•  Testicular exam: Palpation of epididymis, testes, cremasteric reflex; tender, erythematous, swollen spermatic cord & testicular contents c/w epididymitis-orchitis

•  Prehn sign: Relief of pain w/ elevation of testes can be seen w/ epididymitis. Inguinal exam for hernia or swollen, tender nodes.

Evaluation

•  First-void (“dirty”) UA (+LE & ≥10 WBC/hpf suggests urethritis, favoring Dx of epididymitis); Ucx

•  Gram stain of urethral secretions w/ ≥5 WBC/hpf (presence of gram-negative intracellular diplococci c/w gonococcal dz) & culture

•  Urine NAAT for N. gonorrhoeae & C. trachomatis most sens

•  Imaging: Testicular color Doppler ultrasonography (Findings: Thickened epididymis w/ increased blood flow suggesting hyperemia)

Treatment

•  Sexually active men <35 y/o & older men w/ RFs for STDs:

•  Ceftriaxone 250 mg IM × 1

-AND-

•  Doxycycline 100 mg PO BID × 10 d

•  Abstain from intercourse for 7 d & until all sex partners (w/i previous 60 d) are evaluated or empirically treated

•  Men >35 y/o or no RFs for STDs (thus likely caused by enteric organisms):

•  Levofloxacin 500 mg PO QD × 10 d

•  Ofloxacin 300 mg PO BID × 10 d

*Note: Above fluoroquinolones have activity against C. trachomatis & favorable UG tissue Penetration

•  Supportive: NSAIDs for pain, ice/elevation of testes while at rest

Disposition

•  Home

Pearl

•  Pts <35 y/o likely to have an STD organism as etiology; >35 y/o more likely enteric pathogen

Guideline: Grabe M, Bjerklund-Johansen TE, Botto H, et al. Guidelines on Urological Infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2010:1–112.

FLANK PAIN

Approach to the Patient

History

•  Onset (sudden vs. progressive)? Location? Dysuria/hematuria/urinary frequency? Prior h/o similar sxs

•  ROS (fever, rash, trauma, nausea, vomiting, weakness, abdominal pain), PMH (kidney stones, gout, cancer, AAA, congenital kidney dz, cardiac or vascular dz)

Evaluation

•  CBC, Cr; consider renal U/S or noncontrast abdominal CT

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