QuestionSBA
QuestionChoice
Bladder cancer most typically presents as painless haematuria. An acute presentation of dysuria, haematuria and frequency is much more likely to be a urinary tract infection than bladder cancer. However, as there is microscopic haematuria in this woman, she should have a repeat urine dipstick after her symptoms have resolved to check for persistent haematuria. If there is still blood in the urine, alternative diagnoses should be considered, including bladder cancer
33640
c
Bladder cancer
QuestionChoice
Nephritic syndrome is a group of conditions characterised by glomerular destruction. The presentation can vary based on the cause, but symptoms can include haematuria, hypertension and symptoms of nephrotic syndrome if protein loss through the kidneys is also high. Urine dipstick findings include proteinuria and haematuria. As this patient has no proteinuria, in addition to frequency and dysuria, which are primarily symptoms of the lower urinary tract, this makes a diagnosis of urinary tract infection more likely
33641
d
Nephritic syndrome
QuestionChoice
This is a typical history of a urinary tract infection. It is more common in women than men, as women have a shorter urethra. Typical presenting symptoms include urinary frequency, dysuria and visible or non-visible haematuria. Urinary tract infections are typically positive for nitrite and leukocyte esterase. This because E. coli (the most common cause) produces nitrites, but whether nitrites are positive or not also depends on the bacterial cause. Management for this patient would be with a three day course of antibiotics (first-line antibiotics include nitrofurantoin and trimethoprim). This patient should also be brought back after completing antibiotics for a repeat urine dipstick to ensure the haematuria has resolved
33638
a
Urinary tract infection
QuestionChoice
Chlamydia is the most common bacterial sexually transmitted infection in the UK. It can present similarly; with dysuria, and may have other features, including vaginal discharge. However, the majority of cases are asymptomatic (up to 70% in women). In this case, this woman presents with typical symptoms of a urinary tract infection and has a positive urine dip. Chlamydia infection would not cause an abnormal urinalysis
33639
b
Chlamydia
QuestionChoice
Polycystic kidney disease is a genetic condition characterised by the development of multiple cysts on the kidneys, the liver and/or the pancreas. This condition can present with pain and haematuria when a cyst ruptures; however, this is typically back pain. This would also not explain the frequency and dysuria symptoms and the urine dipstick findings of nitrites and leukocyte esterase. This question does not mention any family history of polycystic kidney disease or ballotable kidneys, which can point towards the diagnosis. Therefore urinary tract infection is the most likely diagnosis
33642
e
Polycystic kidney disease
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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A 52-year-old patient presents to the GP with a three-day history of urinary frequency and dysuria. Her husband is her only sexual partner. A urine dipstick is performed, showing blood +1 and is positive for leukocyte esterase and nitrites.

What is the most likely diagnosis?
a