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Pyuria Differential Diagnosis

Differentiating the diseases that can cause pyuria:[1][2][3][4]

Category Disease Clinical manifestations Para−clinical findings Gold standard for diagnosis Associated findings
Symptoms Physical examination
Lab Findings Imaging
Pain Fever N/V Urinary symptoms BP Other CBC Electrolytes Urinalysis
Dysuria Frequency Urgency Gross hematuria Cell Cast Bacteriuria Culture Other
Infectious diseases UTI[5] Bacterial Asymptomatic bacteriuria[6][7] − − − − − − − Nl − Nl Nl ± − + − NA NA Urinalysis
  • Increased risk in pregnancy
  • Must be treated prior to an invasive urologic procedure
Cystitis[8] − − − + + + − Nl − Nl Nl + − + + NA Urinalysis NA
Pyelonephritis[9] + + + + + + − Nl − Nl + WBC cast + + NA Clinical manifestation + urinalysis NA
Viral[10][11] − − + + + + ± Nl − Nl Nl + − − − NA NA PCR viral load
Tuberculosis[12][13][14][15] − ± − + + + + Nl − Nl Nl ± − − Positive mycobacterial urine culture Pulmonary TB on chest CT Urine mycobacterial PCR
Fungal[16][17] − − − + + − − Nl − Nl Nl ± − − + after several weeks of follow up NA Hydronephrosis on ultrasound Urine culture
  • Increased risk in patients with long−term foley catheters
  • Candida as the most prevalent fungus
STD Chlamydia[18][19] Chronic pelvic pain − − + + − − Nl Nl Nl + − − + NA NA PCR
  • Females might have concurrent chlamydial cervicitis
  • Must be considered in young, sexually active males
Gonococcus[20][21][22] Chronic pelvic pain − − + + − − Nl Nl Nl + − − +

High false negative result

NA Nucleic acid amplification testing (NAAT)
  • Females might have concurrent cervical gonococcal infection
  • Must be considered in young, sexually active males
Ureaplasma urealyticum[23] − − − + + − − Nl − Nl Nl + − − −
  • Gram stain −
 NA PCR
  • Associated with complications of pregnancy
Herpes simplex virus[24] + + − + + − − Nl Nl Nl + − − Viral culture + NA NA Clinical manifestation + PCR
  • Associated with extragenital complications, like aseptic meningitis
  • High risk of recurrence 
Herpes zoster[25] − − − + + − − Nl Nl Nl + − − − NA Clinical manifestation + PCR
  • Associated with lumbosacral dermatome involvement
HPV[26] − − − + − − − Nl Nl Nl + − − − NA NA Clinical manifestation + PCR
HIV[27] − + + + + − − Nl Nl + − − − NA NA Combination antigen/antibody immunoassay + PCR HIV viral load test
Prostatitis[28]  Pelvic or perineal pain + + + + + − Nl or ↑
  • Dribbling of urine
  • Firm and tender prostate
 Nl + − ± + NA Clinical manifestation + urinalysis
  • Increased risk of bacteremia, prostatic abscess, and metastatic infection
  • Might be acute or chronic infection
Balanitis[29] Penile pain + − + + + − Nl
  • Pruritus
  • Erythematous lesions on the glans and/or the foreskin
 Nl Nl + − ± − NA NA Clinical manifestation
Appendicitis[30][31] Right lower abdominal pain + + + + + − Nl Nl + − − − Enlarged appendiceal diameter on CT scan or ultrasound Clinical manifestation NA
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
Non−infectious diseases Urinary tract disorders Urinary catheterization[32] − − − + + − − Nl − Nl + − + + − Clinical manifestation + urinalysis
