QuestionSBA
QuestionChoice
His clinical presentation is more consistent with UTI, which does not spontaneously resolve and requires antibiotics. Safety netting is offered irrespective of the diagnosis, as the symptoms can worsen. However, it must be accompanied by antibiotics in this scenario.
62061
d
Reassure and discharge with safety netting
QuestionChoice
A non-urgent referral to a specialist is only required if there are signs of bladder cancer and recurrent or persistent UTIs in people aged 60 years or over.
62062
e
Urgent referral to a urologist
QuestionChoice
A positive urine dipstick is not necessary to treat a UTI in those >65 years of age. This patient has clinical signs and symptoms of a UTI and therefore should have antibiotics started regardless of the urine dipstick result. This would have been the right choice if the patient was less than 65 years.
62060
c
Perform urine dipstick and commence back-up antibiotic only if Nitrite negative and WBC positive
QuestionChoice
A urine dipstick alone cannot confirm the diagnosis as around half of the elderly age group have asymptomatic bacteriuria and test positive on a dipstick without infection however this patient has clinical signs and symptoms of a urinary tract infection. It is therefore important to take a urine sample to culture and a urine dipstick as well as starting antibiotics.
62058
a
Send off urine dipstick, urine culture and commence antibiotic immediately
QuestionChoice
A positive urine dipstick is not necessary to treat a UTI in those >65 years of age. This patient has clinical signs and symptoms of a UTI and therefore should have antibiotics started regardless of the urine dipstick result. This would have been the right choice if the patient was less than 65 years.
62059
b
Perform urine dipstick and commence immediate antibiotic only if Nitrite positive and WBC positive
QuestionComment
If they're over 65 do you not need to do urine culture and then give Antibiotics?
26201
QuestionComment
I think abx shouldn't be delayed as culture takes quite long time, you can start empirically then adjust once culture results come back.
28933
User
subscriber
anon
User
subscriber
Bladder Power
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 

[lightgallery]

[lightgallery1]

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/)

1998
Picture
1431
UTI - choice of antibiotics (NICE).png
images/f8bg7vf71672906675511.jpg
images/f8bg7vf71672906675511_256.jpg
images/f8bg7vf71672906675511_512.jpg
9vcFDYB5hYdwh3eGiFd2iodwkQco
Picture
1430
UTI - flowchart (NICE).png
images/eb6eqo9z1672906675512.jpg
images/eb6eqo9z1672906675512_256.jpg
images/eb6eqo9z1672906675512_512.jpg
sfcFDYSjSQBstWeEnpd4fcF/k+83
3503
Urinary tract infection
Topic
60
General Practice
12473
A 70-year-old woman presents to a GP clinic complaining of dysuria, suprapubic pain, and urgency for the past week. Her past medical and surgical history is unremarkable. Her vital signs are:

 - Temperature: 37.1 °C
 - Pulse rate: 80/min
 - Blood pressure: 120/80 mmHg
 - Respiratory rate: 18/min

What is the most appropriate next course of action?
a