History and exam
Key diagnostic factors
common
dysuria
Typical symptom. Uncomplicated cases presenting with typical symptoms can be diagnosed and treated on the basis of the history alone.
urgency
Typical symptom. Uncomplicated cases presenting with typical symptoms can be diagnosed and treated on the basis of the history alone.
frequency
Typical symptom. Uncomplicated cases presenting with typical symptoms can be diagnosed and treated on the basis of the history alone.
suprapubic pain
Suprapubic tenderness to palpation may be noted in some patients.
prior history of urinary tract infections (UTIs) and treatment history
These patients frequently recognize when they have another UTI.
A history of previous antibiotic therapy should be obtained.
Other diagnostic factors
common
recent urinary tract instrumentation
Qualifies as a complicated case warranting a longer and more aggressive antibiotics course.
uncommon
flank pain
Should be absent in uncomplicated cases. If present, may suggest pyelonephritis or an alternative diagnosis.
abdominal pain
May suggest pyelonephritis or an alternative diagnosis
fever
Should be absent in uncomplicated cases. If present, may suggest pyelonephritis or an alternative diagnosis.
vaginal discharge
Should be absent in uncomplicated cases. If present, may suggest vaginitis or an alternative diagnosis.
vaginal pruritus
Should be absent in uncomplicated cases. If present, may suggest vaginitis or an alternative diagnosis.
dyspareunia
May be caused by vaginitis or UTI.
structurally or functionally abnormal bladder
Qualifies as a complicated case warranting a longer and more aggressive antibiotics course.
Risk factors
strong
frequent sexual intercourse
Organisms may be introduced to the urethra during sexual intercourse. In one study, women who had had sexual intercourse in the previous 30 days were 5.6 times more likely to have a urinary tract infection (UTI) when compared with women in the control group.[14]
history of UTI
anatomic or functional abnormalities within the urinary tract
Anatomic abnormalities include the presence of posterior urethral valves, strictures, or stones. Functional abnormality results from lower urinary tract dysfunction of neurogenic (e.g., spina bifida) or non-neurogenic (e.g., voiding dysfunction) origin, as well as vesicoureteral reflux.[1] Qualifies as a complicated UTI, warranting a longer and more aggressive antibiotics course.
urinary catheter
Catheter-associated UTI (CAUTI) is the most common nosocomial infection.[16] The duration of catheterization is the most important determinant of bacteriuria. CAUTI risk increases by 3% to 7% each day after placement of an indwelling urinary catheter.[17] Qualifies as a complicated UTI, warranting change in therapeutic approach and longer antibiotics course.
asymptomatic bacteriuria during pregnancy or prior to urological surgery
An individual without the symptoms of UTI and a midstream sample of urine (MSU) that shows bacterial growth ≥10⁵ colony-forming units/mL in two consecutive samples in women and one sample in men has asymptomatic bacteriuria (ABU).[1] ABU is considered not to be infection, but rather a commensal colonization. It is a common finding in some healthy female populations and in many women or men with abnormalities of the genitourinary tract that impair voiding.[18] ABU may also be seen in individuals with diabetes or spinal cord injuries, as well as in elderly people living in care homes.[18] Screening and treatment of ABU is generally not recommended, except in pregnant patients as there is a risk of premature labor if pyelonephritis develops, or prior to urinary tract surgery where the mucosa is likely to be breached.[1] An MSU should be obtained after treatment to prove the ABU has been eradicated in these situations.
diabetes
Diabetes is associated with higher infection rates, including genitourinary infections.[19] People with diabetes are thought to be at increased risk due to impaired cell-mediated immunity, which appears to be inversely related to glycemic control.[20] Qualifies as a complicated UTI, warranting a longer and more aggressive antibiotics course.
spinal cord injuries
Bladder dysfunction requiring intermittent or chronic urinary catheterization leads to increased risk of infection.[3] Major cause of morbidity and mortality in these patients.
pregnancy
Asymptomatic bacteriuria and cystitis can quickly progress to pyelonephritis in the pregnant patient, risking possible fetal loss.[21] Low-quality evidence suggests that treatment of asymptomatic bacteriuria modestly reduces the incidence of pyelonephritis and the number of low-birth-weight infants.[22] Qualifies as a complicated case warranting a more aggressive and longer antibiotics course.
immunosuppression
older age
Common in older people, many of whom will not present with classical symptoms.[2]
lack of circumcision
Presence of the foreskin allows for easier bacterial colonization of the periurethral region and so circumcision reduces the rates of UTI in young boys. However, the number needed to treat to prevent 1 case of cystitis is 111.[25]
vaginal atrophy
In the postmenopausal female, estrogen levels decline leading to vaginal atrophy. This has been associated with an increased risk of recurrent UTI. Vaginal estrogen replacement may potentially reduce the risk of recurrent UTI in postmenopausal women.[1]
weak
spermicidal jelly
May increase the risk of UTI by altering the vaginal environment, thereby disrupting the body's natural defenses against infection.[15]
age <15 years for first UTI
In one study, women with first UTI before 15 years of age were 3.9 times more likely to have a UTI than women in the control group.[15]
new sex partner in past year
In one study, women with a new sexual partner in the last year were 2.2 times more likely to have a UTI than women in the control group.[15]
UTI history in mother
In one study, women with a mother with a history of UTIs were 1.6 times more likely to have a UTI than women in the control group.[15]
diaphragm use
May increase the risk of UTI.[3]
obesity
Elevated body mass index is associated with an increased risk of UTI.[26]
low socioeconomic status
Low income, poor education, and urban living have all been associated with increased risk of uncomplicated cystitis in Swedish cohort studies. The increased risk may be due in part to women of low socioeconomic status being less likely to seek self-treatment.[27][28] Further research is needed to better characterize the relationship between socioeconomic status and risk of UTIs like cystitis.
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