Key Feature 1: Take an appropriate history and do the required testing to exclude serious complications of urinary tract infection (UTI) (ex: sepsis, pyelonephritis, impacted infected stones).
Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation Key Feature 2: Appropriately investigate all boys with urinary tract infections, and young girls with recurrences (ex: ultrasound). Skill: Clinical Reasoning Phase: Investigation Key Feature 3: In diagnosing urinary tract infections, search for and/or recognize high-risk factors on history (ex: pregnancy, immune compromise, neonate, a young male, or an elderly male with prostatic hypertrophy). Skill: Clinical Reasoning Phase: Hypothesis generation, History Urinary tract infections are extremely common, and most of the time they aren't complicated. When someone presents to my clinic with symptoms in keeping with a UTI (dysuria, urinary frequency and urgency +/- hematuria +/- suprapubic pain), it's my job to ensure that they don't have symptoms and signs suggesting a more complicated picture. The following features on clinical assessment take a UTI from simple to complicated:
All patients with features suggesting a complicated UTI warrant referral to the nearest ED for further workup. Beyond routine and microscopic urinalysis as well as urine culture and sensitivity, blood cultures are warranted if you are thinking about possible sepsis. In terms of imaging, if you are thinking about pyelonephritis, obtain a CT abdo/pelvis with contrast, and if you are thinking about infected kidney stones, obtain a non-contrast CT abdo/pelvis. If you wish to avoid contrast and have the option, consider starting with a renal ultrasound instead. Speaking of renal ultrasound, besides its utility in looking for pyelonephritis or nephrolithiasis, it is also useful to look for urinary tract malformations in pediatric patients when indicated. As in the adult population, UTIs are much more common in females as their urethral tract is much shorter and they are therefore at greater risk of bacteria finding their way up and into the bladder. However, recurrent UTIs in prepubertal females are not common, and any UTIs in prepubertal males are unusual. UpToDate recommends obtaining renal and bladder ultrasonography if the following indications are met:
Children should also be sent for a voiding cystourethrogram to look for vesicoureteral reflux if the following indications are met:
So now I've singled out two groups to be weary of with suspected UTI: those who have features suggestive of a complicated UTI and children with suspected UTI. Other groups that require special considerations, and the considerations they warrant, are as follows. Note that any patients with a suspected complicated UTI, recurrent UTI, or any features below warrant at the very least a urinalysis and urine culture & sensitivity.
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