Genitourinary Emergencies

• Urinary tract infections (UTIs) are one of the most frequently encountered infectious processes diagnosed by emergency physicians (EPs). The epidemiology of UTIs varies with sex and age.
• It is estimated that women have about a 50% lifetime occurrence rate for a UTI.
• The prevalence of UTIs in febrile infants is about 5%, while in the geriatric population the prevalence approaches 20%.
• While the diagnosis of UTI is relatively straightforward, the treatment and ultimate disposition of patients depends on special circumstances such as extremes of age, pregnancy, treatment failures, and underlying medical conditions.
• UTIs are most often caused by Gram-negative aerobic bacilli, the most common of these being E. coli in 80% of cases.
• The second most common pathogen (10-20%) is Staphylococcus saprophyticus, a coagulase-negative Gram-positive bacteria.
• Proteus mirabilis, Klebsiella, and Enterococcus account for less than 5% of the remaining infections.

Clinical Presentation

• Classically the signs and symptoms of lower UTIs are dysuria, frequency, urgency, hesitancy, hematuria, and suprapubic pain.
• Upper UTIs (pyelonephritis) typically present with fever, chills, flank pain, nausea, vomiting, anorexia, and associated costovertebral angle (CVA) tenderness.
• Some studies have shown that up to 50% of women with classical lower UTI symptoms have silent kidney involvement.
• In women, a history of vaginal discharge should always be elicited, and a pelvic exam, if indicated, will allow one to rule out PID, cervicitis, or vaginitis as the cause of dysuria.
• Males with dysuria and discharge should undergo a urethral swab, which should be sent for gonorrhea and chlamydia cultures.

• The diagnostic mainstay of a UTI is the urinalysis (UA).
• A UA from a properly obtained midstream, clean-catch specimen is as accurate as that of a catheterized specimen, except in debilitated patients, patients of extreme ages, or the morbidly obese. For such patients, a catheterized specimen may be necessary.
• An initial screening test is the urine dipstick. Leukocyte esterase (LE) and nitrites may be present in UTIs.
• The urine dipstick for LE has a reported sensitivity of 75-96% with a specificity of 94-98% in detecting >10 leukocytes per high-powered field.
• The nitrite test detects the presence of bacteria that produce nitrite reductase and is highly specific (92-100%) but not nearly as sensitive (35-85%).
• Empiric treatment is appropriate in symptomatic patients with a positive LE test.
• If the urine dipstick is negative, urine microscopy is not indicated.
• Although direct microscopy techniques lack standardization, it is presently accepted that the presence of 8 leukocytes or more per mL of uncentrifuged urine constitutes pyuria.
• In a patient with pyuria without bacteriuria, the diagnosis of sexually transmitted urethritis should be considered.
• Microscopic hematuria is more commonly caused by a UTI than a sexually transmitted disease (STD).
• In patients with pyelonephritis the UA will often show white blood cell casts.
• Most cases of uncomplicated UTIs do not necessitate a urine culture. But there are several important risk factors for complicated UTI in which urine cultures should be obtained. These include:
• All children, adult males, and debilitated elderly
• Immunosuppressed patients (HIV, steroid use, solid organ transplant patients)
• Pregnant women
• Treatment failures, recurrent UTIs, or previous antimicrobial therapy within 2 wk
• Hospitalized (or recently) patients
• Patients with chronic indwelling catheters or recent instrumentation
• Acute pyelonephritis
• Patients with preexisting anatomic urologic abnormalities or urinary tract obstruction
• Patients with serious medical diseases (DM, sickle cell anemia, cancer)
• Additional laboratory tests such as CBC, electrolytes, BUN and creatinine are optional, and should be tailored to each individual.
• Blood cultures are of little value.

Differential Diagnosis

• For lower UTI:
• Urethritis
• Cervicitis
• PID/STDs
• Vulvovaginitis
• Prostatitis
• Epididymitis
• For upper UTI:
• All of the above
• Nephrolithiasis
• Renal abscess
• Appendicitis
• Cholecystitis
• Lower lobe pneumonia
• Diverticulitis

Special Circumstances

• Pyelonephritis
• Clinical presentation is classic lower UTI symptoms (dysuria, frequency, etc) with associated CVA/flank pain, nausea, vomiting, dehydration or toxic appearance.
• Obtain urine culture in all cases. CBC is optional, and blood cultures are not indicated.
• Resuscitate early with 1-2 L of NS.
• Early parenteral antibiotics
• Antiemetic for vomiting, and analgesia for pain
• Admission criteria
• Inability to tolerate oral intake (persistent nausea/vomiting)
• Pregnancy
• Unstable vital signs and toxic appearance
• Immunocompromised state (diabetes, cancer, transplant, patient AIDS, sickle cell disease)
• Any underlying anatomical urinary tract abnormality or obstruction
• Extremes of age
• Poor social situation or unreliable follow-up
• Pregnancy
• Asymptomatic bacteriuria (ASB) is defined as persistent colonization of the urinary tract without UTI symptomatology.
• Untreated ASB is associated with increased incidence of preterm delivery and low birth weight infants. The progression of ASB to pyelonephritis is associated with significant maternal and fetal morbidity and mortality. About 5-10% of pregnant women will have ASB.
• ASB should always be treated with a 3-7 day course of oral antibiotics followed by culture at the end of treatment to ensure sterilization of the urine.
• There is a paucity of literature on cystitis in pregnancy and its relationship to the risk of preterm birth, low birth weight, or pyelonephritis.
• For cystitis, diagnosis can be obtained from urine culture. Treatment is the same as that for ASB, but should be extended to 7-10 days. Patients should be have a repeat urine culture done after treatment to ensure sterilization.
• Acute pyelonephritis occurs in 1-2% of all pregnancies. Clinical signs and symptoms do not vary much from those of the nonpregnant population, but because of various anatomic and physiologic changes during pregnancy, a broader differential diagnosis must be considered. This includes normal back pain of pregnancy, gallbladder disease, renal abscesses, nephrolithiasis, pulmonary embolism, and appendicitis.
• Any evidence of renal involvement requires admission for IV antibiotics.
• Elderly
• 20-50% of women over 65 yr of age have ASB. The incidence increases with age and is thought to be due to a combination of factors including changes in bladder emptying, increased incontinence (both fecal and urinary), and decrease in estrogen levels. The elderly often lack the usual presenting signs and symptoms. They may present with fever, but hypothermia and euthermia are also not uncommon. The chief complaint may be altered mental status, nausea and vomiting, weakness, dizziness, abdominal pain, or respiratory distress. In general, ASB in the elderly is not treated. However, elderly patients presenting with symptoms consistent with UTI, foul-smelling urine, or new symptoms of urge incontinence should be treated. Acute pyelonephritis usually presents as a septic syndrome with fever, tachycardia and altered mental status. Misdiagnosis of UTI in the geriatric patient is about 20-40% due to the wide range of presenting symptoms. •Men The incidence of bacteruria in the adult male is uncommon, but rises at the age of 50 with increasing incidence of prostatic hypertrophy. By age 65, the incidence of UTIs among males and females becomes equal. UTIs in the male population are always considered complicated because the etiology is usually due to a structural or functional defect, which leads to incomplete voiding or obstruction.