What is the appropriate management for a pregnant woman with a urinary tract infection (UTI) presenting with a tender clitoris?

Management of Tender Clitoris in a Pregnant Woman with UTI

A tender clitoris in a pregnant woman with UTI suggests possible vulvovaginitis, sexually transmitted infection, or local inflammation rather than a typical UTI presentation, and requires evaluation for alternative or concurrent diagnoses before proceeding with standard UTI treatment. 1

Initial Diagnostic Approach

The tender clitoris is not a typical manifestation of uncomplicated UTI and should prompt consideration of:

• Sexually transmitted infections (STIs), particularly Neisseria gonorrhoeae and Chlamydia trachomatis, which can cause cervical motion tenderness and genital inflammation 2
• Vulvovaginitis with secondary urinary symptoms
• Bartholin gland abscess or other localized genital infections
• Herpes simplex virus causing genital lesions with urinary symptoms

Critical Diagnostic Steps

• Obtain urine culture before initiating antibiotics, as this is mandatory for all pregnant women with urinary symptoms 1, 3
• Perform pelvic examination to assess for cervical motion tenderness, abnormal vaginal discharge, or visible genital lesions 2
• Test for STIs including gonorrhea and chlamydia if the patient is sexually active, as these organisms are implicated in many cases of genital tenderness 2
• Assess for mucopurulent cervical or vaginal discharge on examination 2

Treatment Algorithm

If UTI is Confirmed with Concurrent Genital Findings:

First-line antibiotics for UTI in pregnancy:

• Nitrofurantoin 100mg twice daily for 5-7 days (avoid if G6PD deficiency or >36 weeks gestation) 1, 3
• Fosfomycin trometamol 3g single dose (convenient and safe throughout pregnancy) 1, 3
• Cephalexin 500mg four times daily for 7 days (excellent safety profile) 3

If STI is suspected or confirmed:

• Empiric treatment must cover N. gonorrhoeae and C. trachomatis if cervical motion tenderness or mucopurulent discharge is present 2
• Pregnant women with suspected pelvic inflammatory disease (PID) should be hospitalized and treated with parenteral antibiotics due to high risk for maternal morbidity, fetal wastage, and preterm delivery 2

Treatment Duration and Follow-up

• Standard UTI treatment course is 7-14 days to ensure complete eradication 1, 3
• Test-of-cure urine culture 1-2 weeks after treatment is recommended 1
• Male sex partners should be examined and treated if sexual contact occurred within 60 days before symptom onset 2

Critical Clinical Considerations

Common pitfall: Do not assume all urinary symptoms with genital findings represent simple UTI. The presence of clitoral tenderness is atypical and warrants broader evaluation 2.

Pregnancy-specific risks: Untreated bacteriuria increases pyelonephritis risk from 1-4% to 20-35%, and is associated with premature delivery and low birth weight 3, 4. However, concurrent STIs pose additional risks for fetal wastage and preterm delivery 2.

Antibiotic selection must avoid:

• Trimethoprim in first trimester (teratogenic effects) 1, 3
• Fluoroquinolones throughout pregnancy (fetal cartilage damage) 3
• Nitrofurantoin near term (>36 weeks) due to hemolysis risk 1

When to Hospitalize

Admit for parenteral antibiotics if:

• Suspected PID with uterine, adnexal, or cervical motion tenderness 2
• Temperature >38.3°C (101°F) 2
• Clinical signs of pyelonephritis (flank pain, costovertebral angle tenderness) 2
• Failure to improve within 72 hours of oral therapy 2