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CystitisinFemalesDifferentialDiagnoses

CystitisinFemalesDifferentialDiagnoses
Author:JohnLBrusch,MD,FACPChiefEditor:MichaelStuartBronze,MDmore...
Updated:Aug19,2015

DiagnosticConsiderations
Occultpyelonephritisoccursin1550%(ormore)ofallurinarytractinfections
(UTIs),basedonseveralstudiesonlocalizationoforganismswithintheurinary
tract.Thisusuallyoccursinolderwomen.Itappearsthatthesepatientsareunable
tomountafeverordevelopanelevatedwhitecountorcostovertebralangle(CVA)
tenderness.Thesepatientsmaypresentwithanunexplainedfallorachangein
mentalstatus.
Postmenopausalwomenmayalsoexperiencesenileurethritis.Inadditiontourinary
burning,frequency,andurgency,thesepatientsmaycomplainofvaginalandvulvar
itchinganddischarge.Physicalexaminationrevealsadry,palevaginalepithelium
andeversionoftheurethralmucosa.Senileurethritisrespondstotopicalestrogen
therapy.
Thedifferentialdiagnosisforinfectiouscausesofsterilepyuriaincludesperinephric
abscess,urethralsyndrome,renaltuberculosis,andfungalinfectionsoftheurinary
tractsystem.Noninfectiouscausesofpyuriaincludethefollowing:
Uricacidandhypercalcemicnephropathy
Lithiumandheavymetaltoxicity
Sarcoidosisandothergranulomatousdiseases(eg,tuberculosis)
Interstitialcystitis
Polycystickidneydisease
Genitourinarymalignancy
Renaltransplantrejection
Anyperiurethralprocess
ConsiderUTIinanyconditioninvolvingpaintheflankandbackorpaininthe
abdomenandpelvis.AlsoconsidercervicitisandChlamydiainfection.Donot
assumethatasexuallyactivefemalewithdysuriahasaUTIwithoutfirstexcluding
thepossibilityofsexuallytransmitteddiseaserelatedcervicitis,vaginitis,orpelvic
inflammatorydisease.
UTIsinpregnancyhavepotentiallyadverseoutcomesforboththemotherandthe
fetus.ObtainaurinecultureinallpregnantpatientswithsuspectedUTI,asthe
resultsmayprovidethephysicianorthefollowupphysicianwithvaluable
informationifthepatientdoesnotrespondasexpectedtotreatment.Pyuriaand
bacteriuriaarealwaystreatedduringpregnancy,regardlessofwhethersymptoms
arepresent.
PatientswithdiabetesmellitusareatincreasedriskforcomplicatedUTIs.
Diagnosticconsiderationsincludethefollowing:
Renalandperirenalabscess
Emphysematouspyelonephritis
Emphysematouscystitis
Fungalinfections
Xanthogranulomatouspyelonephritis
Papillarynecrosis
Olderpatientswhoappeartoxicaremorelikelytohaveobstructioncomplicating
theirUTI.Obtainastructuralstudytoruleoutthispossibility.

DifferentialDiagnoses
AcutePyelonephritis
BladderCancer
ChlamydialGenitourinaryInfections
Cystitis,Nonbacterial
HerpesSimplex
InterstitialCystitis
PelvicInflammatoryDisease
Urethritis
Vaginitis
Workup