Urinary tract stone[33][34] Colicky pain − + + + + ± Nl − Nl Nl + − − − Visible stone on CT scan Clinical manifestation
  • Might cause renal obstruction
Urinary tract neoplasm[35] + + + + + + + Nl − Nl Nl + − − − Visible tumor on CT scan Cystoscopy  + biopsy
Urinary fistula[36] − − − + + − − Nl Nl Nl + − − − NA Fistula on cystoscopy or IVP Physical examination
  • History of recent surgery
Interstitial cystitis
Vesicoureteral reflux
Hydronephrosis
Renal diseases Polycystic kidney disease
Renal vein thrombosis
Interstitial nephritis
Papillary necrosis
IgA nephropathy
Renal transplant rejection
Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
Systemic disease Malignant hypertension
Diabetic nephropathy
Sickle cell disease
Sarcoidosis
Systemic lupus erythematosus
Sjögren’s syndrome
Kawasaki's disease[37] − + − + + + − Nl + − − − − − Clinical manifestation
Henoch−Schönlein purpura + + + +
  • Proteinuria
Graft versus host disease (GVHD)
Medication/toxin Analgesic nephropathy
Contrast−induced nephropathy
Glucocorticoids
Toluene
Lead poisoning
Category Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings
  1. ↑ Wise, Gilbert J.; Longo, Dan L.; Schlegel, Peter N. (2015). "Sterile Pyuria". New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 0028-4793.
  2. ↑ Stamm, Walter E. (1983). "Measurement of pyuria and its relation to bacteriuria". The American Journal of Medicine. 75 (1): 53–58. doi:10.1016/0002-9343(83)90073-6. ISSN 0002-9343.
  3. ↑ Groah, Suzanne; Perez-Losada, Marcos; Caldovic, Ljubica; Ljungberg, Inger; Sprague, Bruce; Castro-Nallar, Eduardo; Shah, Neel; Hsieh, Michael; Pohl, Hans (2015). "MP20-08 PYURIA AND ASYMPTOMATIC BACTERIURIA IS ASSOCIATED WITH NOVEL AND SPECIFIC URINE MICROBIOMES". The Journal of Urology. 193 (4): e226. doi:10.1016/j.juro.2015.02.980. ISSN 0022-5347.
  4. ↑ Shaikh, N.; Shope, T. R.; Hoberman, A.; Vigliotti, A.; Kurs-Lasky, M.; Martin, J. M. (2016). "Association Between Uropathogen and Pyuria". PEDIATRICS. 138 (1): e20160087–e20160087. doi:10.1542/peds.2016-0087. ISSN 0031-4005.
  5. ↑ Neal DE (February 2008). "Complicated urinary tract infections". Urol. Clin. North Am. 35 (1): 13–22, v. doi:10.1016/j.ucl.2007.09.010. PMID 18061020.
  6. ↑ Nicolle, Lindsay E. (2014). "Asymptomatic bacteriuria". Current Opinion in Infectious Diseases. 27 (1): 90–96. doi:10.1097/QCO.0000000000000019. ISSN 0951-7375.
  7. ↑ Nicolle, Lindsay E. (2015). "Asymptomatic Bacteriuria and Bacterial Interference". Microbiology Spectrum. 3 (5). doi:10.1128/microbiolspec.UTI-0001-2012. ISSN 2165-0497.
  8. ↑ Sabih A, Leslie SW. PMID 28613784. Missing or empty |title= (help)
  9. ↑ Pietrucha-Dilanchian P, Hooton TM (December 2016). "Diagnosis, Treatment, and Prevention of Urinary Tract Infection". Microbiol Spectr. 4 (6). doi:10.1128/microbiolspec.UTI-0021-2015. PMID 28087935.
  10. ↑ Aboumohamed A, Flechner SM, Chiesa-Vottero A, Srinivas TR, Mossad SB (November 2014). "Disseminated adenoviral infection masquerading as lower urinary tract voiding dysfunction in a kidney transplant recipient". Clin. Nephrol. 82 (5): 332–6. doi:10.5414/CN107977. PMID 23816478.
