Differentials
Asymptomatic bacteriuria
Pyelonephritis
SIGNS / SYMPTOMS
Often a complication of urinary tract infection (UTI), but can occur without history of UTI.
May be indicated by costovertebral angle pain with tenderness on examination.
INVESTIGATIONS
Presence of WBC casts on urinalysis indicates pyelonephritis.
Urinary tract stones
SIGNS / SYMPTOMS
Urinary tract stones may result in damage of the urinary epithelium and consequently dysuria; however, they also typically cause pain.
A past medical history of stone formation can help identify risk.
INVESTIGATIONS
Intravenous urogram and CT scan both will identify the presence of a urinary tract stone, but CT scan is more accurate and does not require use of intravenous contrast.
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.
Overactive bladder
SIGNS / SYMPTOMS
Urinary urgency and frequency in the absence of a UTI.
INVESTIGATIONS
Negative urine dipstick, microscopic urinalysis, and urine culture.
Noninfectious 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) visualized 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 gonorrhea, 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 gonorrhea 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 etiology. The course of the disease is usually marked by flare-ups and remissions.[52]
Dyspareunia and suprapubic discomfort as well as anterior vaginal wall tenderness on exam.
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 exam, a fluctuant urethral mass as well as purulent meatal discharge upon mass compression may be noted.
INVESTIGATIONS
Characteristic radiographic findings on voiding cystourethrography (periurethral fluid collection) or T2-weighted MRI (bright image in periurethral area).
Infected Skene gland cyst
SIGNS / SYMPTOMS
May present with urethral pain, discharge, and/or urgency and frequency.
INVESTIGATIONS
May be visualized 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.
Renal cancer
Urothelial carcinoma of the bladder or upper urinary tract
SIGNS / SYMPTOMS
Microscopic and/or gross hematuria in the absence of a UTI.
INVESTIGATIONS
Positive urine cytology. Cystoscopy with confirmatory tissue biopsy determines the presence of bladder cancer.
Urethral cancer
SIGNS / SYMPTOMS
May present with voiding symptoms or hematuria.
Urethral induration may be noted on physical exam.
INVESTIGATIONS
A urethral mass can be visualized on cystoscopy and confirmed by pathologic diagnosis of biopsy specimen.
Reactive arthritis
SIGNS / SYMPTOMS
Symptoms unrelated to the urinary tract may be present, such as arthralgia, back pain, or ocular symptoms.
INVESTIGATIONS
Urine culture will be sterile.
Blood testing may reveal hypergammaglobulinemia and a positive HLA-B27 tissue antigen.
Behcet syndrome
SIGNS / SYMPTOMS
Symptoms unrelated to the urinary tract may be present, such as arthralgia, back pain, ocular symptoms, and oral ulcers.
INVESTIGATIONS
Urine culture will be sterile.
Seems to have relationship to HLA-B5 antigen.
A positive pathergy test and the presence of serum immune complexes may aid in diagnosis.
Radiation cystitis
SIGNS / SYMPTOMS
History of pelvic radiation.
May have voiding symptoms and/or hematuria.
INVESTIGATIONS
Findings on cystoscopy include diffuse erythema, edema, vascularity, petechiae, and patches of pallor.
Postcyclophosphamide (Cytoxan) cystitis
SIGNS / SYMPTOMS
History of cyclophosphamide (Cytoxan) treatment.
Irritative voiding symptoms.
INVESTIGATIONS
Diagnosed by cystoscopy (diffuse erythema, edema, vascularity, petechiae, patches of pallor) and, possibly, biopsy.
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