QuestionSBA
QuestionChoice
Muscular back pain would not be expected to cause infective symptoms, such as a high fever
33395
c
Muscular back pain
QuestionChoice
Although kidney stones can act as a focus for infection, they more commonly present with **pain as the primary symptom**. The pain is characteristically very severe and radiates in a "loin to groin" pattern
33394
b
Kidney stone
QuestionChoice
This patient has recently been treated for a urinary tract infection. This treatment was likely insufficient, and she has now gone on to develop pyelonephritis - an upper urinary tract infection that involves infection/ inflammation of the kidney itself. This commonly presents with nausea, vomiting, fever and flank pain
33396
d
Urinary tract infection
QuestionChoice
Pyelonephritis is an upper urinary tract infection involving infection/ inflammation of the kidney itself. This commonly presents with nausea, vomiting, fever and flank pain - this patient has all of the classic symptoms. There is also the additional clue of recent treatment for UTI via the GP - this treatment was likely insufficient, and the infection has now tracked up the urinary tract to the kidney
33393
a
Pyelonephritis
QuestionChoice
A psoas abscess would also present with flank pain and fever, however, this patient has none of the classic risk factors (underlying immunosuppression, intravenous drug use, recent local surgery or trauma). Additionally, the recent history of urinary tract infection is more suggestive of pyelonephritis. A psoas abscess may also present with a limp, or pain that is exacerbated by movement of the ipsilateral limb
33397
e
Psoas abscess
Concept
Chapter
# Summary 

Lower urinary tract infections (LUTIs), often manifesting as cystitis, typically involve the infection of the bladder. Primarily caused by transurethral ascent of colonic commensals like E. coli, symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and suprapubic pain. Investigations are generally limited to a urine dipstick test for leucocytes and nitrites, while management involves oral nitrofurantoin or trimethoprim, and conservative measures. A key differential diagnosis is pyelonephritis, a urinary tract infection affecting the kidneys. Pyelonephritis exhibits more severe symptoms like fever, malaise, loin pain, and vomiting, and requires hospital admission and intravenous antibiotics.

# Definition 

A lower urinary tract infection (LUTI) is generally defined as an infection of the bladder, often manifesting as cystitis.

# Aetiology 

LUTIs are caused by the transurethral ascent of colonic commensals, most commonly **E. coli**.

# Signs and symptoms

Patients with LUTIs generally present with:

- Urinary frequency
- Dysuria
- Urgency
- Foul-smelling urine
- Suprapubic pain
- Clinical examination may be normal or reveal suprapubic tenderness.

Red flag symptoms such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state may indicate more serious infection, and these patients may have/are at risk of developing pyelonephritis (see below) and likely need referral to A&E.


# Investigations

For LUTIs:

- Urine dipstick is positive for leucocytes and nitrites in most cases.
- In uncomplicated cases, no further investigations are required.
- In children, men, and pregnant women a mid-stream urine sample should be sent.

NB: Urine dipstick is unreliable in women aged older than 65 years and those who are catheterised.

If being managed in secondary care due to red flag symptoms consider:

- If there are signs of systemic upset consider routine blood tests such as FBC, U+E, and CRP.
- For uncomplicated UTIs, imaging is rarely required, but if there are concerns over antecedents/complications such as urinary retention/obstruction, an USS bladder/kidney scan would be the first port of call.

# Management 

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For LUTIs:

- First line management is with oral nitrofurantoin or trimethoprim. Antibiotic duration can vary (see below) however in women the standard course length is 3 days.
- The patient should be advised on conservative measures to reduce the risk of further infection e.g. regular fluid intake, post-coital voiding.

## Specific situations

**UTI in Men:**

- Empirical antibiotic drug treatment (if no cultures with sensitivities) with trimethoprim or nitrofurantoin for **7 days.**
- Refer to urology if there are ongoing symptoms despite treatment, if there is an underlying risk factor for UTIs (e.g. urinary calculi, suspected obstruction, previous GU surgery), or if there are recurrent episodes of UTI.

**UTI during Pregnancy (with no haematuria):**

- First-line antibiotics are nitrofurantoin (but *avoid at term),* for **7 days.**
- If nitrofurantoin is not suitable due to e.g. renal function, or there is no improvement in symptoms, consider second-choice antibiotics such as amoxicillin/cefalexin for 7 days.


# NICE Guidelines

[Click here for NICE CKS on urinary tract infection (lower) - women](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/)

[Click here for NICE CKS on pyelonephritis - acute](https://cks.nice.org.uk/topics/pyelonephritis-acute/)

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Quesmed Tutorial: Geriatrics
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A 25-year-old female presents to the Emergency Department feeling generally unwell, with nausea, vomiting and a high fever. She has no significant past medical history, but completed a 3 day course of antibiotics (trimethoprim) for a urinary tract infection yesterday.

On examination her abdomen is soft, but there is significant tenderness in her left flank.

What is the most likely diagnosis?
a