History and exam
Key diagnostic factors
common
dysuria
Ask if the patient experiences a burning pain when passing urine.
Dysuria is 1 of the 3 key diagnostic signs and symptoms of UTI in women aged under 65 years without a catheter (along with new nocturia and cloudy-looking urine).[4]
In patients with all 3 of these signs and symptoms, 82% will have a positive urine culture; with 2 of the signs/symptoms, 74% will have a positive urine culture; and with only 1 of these signs/symptoms, 68% will have a positive urine culture.[49]
New-onset dysuria is a key diagnostic symptom in women aged over 65 years without a catheter.[4]
The presence of new-onset dysuria alone indicates that UTI is likely.[4]
new nocturia
Ask if the patient is passing urine more often than usual at night.
New nocturia is 1 of the 3 key diagnostic signs and symptoms of UTI in women under 65 years without a catheter (along with dysuria and cloudy-looking urine).[4]
In patients with all 3 of these signs and symptoms, 82% will have a positive urine culture; with 2 of the signs/symptoms, 74% will have a positive urine culture; and with only 1 of these signs/symptoms, 68% will have a positive urine culture.[49]
New nocturia may be a sign of other problems, such as urinary retention and diabetes.
cloudy-looking urine
Check if the urine is cloudy to the naked eye.
Cloudy-looking urine is 1 of the 3 key diagnostic signs/symptoms of UTI in women under 65 years without a catheter (along with dysuria and new nocturia).[4]
In patients with all 3 of these signs and symptoms, 82% will have a positive urine culture; with 2 of the signs/symptoms, 74% will have a positive urine culture; and with only 1 of these signs/symptoms, 68% will have a positive urine culture.[49]
risk factors
Ask about any risk factors present. Risk factors vary according to the patient’s age.[26]
In premenopausal women, ask about:[26]
History of UTI[55]
Positive family history
Having a mother with a history of UTI is associated with a two- to fourfold increase in risk of recurrent UTI.[22]
Diaphragm use, especially when used with spermicide[55]
Pregnancy[36]
Carry out a pregnancy test if the woman is unsure.
Urinary tract infections are common during pregnancy. Infections and untreated asymptomatic bacteriuria during pregnancy have been associated with an increased risk of pyelonephritis, premature delivery, and fetal mortality.[36]
In postmenopausal women, ask about:[26]
Oestrogen deficiency
However recurrent UTI may be a symptom of vaginal atrophy.
Changes caused by oestrogen deficiency may predispose the urinary tract to infection.[53]
History of UTI[55]
Incontinence
Presence of a cystocele.
In older, institutionalised women ask about:[26]
Urinary catheterisation[2]
Incontinence
Medication, including recent antibiotics
Functional status.
Consider diabetes as a risk factor in any age group.[2][55]
Ask women with a catheter how long it has been in place. The duration of catheterisation is an important risk factor for the development of catheter-associated UTI.[2]
fever
In women aged over 65 years, an abnormal temperature and any non-specific signs of infection could indicate a UTI.[4]
A temperature of 1.5°C above normal twice in the last 12 hours is a sign of UTI, when combined with another new-onset urinary symptom.[4][54]
A temperature of ≥37.9°C or ≤36°C may indicate pyelonephritis or sepsis.
In women aged under 65 years, a temperature of ≥37.9°C may indicate pyelonephritis or sepsis.[4]
Other diagnostic factors
common
urgency
Urgency in women aged under 65 years and new urgency in women over 65 years is a common symptom that can indicate a UTI. It can also be a sign of an overactive bladder.[4]
visible haematuria
In women aged under 65 years, visible haematuria can be an indication for UTI.[4][2] However, when it is a finding on its own, consider causes other than a UTI and investigate as appropriate.[35]
Refer patients with persistent haematuria to a urologist after resolution of UTI.[4]
Visible haematuria may be a symptom in patients with catheter-associated UTI.[2]
frequency
This is a common symptom that can indicate a UTI.[4]
suprapubic pain or tenderness
flank pain
May be noted in patients with catheter-associated UTI.[2]
costo-vertebral angle tenderness
May be noted in patients with catheter-associated UTI.[2]
new incontinence
new or worsening delirium/debility
In women aged over 65 years, this can indicate a UTI when combined with another symptom in this group.[54] Also consider other causes of delirium (use the PINCH ME mnemonic - pain, other infection, poor nutrition, constipation, poor hydration, other medications, environment change).[4]
Altered mental state may be noted in patients with catheter-associated UTI.[2]
loss of diabetic control
A general sign of infection. It is not specific to UTI.
malaise
Malaise or lethargy may be associated with UTI in a patient with a catheter.[2]
rigors
May be noted in patients with catheter-associated UTI.[2]
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