Pyuria resident survival guide

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Pyuria
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ibtisam Ashraf, M.B.B.S.[2] Sahar Memar Montazerin, M.D.[3]

Synonyms and Keywords: Approach to pyuria, Pyuria workup, Pyuria management

Overview

Pyuria is a urinary condition characterized by a high number of white blood cells in the urine. It is generally characterized as the presence of 10 or more white blood cells per cubic millimetre in a sample of urine, 3 or more white cells per high-power field of unspun urine, a positive result on Gram's staining of an unspun urine specimen or a urinary dipstick test that is positive for leukocyte esterase. Pyuria occurs in urinary tract infections (UTI) and/or sepsis. Other causes include sterile pyuria, STDs, pneumonia, interstitial cystitis, kidney stones, pelvic infections and urinary fistulas. Long-term usage of some medications, including aspirin, diuretics, nitrofurantoin, proton pump inhibitors and NSAIDs, induces pyuria. There may be visible changes in the urine, which may appear cloudy or thick or look like pus.

Causes

Life Threatening Causes

Life-threatening causes of pyuria include

Common Causes

The table below demonstrates the possible causes of pyuria:[2][3]

Common causes of pyuria
Non-iInfectious Infectious
Medication side effect Systemic disease Accompanied with hematuria History of surgery/radiotherapy Accompanied with weight loss Infections
  • Urinary catheters
  • Ureteric stents
  • Recent cystourethroscopy/nephroscopy
  • Post-intrabdominal surgery
  • Post-pelvic irradiation

Diagnosis

The below algorithms shows primary approach to patients with pyuria:[2]

 
 
 
 
 
 
History and Physical Eexamination

Ask for urinary symptoms such as:
Dysuria
Hematuria
Physical Examination should asses for the presence of:
Hypotension
Pallor
Edema
❑ Muffled heart sounds
Swollen joints
Organomaegally
Lymphadenopathy
Abdominal and pelvic examination

❑ Digital rectal examination
Vaginal examination (in female)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laboratory Investigations

Check for urinanalysis and urine cullture
❑ Midstream clean catch is preferred.
❑ Avoid the use of antiseptic solutions prior to collection.
Check routine blood tests such as:
Complete blood count
Liver function test
❑ Renal function test
Perform a vaginal swab in sexually active patients to rule out:
Chlamydia
Gonorrhoea
In case of suspicion to urinary tuberculosis:
❑ Consider 3 consecutive first-void morning samples for
acid-fast bacilli and polymerase chain reaction (PCR) testing
In case of suspicion to schistosomiasis:
❑ Consider collecting a terminal urine sample between noon and 3 pm

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Investigations

Consider urinary tract ultrasound or computed tomography:
❑ If suspicious for renal stone
❑ If suspicious for masses
❑ If suspicious for nephritis
Consider flexible cystourethroscopy and tissue biopsy:
❑ If suspicious for neoplasm

 
 
 

Shown below is an algorithm summarizing the diagnosis of pyuria.[4]



 
 
 
Patient with Pyuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with pelvic pain, urinary
symptoms and urethral symptoms
 
Patient with fever, systemic
symptoms, urinary symptoms,
abdominal or pelvic pain
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate for: STDs, Prostatitis, PID
 
Reassess for bacterial infection
by means of aerobic and
anaerobic culture
 
 
 
 
 
 
 
 
 
 
 
 
If not detected, consider:
Urinary stone,
Foreign body,
Interstitial cystitis,
Bladder tumor,
Schistosomiasis
 
No bacteria detected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate for: Tuberculosis
If patient is a immigrant
from tuberculosis endemic country
Fungal infection
If patient is immunocompromised,
check for candida, aspergillus or
cryptococcus infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no infection detected, consult
with infectious disease
specialist or nephrologist

Treatment

Shown below are the algorithms summarizing the treatment of pyuria.[5] It typically depends on the specific cause of pyuria.

