• The sensation of pain, burning or
discomfort on urination.
• In adulthood, more common in women
• Approximately 25% of women report
one episode of acute dysuria per year.
• Most common in women 25-54 years of
age and in those who are sexually
• In men, dysuria becomes more
prevalent with increasing age.
- Most common cause
- Presents as; cystitis, urethritis,
pyelonephritis, vaginitis or prostatitis
• Non- infectious:
- Hormonal conditions (hypoestrogenism),
obstruction (BPH, urethral strictures),
neoplasms, allergic reactions, chemicals,
foreign body and trauma.
Differential Diagnosis of Dysuria
• STD Chlamydia trachomatis , N. gonorrhea ,
and HSV all can cause urethritis and
symptoms of LUTI.
• Candidal infections
• Urethral or bladder irritation.
• Interstitial cystitis in young women.
• Bladder tumors
• BPH , prostatitis , epididymitis.
• Renal stones, renal infarction papillary
Urinary Tract Infections
• UTI is Any infection involving the
urothelium, which includes urethral,
bladder, prostate and kidney infections.
• The term UTI and uncomplicated UTI
are often used to refer to cystitis
• Urinary tract infection (UTI) is common
in women, in whom it usually occurs in
an anatomically normal urinary tract.
• The incidence of UTI is 50 000 per
million persons per year and accounts
for 1–2% of patients in primary care.
• Recurrent infection causes considerable
morbidity; if complicated, it can cause
severe renal disease including end-
stage renal failure. It is also a common
source of life-threatening Gram-
• Frequency, urgency, dysuria, hematuria, supra-
pubic pain, grossly cloudy and malodorous
urine THINK OF CYSTITIS
• High grade Fever, rigors (shaking chills),
nausea, vomiting, diarrhea, loin pain THINK
OF ACUTE PYELONEPHRITIS
• Flu like symptoms low backache, few urinary
symptoms THINK OF PROSTATITIS
• Infection is most often due to bacteria
from the patient’s own bowel flora
transferred to the urinary tract via the
ascending transurethral route
• May be via the bloodstream, the
lymphatics or by direct extension
(e.g.from a vesicocolic fistula).
• Escherichia coli and other ‘coliforms’ –
• Proteus mirabilis
• Klebsiella aerogenes
• Enterococcus faecalis
• Staphylococcus saprophyticus or
epidermidis – 5-15%
Lower Urinary Tract Infection
Uncomplicated (Simple) cystitis
In healthy woman, with no signs of
In men, or woman with co-morbid
Healthy adult woman (over age 12)
Rarely in men.
• Signs and symptoms
Frequency , urgency or both
No fever, nausea, vomiting, flank pain and no vaginal discharge
Dipstick urinalysis positive for nitrites or leukocyte esterase. (no culture or
lab tests needed)
• Prognosis :
Treatment is usually successful.
Symptoms of a bladder infection usually disappear within 24 - 48 hours
Risk Factors and Treatment
• Major risk factor for uncomplicated simple
cystitis is sexual activity.
• Females with comorbid medical
• All male patients
• Indwelling foley catheters
• CBC + blood culture .
• Urine dipstick : pyuria on microscopic examination urine
WBC positive for nitrites or leukocyte esterase.
• Middle stream urine culture: bacterial account > 10^5/ml
• The following tests may be done to help rule out problems
in the urinary system that might lead to infection or make
a UTI harder to treat:
CT scan of the abdomen
Intravenous pyelogram (IVP)
Risk Factors and Treatment
• Blockages in the urinary tract: Kidney stones or an enlarged
prostate can trap urine in the bladder and increase the risk of
urinary tract infection.
• Urinary tract abnormalities: that don't allow urine to leave the body
or cause urine to back up in the urethra
• Catheter to urinate:
• Advanced age
• Fluoroquinolone (or other broad spectrum antibiotic)
• 7-14 days of treatment (depending on severity)
• May treat even longer (2-4 weeks) in males with UTI
• Recurrent cystitis is usually defined as
three episodes of urinary tract infection
in previous 12 months or two episodes
in previous six months.
