What history, physical exam, and workup should be done for a patient complaining of a Urinary Tract Infection (UTI)?

Evaluation and Management of Urinary Tract Infection

For patients complaining of UTI symptoms, obtain a thorough history focusing on urinary symptoms, perform a targeted physical examination, and collect a urine sample for culture before initiating treatment. 1

History Taking

Focus on the following key elements:

• Urinary symptoms:

  • Dysuria (painful urination) - increases likelihood of UTI (LR 1.5) 2
  • Frequency - increases likelihood of UTI (LR 1.8) 2
  • Urgency
  • Hematuria - increases likelihood of UTI (LR 2.0) 2
  • Suprapubic pain
  • Back pain - increases likelihood of UTI (LR 1.6) 2

• Red flags that decrease likelihood of UTI:

  • Vaginal discharge (LR 0.3) 2
  • Vaginal irritation (LR 0.2) 2

• Risk factors and complicating factors:

  • Previous UTIs (frequency, timing, treatment)
  • Sexual activity patterns
  • Menopause status
  • Diabetes or immunocompromised status
  • Pregnancy
  • Urological abnormalities or recent procedures
  • Catheter use

Physical Examination

• Vital signs (fever may indicate upper tract involvement)
• Abdominal examination for suprapubic tenderness
• Costovertebral angle tenderness (increases likelihood of pyelonephritis, LR 1.7) 2
• Pelvic examination if vaginal symptoms are present (to rule out vaginitis)

Diagnostic Workup

1. Urine culture (essential):

   • Obtain urine culture before starting antibiotics 1
   • Document positive cultures for diagnosis of recurrent UTI 1

2. Urinalysis:

   • Dipstick testing for leukocyte esterase and nitrite
   • Microscopy for white blood cells, red blood cells, and bacteria
   • Positive predictors of UTI include leukocyte esterase, nitrite positivity, and leukocyte clusters 3

3. Additional testing for complicated cases:

   • Do not routinely perform cystoscopy or upper tract imaging in uncomplicated UTI 1
   • Consider imaging in patients with:
     • Recurrent infections (>2 in 6 months or >3 in a year) 1
     • Failure to respond to appropriate therapy
     • Hematuria after treatment
     • Suspected anatomical abnormality

Common Pitfalls to Avoid

1. Treating without culture: Always obtain a urine culture before starting antibiotics to confirm diagnosis and guide therapy 1

2. Misdiagnosing vaginitis as UTI: Vaginal symptoms significantly decrease likelihood of UTI; perform pelvic exam when indicated 2, 4

3. Unnecessary imaging: Most women with uncomplicated UTIs have normal urinary tracts and don't require imaging 1

4. Treating asymptomatic bacteriuria: This can foster antimicrobial resistance and increase recurrent UTI episodes 1

5. Overlooking complicating factors: Thoroughly assess for factors that may require additional evaluation or different management approaches 1

By following this systematic approach to evaluation, you can accurately diagnose UTIs, minimize unnecessary antibiotic use, and identify patients who may need additional workup for complicated infections.