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ContributorInformationandDisclosures
Author
JohnLBrusch,MD,FACPAssistantProfessorofMedicine,HarvardMedicalSchoolConsultingStaff,
DepartmentofMedicineandInfectiousDiseaseService,CambridgeHealthAlliance
JohnLBrusch,MD,FACPisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
Coauthor(s)
BurkeACunha,MDProfessorofMedicine,StateUniversityofNewYorkSchoolofMedicineatStonyBrook
Chief,InfectiousDiseaseDivision,WinthropUniversityHospital
BurkeACunha,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanCollegeofPhysicians,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
JeffreyMTessier,MDAssistantProfessor,DivisionofInfectiousDiseases,DepartmentofInternalMedicine,
VirginiaCommonwealthUniversitySchoolofMedicine
JeffreyMTessier,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysiciansAmerican
SocietyofInternalMedicine
Disclosure:Nothingtodisclose.
MaryFBavaro,MDFellowshipDirector,DivisionofInfectiousDisease,NavyMedicalCenter,SanDiego
MaryFBavaro,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,Infectious
DiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
ChiefEditor
MichaelStuartBronze,MDDavidRossBoydProfessorandChairman,DepartmentofMedicine,StewartG
WolfEndowedChairinInternalMedicine,DepartmentofMedicine,UniversityofOklahomaHealthScience
CenterMasteroftheAmericanCollegeofPhysiciansFellow,InfectiousDiseasesSocietyofAmerica
MichaelStuartBronze,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
MedicalAssociation,OklahomaStateMedicalAssociation,SouthernSocietyforClinicalInvestigation,
AssociationofProfessorsofMedicine,AmericanCollegeofPhysicians,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
Acknowledgements
MichaelSBeeson,MD,MBA,FACEPProfessorofEmergencyMedicine,NortheasternOhioUniversities
CollegeofMedicineandPharmacyAttendingFaculty,AkronGeneralMedicalCenter
MichaelSBeeson,MD,MBA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,CouncilofEmergencyMedicineResidencyDirectors,NationalAssociationofEMS
Physicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
PamelaLDyne,MDProfessorofClinicalMedicine/EmergencyMedicine,UniversityofCalifornia,LosAngeles,
DavidGeffenSchoolofMedicineAttendingPhysician,DepartmentofEmergencyMedicine,OliveViewUCLA
MedicalCenter
PamelaLDyne,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidSHowes,MDProfessorofMedicineandPediatrics,SectionChiefandEmergencyMedicineResidency
ProgramDirector,UniversityofChicagoDivisionoftheBiologicalSciences,ThePritzkerSchoolofMedicine
DavidSHowes,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
EliciaSKennedy,MDClinicalAssistantProfessor,DepartmentofEmergencyMedicine,UniversityofArkansas
forMedicalSciences
EliciaSKennedy,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
KlausDieterLessnau,MD,FCCPClinicalAssociateProfessorofMedicine,NewYorkUniversitySchoolof
MedicineMedicalDirector,PulmonaryPhysiologyLaboratoryDirectorofResearchinPulmonaryMedicine,
DepartmentofMedicine,SectionofPulmonaryMedicine,LenoxHillHospital
KlausDieterLessnau,MD,FCCPisamemberofthefollowingmedicalsocieties:AmericanCollegeofChest
Physicians,AmericanCollegeofPhysicians,AmericanMedicalAssociation,AmericanThoracicSociety,and
SocietyofCriticalCareMedicine

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Disclosure:SepracorNoneNone
AllisonMLoynd,DOResidentPhysician,DepartmentofEmergencyMedicine,WayneStateUniversitySchool
ofMedicine,DetroitReceivingHospital
AllisonMLoynd,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,andEmergencyMedicineResidentsAssociation
Disclosure:Nothingtodisclose.
MarkJeffreyNoble,MDConsultingStaff,UrologicInstitute,ClevelandClinicFoundation
MarkJeffreyNoble,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,
AmericanMedicalAssociation,AmericanUrologicalAssociation,KansasMedicalSociety,SigmaXi,Societyof
UniversityUrologists,andSouthwestOncologyGroup
Disclosure:Nothingtodisclose.
AdamJRosh,MDAssistantProfessor,DepartmentofEmergencyMedicine,DetroitReceivingHospital,Wayne
StateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
JosephASalomoneIII,MDAssociateProfessorandAttendingStaff,TrumanMedicalCenters,Universityof
MissouriKansasCitySchoolofMedicineEMSMedicalDirector,KansasCity,Missouri
JosephASalomoneIII,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,NationalAssociationofEMSPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
RichardHSinert,DOAssociateProfessorofEmergencyMedicine,ClinicalAssistantProfessorofMedicine,
ResearchDirector,StateUniversityofNewYorkCollegeofMedicineConsultingStaff,Departmentof
EmergencyMedicine,KingsCountyHospitalCenter
RichardHSinert,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysiciansand
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
MarkZwanger,MD,MBAAssistantProfessor,DepartmentofEmergencyMedicine,JeffersonMedicalCollege
ofThomasJeffersonUniversity
MarkZwanger,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,andAmericanMedicalAssociation
Disclosure:Nothingtodisclose.

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