• It’s common in young, healthy women .
One study show that 27% of women
developed a second infection within six
months of the first attack.
Evaluation and Treatment
• May consider urologic work-up to evaluate for
• Postcoital antibiotics (taken within two hours of
intercourse) reduce the rate of clinical recurrence
of cystitis as effectively as continuous treatment.
• Self-administered trimethoprim/sulfa-methoxazole or
continuous prophylaxis are effective in preventing
recurrence of cystitis in 95% of the cases
• Cranberry products (juice or capsules) seem to
significantly reduce the recurrence of symptomatic
• Typical clinical history (fevers, chills,
dysuria, malaise, myalgias,
pelvic/perineal pain,cloudy urine)
• The finding of an edematous and tender
prostate on physical examination
• Increased PSA
• Urinalysis, urine culture
Risk Factors and Treatment
• Being a young or middle-aged man
• Having a past episode of prostatitis
• Cystitis or urethritis
• Having a pelvic trauma, such as injury from cycling or
• Not drinking enough fluids (dehydration)
• Using a urinary catheter
• Having unprotected sexual intercourse
• Having HIV/AIDS
• Being under psychological stress
• Trimethoprim/sulfamethoxazole, fluroquinolone or other
broad spectrum antibiotic
• 4-6 weeks of treatment
Complications of Prostatitis
• Bacterial infection of the blood
• Prostatic abscess
• Abnormalities in semen and infertility
(this can occur with chronic prostatitis).
Urethritis is swelling and irritation (inflammation) of the urethra.
Urethritis may be caused by bacteria or a virus. The same bacteria that
cause urinary tract infections (E. coli) and some sexually transmitted
diseases (chlamydia, gonorrhea) can lead to urethritis.
Viral causes of urethritis include herpes simplex virus and
Other causes include:
Sensitivity to the chemicals used in spermicides or contraceptive
jellies,creams, or foams
Risks for urethritis include:
• Being a female in the reproductive years
• Being male, ages 20 - 35
• Having many sexual partners
• High-risk sexual behavior (such as anal sex without a condom)
• History of sexually transmitted diseases
• In men:
Blood in the urine or semen
Burning pain while urinating (dysuria)
Discharge from penis
Frequent or urgent urination
Pain with intercourse or ejaculation
• In women:
Burning pain while urinating
Fever and chills
Frequent or urgent urination
Infection of the pelvis of kidney
• Symptoms of acute pyelonephritis : short
duration; hours to days
It can cause high fever, pain on passing urine,
and abdominal pain that radiates along the flank
towards the back. There is often associated
• Physical examination may reveal fever and
tenderness at the costovertebral angle on the
• Most cases of "community-acquired" pyelonephritis
are due to bowel organisms that enter the urinary
• Common organisms are E. coli (70–80%) and
• Hospital-acquired infections may be due to coliform
bacteria and enterococci, as well as other organisms
uncommon in the community (e.g. Pseudomonas
aeruginosa and various species of Klebsiella).
• Most cases of pyelonephritis start off as lower urinary
tract infections, mainly cystitis and prostatitis.
• Symptoms + U/A (+ve Nitrite and WBCs) are sufficient to diagnose
and are an indication for empirical treatment,
• CBC shows neutrophilia
• Urine culture and antibiotic sensitivity are useful to establish a formal
• KUB if suspected stone
• Where available, a noncontrast CT scan is the diagnostic
modality of choice in the radiographic evaluation of suspected
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take oral
• Perinephric/Renal abscess: suspect in
patient who is not improving on
• Renal failure
Habits that might prevent UTI
• Maintain good hydration (especially with
• Wipe urethra from front to back to avoid
contamination of the urethra with feces
from the rectum.
• Avoid feminine hygiene sprays and
• Empty bladder immediately before
Types of Sample Collection
There are 3 ways to obtain a urine
• Spontaneous voiding
• Urethral catheterization
• Suprapubic bladder aspiration
• A clean catch - midstream urine sample
is collected after cleaning the external
urethral meatus with soap & water, this
avoids contamination of urine by
contents of urethra or vagina and
therefore its constituents are more likely
to reflect kidney origin.
