Pyuria

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Pyuria

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Overview

Definition

Classification

Pyuria Differential Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

To view a comprehensive algorithm of common findings of urine composition and urine output, click here

Overview

Pyuria is a condition in which urine contains 10 or more white cells/mm³. Gram stain and leukocyte esterase might be positive. Pyuria might be a sign of a bacterial or non bacterial urinary tract infection, genitourinary abnormalities, inflammatory disorders, and systemic diseases. Pyuria may be classified into sterile pyuria or bacteriuria. Treatment is not required for pyuria. However, underlying diseases must be treated.

Definition

Pyuria is a condition in which urine contains pus. Definition of pyuria is as follow:[1]

  • Presence of 10 or more white cells/mm³ in a urine specimen
  • Positive result on Gram’s stain of an unspun urine specimen
  • Positive leukocyte esterase on urinary dipstick test

Pyuria might be a sign of a bacterial or non bacterial urinary tract infection.

Classification

Pyuria may be classified based on the presence of detectable infection as shown below:[2][3]

Classification of pyuria
Group Cell count Bacteria Etiology
Sterile pyuria - Might have infectious or non-infectious etiologies.
Bacteriuria Positive bacterial colony >1000 colony-forming units/ml Mostly have infectious etiologies.

Pyuria Differential Diagnosis

Differentiating the diseases that can cause pyuria:[4][5][6][7]

To review differential diagnosis of sterile pyuria, click here.

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[8] Bacterial Asymptomatic bacteriuria[9][10] Nl Nl Nl ± + NA NA Urinalysis
  • Increased risk in pregnancy
  • Must be treated prior to an invasive urologic procedure
Cystitis[11] + + + Nl Nl Nl + + + NA Urinalysis NA
Pyelonephritis[12] + + + + + + Nl Nl + WBC cast + + NA Clinical manifestation + urinalysis NA
Viral[13][14] + + + + ± Nl Nl Nl + NA NA PCR viral load
Tuberculosis[15][16][17][18] ± + + + + Nl Nl Nl ± Positive mycobacterial urine culture Pulmonary TB on chest CT Urine mycobacterial PCR
Fungal[19][20] + + 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[21][22] Chronic pelvic pain + + Nl Nl Nl + + NA NA PCR
  • Females might have concurrent chlamydial cervicitis
  • Must be considered in young, sexually active males
Gonococcus[23][24][25] 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[26] + + Nl Nl Nl +
  • Gram stain −
NA PCR
  • Associated with complications of pregnancy
Herpes simplex virus[27] + + + + Nl Nl Nl + Viral culture + NA NA Clinical manifestation + PCR
  • Associated with extragenital complications, like aseptic meningitis
  • High risk of recurrence 
Herpes zoster[28] + + Nl Nl Nl + NA Clinical manifestation + PCR
  • Associated with lumbosacral dermatome involvement
HPV[29] + Nl Nl Nl + NA NA Clinical manifestation + PCR
HIV[30] + + + + Nl Nl + NA NA Combination antigen/antibody immunoassay + PCR HIV viral load test
Prostatitis[31]  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[32] Penile pain + + + + Nl
  • Pruritus
  • Erythematous lesions on the glans and/or the foreskin
Nl Nl + ± NA NA Clinical manifestation
Appendicitis[33][34] 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[35] + + Nl Nl + + + Clinical manifestation + urinalysis
Urinary tract stone[36][37] Colicky pain + + + + ± Nl Nl Nl + Visible stone on CT scan Clinical manifestation
  • Might cause renal obstruction
Urinary tract neoplasm[38] + + + + + + + Nl Nl Nl + Visible tumor on CT scan Cystoscopy  + biopsy
Urinary fistula[39] + + Nl Nl Nl + NA Fistula on cystoscopy or IVP Physical examination
  • History of recent surgery
Interstitial cystitis[40] Chronic bladder pain + + + Nl Nl Nl + NA NA Clinical manifestation Associated with other chronic pain syndromes
Vesicoureteral reflux[41] + + Nl Nl Nl + Imaging
Hydronephrosis[42] + Nl Nl Nl + Imaging
Renal diseases Polycystic kidney disease[43]  Flank or back pain + + + Nl Nl + Multiple cysts on ultrasound Imaging
Renal vein thrombosis[44] Flank pain + + + + + + Nl or ↑ + Thrombosis on CT scan Renal venography
Interstitial nephritis[45] Lower back pain + + Nl or ↑ + + Nl Clinical manifestation + urinalysis
IgA nephropathy[46] + Nl or ↑
  • Might be asymptomatic
Nl Nl + Nl Biopsy
Renal transplant rejection[47] Flank pain + + + + + + Nl + + Increased graft size on ultrasound Renal allograft biopsy
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 Diabetic nephropathy[48] ±
  • Might be asymptomatic
Nl Nl + Nl Clinical manifestation + laboratory tests
Lupus nephritis[49] + + + + + Nl + + Enlarged kidneys on CT scan Biopsy
  •  Abnormal results of specific serologic tests
Sjögren’s syndrome[50] + + Nl + + Abnormal diffuse fat tissue deposition and diffuse punctate calcification on parotid gland CT scan Clinical manifestation + laboratory tests
  •  Abnormal results of specific serologic tests
Kawasaki's disease[51] + + + + Nl + Vessels involvement on angiography Clinical manifestation Associated with multiple organ involvement including heart
Medication/toxin Analgesic nephropathy[52] Flank pain + + + + + + + + Renal impairment on CT scan Imaging
Contrast−induced nephropathy[53] + + + Nl Nl + + NA Clinical manifestation + exclusion of other causes of AKI
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

Treatment

  • Sterile pyuria
  • Pathogen-directed antimicrobial therapy[54]
  • Renal Tuberculosis
  • Gonorrhea
  • Chlamydia
  • Mycoplasma and Ureaplasma
  • Genital herpes
  • Trichomoniasis
Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.
  • Fungal infections[55]
  • Preferred regimen, Candida albicans: Fluconazole 100 mg PO qd for 2-5 days
  • Preferred regimen, non-albicans Candida: Amphotericin B 0.1 mg/kg/day IV for 2-5 days OR Amphotericin B bladder irrigation 5-50 mg/L of sterile water qd for 2-5 days
  • Schistosomiasis
  • Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

References

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