  11. ↑ Santiago-Rodriguez TM, Ly M, Bonilla N, Pride DT (2015). "The human urine virome in association with urinary tract infections". Front Microbiol. 6: 14. doi:10.3389/fmicb.2015.00014. PMC 4304238. PMID 25667584.
  12. ↑ Altiparmak MR, Trabulus S, Balkan II, Yalin SF, Denizli N, Aslan G, Doruk HE, Engin A, Tekin R, Birengel S, Cetin BD, Arslan F, Turhan V, Mert A (August 2015). "Urinary tuberculosis: a cohort of 79 adult cases". Ren Fail. 37 (7): 1157–63. doi:10.3109/0886022X.2015.1057460. PMID 26123266.
  13. ↑ Verma AK, Mishra AK, Kumar M, Kant S, Singh A, Singh A (July 2016). "Renal tuberculosis presenting as acute pyelonephritis - A rarity". Indian J Tuberc. 63 (3): 210–213. doi:10.1016/j.ijtb.2015.07.010. PMID 27865246.
  14. ↑ Daher Ede F, da Silva GB, Barros EJ (January 2013). "Renal tuberculosis in the modern era". Am. J. Trop. Med. Hyg. 88 (1): 54–64. doi:10.4269/ajtmh.2013.12-0413. PMC 3541747. PMID 23303798.
  15. ↑ Czapka M, Shukla S, Slosar-Cheah M (August 2017). "Urine trouble: genitourinary tuberculosis and subsequent DRESS syndrome". BMJ Case Rep. 2017. doi:10.1136/bcr-2017-220440. PMID 28784884.
  16. ↑ Kim J, Kim DS, Lee YS, Choi NG (September 2011). "Fungal urinary tract infection in burn patients with long-term foley catheterization". Korean J Urol. 52 (9): 626–31. doi:10.4111/kju.2011.52.9.626. PMC 3198237. PMID 22025959.
  17. ↑ Carvalho M, Guimarães CM, Mayer JR, Bordignon GP, Queiroz-Telles F (December 2001). "Hospital-associated funguria: analysis of risk factors, clinical presentation and outcome". Braz J Infect Dis. 5 (6): 313–8. PMID 11980593.
  18. ↑ Matthews, R.S.; Bonigal, S.D.; Wise, R. (1990). "Sterile pyuria and Chlamydia trachomatis". The Lancet. 336 (8711): 385. doi:10.1016/0140-6736(90)91936-5. ISSN 0140-6736.
  19. ↑ Tayal SC, Pattman RS (1996). "Sterile pyuria: consider chlamydial infection". Br J Clin Pract. 50 (3): 166–7. PMID 8733337.
  20. ↑ Clarke M, Maskell R (December 1981). "Gonorrhoea presenting as "sterile" pyuria". Br Med J (Clin Res Ed). 283 (6305): 1546. PMC 1507898. PMID 6799059.
  21. ↑ Jephcott AE (August 1997). "Microbiological diagnosis of gonorrhoea". Genitourin Med. 73 (4): 245–52. PMC 1195851. PMID 9389943.
  22. ↑ Tomas ME, Getman D, Donskey CJ, Hecker MT (August 2015). "Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department". J. Clin. Microbiol. 53 (8): 2686–92. doi:10.1128/JCM.00670-15. PMC 4508438. PMID 26063863.
  23. ↑ Nassar FA, Abu-Elamreen FH, Shubair ME, Sharif FA (2008). "Detection of Chlamydia trachomatis and Mycoplasma hominis, genitalium and Ureaplasma urealyticum by polymerase chain reaction in patients with sterile pyuria". Adv Med Sci. 53 (1): 80–6. doi:10.2478/v10039-008-0020-1. PMID 18614434.
  24. ↑ Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, Berman SM, Markowitz LE (August 2006). "Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States". JAMA. 296 (8): 964–73. doi:10.1001/jama.296.8.964. PMID 16926356.
