Differentials
Appendicitis
SIGNS / SYMPTOMS
Focal right lower quadrant pain, guarding.
INVESTIGATIONS
Ultrasound or CT scan abdomen may show enlarged appendix.
Gastroenteritis
SIGNS / SYMPTOMS
Diarrhea present.
INVESTIGATIONS
Rotavirus detection in stool may be positive.
Kawasaki disease
SIGNS / SYMPTOMS
Rash, mucositis, extremity swelling, cervical lymph node swelling, conjunctivitis.
No signs may be present in those <6 months of age.
INVESTIGATIONS
Sterile pyuria, transaminase elevation, coronary ectasia, or aneurysms on echocardiogram (late).[62]
Vulvovaginitis or vaginal foreign body
SIGNS / SYMPTOMS
History of sexual activity/abuse, use of bubble baths, poor hygiene. Dysuria may be associated with vaginal discharge. Vulval appears erythematous on examination.
INVESTIGATIONS
May be diagnosed clinically based on history, examination, and sterile urine culture. Group A Streptococcus isolated on vaginal culture.
Pinworm prep may be positive.
Sexually transmitted infection
SIGNS / SYMPTOMS
History of sexual activity, urethral discharge, frequency, urgency, dysuria.
INVESTIGATIONS
Chlamydia infection or gonococcus identified on nucleic acid amplification test.
Nephrolithiasis
SIGNS / SYMPTOMS
Colicky pain, family history of urolithiasis, passing of particulate matter in urine.
INVESTIGATIONS
Urine calcium-creatinine, crystals on microscopic exam.
Calculus may be visible on ultrasound.
Bladder and bowel dysfunction
SIGNS / SYMPTOMS
Urinary storage symptoms (incontinence, increased or decreased voiding frequency, urgency, nocturia); urinary voiding symptoms (hesitancy, straining, weak stream, intermittent micturition, dysuria); holding maneuvers to postpone micturition (e.g., forcefully crossing legs, pushing on the genitals or abdomen); a feeling of incomplete bladder emptying; pain in the bladder, urethra, or genitals; fecal incontinence and constipation.
INVESTIGATIONS
Abnormal urodynamic testing and negative urine cultures.
Imaging may show ureterocele, stones, trabeculation, high post-void residual volume, or enlarged rectal diameter.
Sepsis with no urinary tract source
SIGNS / SYMPTOMS
Hemodynamic instability.
In infants, symptoms are often nonspecific and may include vomiting, irritability, poor feeding, and jaundice.
INVESTIGATIONS
Positive blood and cerebrospinal fluid cultures.
Urethritis
SIGNS / SYMPTOMS
Urethral discharge, pelvic pain.
INVESTIGATIONS
Urine positive polymerase chain reaction results for gonorrhea, chlamydia, or candida.
Hemorrhagic (viral) cystitis
SIGNS / SYMPTOMS
Hematuria more likely.
INVESTIGATIONS
Negative urine culture.
Interstitial cystitis
SIGNS / SYMPTOMS
Specific symptoms of urinary frequency, urgency, bladder pain with relief on voiding.
INVESTIGATIONS
Negative urine culture, hypervascular bladder mucosa, and linear scarring on cystoscopy.[63]
Some children have persistently positive urine cultures due to bacterial colonization of the bladder.
Glomerulonephritis
SIGNS / SYMPTOMS
Swelling of hands or feet; gross hematuria; hypertension.
INVESTIGATIONS
Significant proteinuria; red cell casts on urinalysis or urine microscopy.
Meningitis
SIGNS / SYMPTOMS
Photophobia, rash, neck stiffness.
In infants, symptoms are often nonspecific and may include vomiting, irritability, and poor feeding.
INVESTIGATIONS
Infants <6 weeks of age may have associated meningitis when Escherichia coli is the UTI pathogen.
Wilms tumor
SIGNS / SYMPTOMS
Pain, hematuria, no urinary symptoms.
INVESTIGATIONS
Ultrasound shows an abdominal mass.
This is the most common form of renal malignancy in childhood.
Schistosomiasis
SIGNS / SYMPTOMS
Can cause urinary symptoms, including gross hematuria or dysuria.
History of travel to tropical countries, even going several years back, as the child may have been asymptomatic for a prolonged period of time.
The prevalence of infection among school-aged children can be as high as 90%, even in urban areas.[64]
INVESTIGATIONS
Circulating cathodic antigen urine reagent strip: a rapid enzyme-linked immunosorbent assay test that detects adult worm gut-associated glycoproteins and eggs, with a sensitivity of 88.2% (for glycoproteins) and 95.8% (for eggs). Specificity is 100%. Detects Schistosomamansoni and Schistosomahaematobium. It is used as a diagnostic and monitoring tool to assess the success of treatment.[65]
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