Symptoms of Urinary Tract Infection
The diagnosis of UTI should be primarily based on acute-onset urinary symptoms, with dysuria being the central and most specific symptom, accompanied by variable degrees of urgency, frequency, hematuria, suprapubic pain, or new/worsening incontinence. 1
Core Diagnostic Symptoms in Adults
Classic Presentation in Women
- Dysuria (burning with urination) is the hallmark symptom with >90% accuracy for UTI in young women when vaginal irritation or discharge is absent 1
- Urinary frequency - needing to urinate more often than usual 1
- Urinary urgency - sudden compelling need to urinate 1
- Suprapubic pain or tenderness - discomfort in the lower abdomen 1
- Hematuria - blood in urine (visible or microscopic) 1
- New or worsening incontinence 1
Symptoms Suggesting Upper Tract Infection (Pyelonephritis)
- Costovertebral angle (flank) pain or tenderness - pain in the back/side where kidneys are located 1
- Fever (temperature >37.8°C orally, or >37.5°C rectally) 1
- Rigors/shaking chills 1
- Systemic symptoms including nausea and vomiting 1
Atypical Presentations in Older Adults
Older patients frequently present with non-specific symptoms rather than classic urinary complaints, making diagnosis more challenging. 1
Atypical Symptoms in Frail/Geriatric Patients
- Altered mental status - new onset confusion or delirium 1
- Functional decline - decreased ability to perform daily activities 1
- Falls - new or increased fall risk 1
- Fatigue or weakness (new or worsening) 1
- Decreased fluid or food intake 1
- Agitation or aggression (worsening) 1
Critical Diagnostic Pitfalls to Avoid
Do NOT diagnose UTI based solely on urinalysis findings or non-specific symptoms without acute urinary complaints. 1
Common Mistakes
- Pyuria alone does NOT confirm infection - it indicates genitourinary inflammation from many non-infectious causes and has exceedingly low positive predictive value 1
- Asymptomatic bacteriuria is NOT a UTI - positive urine culture without symptoms should not be treated (except in pregnancy or before urologic procedures) 1
- Non-specific symptoms in elderly (cloudy urine, odor changes, nocturia, malaise) should NOT trigger antibiotic treatment without acute dysuria, frequency/urgency, or systemic signs 1
When Symptoms Are Insufficient for Diagnosis
In frail or comorbid older patients, prescribe antibiotics ONLY if there is recent onset of dysuria with frequency/incontinence/urgency OR costovertebral angle pain/tenderness OR systemic signs (fever, rigors, clear-cut delirium). 1
- If only non-specific symptoms present (urine color/odor changes, nocturia, suprapubic pain alone, mental status changes without delirium, fatigue, decreased intake), evaluate for other causes and actively monitor rather than treating as UTI 1
Role of Laboratory Testing
Urinalysis
- Negative nitrite AND negative leukocyte esterase on dipstick can help rule out UTI in most populations 1
- Dipstick specificity ranges only 20-70% in elderly patients 1
- Positive urinalysis should NOT drive treatment decisions alone - must correlate with symptoms 1
Urine Culture
- Required for complicated UTI, recurrent UTI, suspected pyelonephritis, treatment failure, or atypical presentations to guide targeted therapy 1
- NOT routinely necessary for simple uncomplicated cystitis in healthy non-pregnant patients 1
- Should be obtained before starting antibiotics when performed 1
Treatment Overview
Uncomplicated Cystitis (First-Line Options)
- Nitrofurantoin 5 days 2, 3, 4
- Trimethoprim-sulfamethoxazole 3 days (if local resistance <20%) 2, 5, 3
- Fosfomycin single dose 2, 5, 3
Complicated UTI/Pyelonephritis
- Treatment duration 7-14 days depending on severity and response 2
- Third-generation cephalosporins preferred for pyelonephritis 4
- Men require 14-day treatment when prostatitis cannot be excluded 6