Differentials
Over-active bladder
SIGNS / SYMPTOMS
Urinary urgency and frequency in the absence of a UTI.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture.
Urothelial carcinoma of the bladder or upper urinary tract
SIGNS / SYMPTOMS
Microscopic and/or gross haematuria in the absence of a UTI.
INVESTIGATIONS
Positive urine cytology. Tumour seen on cystoscopy or upper tract imaging.
Non-infectious urethritis
SIGNS / SYMPTOMS
Dysuria, possibly with irritative voiding symptoms, in the absence of a UTI.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture.
Foreign body in bladder
SIGNS / SYMPTOMS
Recurrent or unresolved UTI.
INVESTIGATIONS
Foreign body (e.g., stone, stitch from prior pelvic surgery) visualised on imaging or cystoscopy.
Vaginitis due to Candida
SIGNS / SYMPTOMS
Presence of vaginal discharge and/or vaginal irritation.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture; positive vaginal cultures.
Direct examination yields budding yeasts and hyphae - the use of potassium hydroxide enhances the recovery of these fungal elements; yeasts provoke a large white blood cell response with a negative amine test. Normal vaginal flora will be present.
Vaginitis due to trichomonas
SIGNS / SYMPTOMS
Presence of vaginal discharge and/or vaginal irritation.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture; positive vaginal cultures.
Direct examination commonly reveals motile parasite with its flagella whipping back and forth; the infection is associated with large numbers of white cells with a positive amine test and the absence of normal vaginal flora.
Bacterial vaginosis and cervicitis due to Neisseria gonorrhoeae, Chlamydia trachomatis, or herpes simplex
SIGNS / SYMPTOMS
Presence of vaginal discharge and/or vaginal irritation.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture.
Positive vaginal cultures; positive DNA probe assay for gonorrhoea and chlamydia.
Interstitial cystitis (painful bladder syndrome)
SIGNS / SYMPTOMS
Pain associated with bladder filling as well as urinary urgency and frequency in the absence of a UTI or other aetiology. The course of the disease is usually marked by flare-ups and remissions.[59]
Dyspareunia and supra-pubic discomfort as well as anterior vaginal wall tenderness on examination.
INVESTIGATIONS
Symptoms with negative urine cultures are characteristic of interstitial cystitis.
Urethral diverticulum
SIGNS / SYMPTOMS
May present with dysuria, dyspareunia, and/or dribbling.
On physical examination, a fluctuant urethral mass as well as purulent meatal discharge upon mass compression may be noted.
INVESTIGATIONS
Characteristic radiographic findings on voiding cystourethrography (peri-urethral fluid collection) or T2-weighted MRI (bright image in peri-urethral area).
Infected Skene gland cyst
SIGNS / SYMPTOMS
May present with urethral pain, discharge, and/or urgency and frequency.
INVESTIGATIONS
May be visualised on MRI.
Pelvic organ prolapse
SIGNS / SYMPTOMS
May present with vaginal bulge symptoms, pelvic fullness or pressure and/or voiding dysfunction.
INVESTIGATIONS
Diagnosis is clinical.
No evidence of infection in urine studies.
Urethral cancer
SIGNS / SYMPTOMS
May present with voiding symptoms or haematuria.
Urethral induration may be noted on physical examination.
INVESTIGATIONS
A urethral mass can be visualised on cystoscopy and confirmed by pathological diagnosis of biopsy specimen.
Radiation cystitis
SIGNS / SYMPTOMS
History of pelvic radiation.
May have voiding symptoms and/or haematuria.
INVESTIGATIONS
Findings on cystoscopy include diffuse erythema, oedema, vascularity, petechiae, and patches of pallor.
Post-cyclophosphamide cystitis
SIGNS / SYMPTOMS
History of cyclophosphamide treatment.
Irritative voiding symptoms.
INVESTIGATIONS
Diagnosed by cystoscopy (diffuse erythema, oedema, vascularity, petechiae, patches of pallor) and, possibly, biopsy.
Atypical infections of lower urinary tract (fungal, adenovirus, tuberculosis)
SIGNS / SYMPTOMS
May present with recurrent voiding symptoms or sterile pyuria.
INVESTIGATIONS
Diagnosed by culture of atypical organisms.
Asymptomatic bacteriuria
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