  25. ↑ Chen, Po-Hong; Hsueh, Hsiu-Fang; Hong, Chang-Zern (2002). "Herpes zoster–associated voiding dysfunction: A retrospective study and literature review". Archives of Physical Medicine and Rehabilitation. 83 (11): 1624–1628. doi:10.1053/apmr.2002.34602. ISSN 0003-9993.
  26. ↑ Guo CC, Fine SW, Epstein JI (July 2006). "Noninvasive squamous lesions in the urinary bladder: a clinicopathologic analysis of 29 cases". Am. J. Surg. Pathol. 30 (7): 883–91. doi:10.1097/01.pas.0000213283.20166.5a. PMID 16819332.
  27. ↑ Parkhie SM, Fine DM, Lucas GM, Atta MG (May 2010). "Characteristics of patients with HIV and biopsy-proven acute interstitial nephritis". Clin J Am Soc Nephrol. 5 (5): 798–804. doi:10.2215/CJN.08211109. PMC 2863972. PMID 20338962.
  28. ↑ Wagenlehner FM, Pilatz A, Bschleipfer T, Diemer T, Linn T, Meinhardt A, Schagdarsurengin U, Dansranjavin T, Schuppe HC, Weidner W (August 2013). "Bacterial prostatitis". World J Urol. 31 (4): 711–6. doi:10.1007/s00345-013-1055-x. PMID 23519458.
  29. ↑ Hsu CY, Lin CL, Kao CH (May 2015). "Balanitis is a risk factor for herpes zoster". Eur. J. Clin. Microbiol. Infect. Dis. 34 (5): 985–90. doi:10.1007/s10096-015-2314-0. PMID 25596845.
  30. ↑ Lee SL, Walsh AJ, Ho HS (May 2001). "Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis". Arch Surg. 136 (5): 556–62. PMID 11343547.
  31. ↑ Mahattanobon S, Samphao S, Pruekprasert P (August 2014). "Clinical features of complicated acute appendicitis". J Med Assoc Thai. 97 (8): 835–40. PMID 25345259.
  32. ↑ Forster, C.S.; Haslam, D.B.; Jackson, E.; Goldstein, S.L. (2017). "Utility of a routine urinalysis in children who require clean intermittent catheterization". Journal of Pediatric Urology. 13 (5): 488.e1–488.e5. doi:10.1016/j.jpurol.2017.01.016. ISSN 1477-5131.
  33. ↑ Fwu CW, Eggers PW, Kimmel PL, Kusek JW, Kirkali Z (March 2013). "Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States". Kidney Int. 83 (3): 479–86. doi:10.1038/ki.2012.419. PMC 3587650. PMID 23283137.
  34. ↑ Singh P, Enders FT, Vaughan LE, Bergstralh EJ, Knoedler JJ, Krambeck AE, Lieske JC, Rule AD (October 2015). "Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community". Mayo Clin. Proc. 90 (10): 1356–65. doi:10.1016/j.mayocp.2015.07.016. PMC 4593754. PMID 26349951.
  35. ↑ Azuma T, Nagase Y, Oshi M (September 2013). "Pyuria predicts poor prognosis in patients with non-muscle-invasive bladder cancer". Clin Genitourin Cancer. 11 (3): 331–6. doi:10.1016/j.clgc.2013.04.002. PMID 23664207.
  36. ↑ Hampton BS, Kay A, Pilzek A (January 2015). "Urinary fistula and incontinence". Semin. Reprod. Med. 33 (1): 47–52. doi:10.1055/s-0034-1395279. PMID 25565512.
  37. ↑ Wirojanan J, Sopontammarak S, Vachvanichsanong P (March 2004). "Sterile pyuria in Kawasaki disease". Pediatr. Nephrol. 19 (3): 363. doi:10.1007/s00467-003-1394-8. PMID 14745638.
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