Management of Negative Urinalysis with UTI or Vulvovaginitis Symptoms
In patients with symptoms of UTI but negative urinalysis, empiric antibiotic treatment is not recommended as it may foster antimicrobial resistance and increase the number of recurrent UTI episodes. 1
Diagnostic Considerations
When urinalysis is negative despite urinary symptoms, clinicians should consider:
- Vulvovaginitis as a potential cause of dysuria, especially in women with vaginal discharge or vulvar itching 2
- Non-infectious causes of urinary symptoms including medication side effects, anatomical abnormalities, trauma, or interstitial cystitis/bladder pain syndrome 3
- The excellent negative predictive value of urinalysis, which effectively rules out UTI when negative 1
Management Algorithm
Step 1: Evaluate for Vulvovaginitis
- Assess for vaginal discharge, vulvar itching, and other vulvovaginal symptoms 2
- Perform microscopic examination of vaginal fluid if symptoms suggest vaginitis 2
- Common causes include candidiasis, bacterial vaginosis, and trichomoniasis 4
Step 2: For Confirmed Vulvovaginitis
- For candidiasis: Prescribe antifungal treatment (topical or oral) 5
- For bacterial vaginosis: Prescribe appropriate antibiotics based on microscopy findings 5
- For trichomoniasis: Prescribe antiprotozoal medication 4
Step 3: For Persistent Urinary Symptoms Without Vulvovaginitis
- Consider non-infectious causes of dysuria 3
- Evaluate for anatomical abnormalities or other urological conditions 1
- Consider interstitial cystitis/bladder pain syndrome if symptoms persist 3
Special Considerations
For Postmenopausal Women
- Consider vaginal estrogen therapy with or without lactobacillus-containing probiotics for recurrent symptoms 1
- Evaluate for atrophic vaginitis as a potential cause 1
For Patients with Indwelling Catheters
- A negative urinalysis effectively rules out catheter-associated UTI 1
- Avoid treating asymptomatic bacteriuria in patients with urinary catheters 1
For Recurrent Symptoms
- If symptoms persist despite treatment, repeat the urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 1
- Consider behavioral and lifestyle modifications for prevention 1
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria, which can foster antimicrobial resistance 1
- Failing to consider vulvovaginitis as a cause of dysuria, especially in adolescent girls 6
- Overlooking less common bacterial pathogens that may cause vulvovaginitis, such as Haemophilus influenzae, beta-hemolytic streptococci, and Staphylococcus aureus, particularly in children and postmenopausal women 5
- Using broad-spectrum antibiotics for presumed UTI when urinalysis is negative 1
Prevention Strategies for Recurrent Symptoms
- Increase fluid intake in premenopausal women 1
- Consider methenamine hippurate for women without urinary tract abnormalities who experience recurrent symptoms 1
- For recurrent symptoms related to sexual activity, consider post-coital antibiotic prophylaxis only after non-antimicrobial interventions have failed 1