 
 
 
 
 
 
 
Gonorrhea
and
Chlamydia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NAAT
with first-catch
urine sample
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gonorrhea
 
Chlamydia
 
 
 
 
 
Evaluate for
other causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ceftriaxone 250mg
Intramuscularly
and either
Azithromycin 1g
Orally
Doxycycline 100mg
Orally
twice a day
for 7 days
 
Azithromycin 1g
Orally
Doxycycline 100mg
Orally
twice a day
for 7 days
Alternatively
Erythromycin 500mg
Four times a day
for 7 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Abbreviations: NAAT: Nucleic Acid Amplification Test

 
 
 
Fungal Infections
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antifungal drugs:
Fluconazole,
Posaconazole,
Echinocandins and
Amphotericin B
 
 
 
Candida albicans:
Fluconazole 100 mg PO
qd for 2-5 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the patient has
coexisting diabetes mellitus or
immunosuppression
 
 
 
Non-albicans Candida:
Amphotericin B
0.1 mg/kg/day IV
for 2-5 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
More than one
Antifungal drugs
+
Antibiotics
 
 
 
 
 
 
 
 



 
 
 
Renal Tuberculosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Isoniazid 300 mg PO qd for 2 months
AND
Rifampicin 450-600 mg qd for 2 months
AND
Ethambutol 15-25 mg/kg PO qd for 2 months
AND
Pyrazinamide 1500 mg for 2 months
THEN
Isoniazid 300 mg PO qd for 4-6 months
AND
Rifampicin 450-600 mg qd for 4-6 months
 
 
 
 
 


 
 
 
 
 
Trichomoniasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preferred regimen:
Metronidazole 2 g PO
single dose
OR
Tinidazole 2 g PO
single dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat patient’s sex partner
if trichomoniasis
is diagnosed in patient
 
 
 
 
 
 


 
 
 
Genital herpes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preferred regimen:
Acyclovir 400 mg PO tid for 7–10 days
OR
Acyclovir 200 mg PO five times a day
for 7–10 days
OR
Famciclovir 250 mg PO tid for 7–10 days
OR
Valacyclovir 1 g PO bid for 7 days
 
 
 
 
 


 
 
 
 
Mycoplasma and Ureaplasma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preferred regimen:
Azithromycin
OR
Levofloxacin
OR
Moxifloxacin
 
 
 
 
 


 
 
 
 
Schistosomiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preferred regimen:
Praziquantel 20 mg/kg PO bid
for 1–2 days
 
 
 
 
 

Do's

Evaluate for sexually transmitted diseases, if risk factors are present including unprotected sexual encounters.[6]
Instruct the female patients to:

  • Lose weight (if they are overweight or obese).
  • Always stay hydrated.
  • Urinate after sexual intercourse.
  • Always wipe front to back.
  • Wear cotton/comfortable underwear.
  • Use menstrual cups, sanitary pads, or clean period-proof underwear.
  • Maintain personal hygiene.

Don'ts

References

  1. Glen P, Prashar A, Hawary A (2016). "Sterile pyuria: a practical management guide". Br J Gen Pract. 66 (644): e225–7. doi:10.3399/bjgp16X684217. PMC 4758505. PMID 26917663.
  2. 2.0 2.1 Glen, Peter; Prashar, Akash; Hawary, Amr (2016). "Sterile pyuria: a practical management guide". British Journal of General Practice. 66 (644): e225–e227. doi:10.3399/bjgp16X684217. ISSN 0960-1643.
  3. Dieter, Robert S. (2000). "Sterile pyuria: A differential diagnosis". Comprehensive Therapy. 26 (3): 150–152. doi:10.1007/s12019-000-0001-1. ISSN 0098-8243.
  4. 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.
  5. Wise, Gilbert J (2005). "Genitourinary fungal infections: a therapeutic conundrum". Expert Opinion on Pharmacotherapy. 2 (8): 1211–1226. doi:10.1517/14656566.2.8.1211. ISSN 1465-6566.
  6. Gungor, Ilkay; Beji, Nezihe Kizilkaya (2011). "Lifestyle changes for the prevention and management of lower urinary tract symptoms in women". International Journal of Urological Nursing. 5 (1): 3–13. doi:10.1111/j.1749-771X.2011.01112.x. ISSN 1749-7701.