• The healthcare provider inserts
a foley catheter into the
bladder through the urethra to
collect the urine specimen.
• Required only in special
• Has the danger of introducing
microorganisms from urethra
and perineum and causing
urinary tract infection.
Suprapubic Bladder Aspiration
• This method is used
when a bedridden
patient cannot be
catheterized or a
sterile specimen is
required. The urine
specimen is collected
by needle aspiration
abdominal wall into
MARCOSCOPIC EXAMINATION OF THE URINE
Chemical examination using dipsticks
6. Leukocyte esterase test
7. Specific gravity
MICROSCOPIC EXAMINATION OF URINE:
1. Red Blood Cells
2. White Blood Cells
3. Epithelial Cells
Diseases Identified with a Urine
• Diseases of the kidneys and the urinary
• Carbohydrate metabolism disorders
• Liver diseases and haemolytic disorders
Diseases of the kidneys and the
• Specific gravity
Glomerular/ Tubular diseases
Leukocyte esterase and Nitrite
Used to detect leucocytes in the urine
The test is positive if there are more than 5 leucocytes/hpf.
A negative leukocyte esterase test means that an infection is
unlikely and that, without additional evidence of urinary tract
infection, microscopic exam and/or urine culture need not be
done to rule out significant bacteriuria.
Normal urine does not contain nitrites. Urine nitrite test is used
for screening for bacteria
A positive test indicates presence of more than 10
• A more acidic pH may be the result of fever, phenylketonuria or
• Alkaline urine may occur in urinary tract infections, metabolic or
• pH of normal urine is between 4.5 and 7.8, but usually it ranges
between 5.0 and 6.0, due to obligatory excretion of acid produced
• Very alkaline urine is suggestive of infection with a urea splitting
organism. Prolonged storage can lead to overgrowth of urea splitting
organism and falsely cause high urine pH. Rarely alkaline pH may be
due to metabolic alkalosis or acidification defect.
• Low urine pH (<5.0) is most commonly due to metabolic acidosis. Acid
urine may also be associated with ingestion of large amounts of meat.
• Specific gravity determines the ability of the kidney to
concentrate or dilute urine.
• Specific gravity –depends on both the weight and the number of
particles in solution The normal range is between 1.005 and
• Osmolality is dependent only on the number of particles
Osmolality of urine is between 40 to 1200mosm/kg.
• Specific gravity is a convenient and easily measured indicator
of urine osmolality
• To determine specific gravity, urine should be collected after a
period of water deprivation such as an early morning sample
before ingestion of any fluid.
• Increased: Volume depletion, congestive heart
failure (CHF), adrenal insufficiency, diabetes
mellitus, inappropriate antidiuretic hormone
(ADH), increased proteins (nephrosis)
• If markedly increased (1.040–1.050), suspect
artifact or excretion of radiographic contrast
• Decreased: Diabetes insipidus, pyelonephritis,
glomerulonephritis, water load with normal
• Most healthy individuals excrete between
30-130 mg/day of protein in urine.
• More than 150 mg/day is defined as
• Trace proteinuria = 10mg/dl
1+ proteinuria = 30mg/dl
2+ proteinuria =100mg/dl
3+ proteinuria =300mg/dl
4+ proteinuria = 1gm/ dl
• The urine dipstick is most sensitive to
albumin and is often insensitive to
other proteins. Hence, this may give a
false negative result with
immunoglobulin light chains (Bence-
Jones protein) or microalbuminuria.
• False positive may occur if there is
delay in reading the strip.
• Indication by dipstick of persistent proteinuria
should be quantified by 24-hr urine studies:
• Positive: Pyelonephritis, glomerulonephritis,
Kimmelstiel-Wilson syndrome (diabetes),
nephrotic syndrome, myeloma, postural causes,
preeclampsia, inflammation, and malignancies
of the lower tract, functional causes (fever,
stress, heavy exercise), malignant hypertension,
congestive heart failure
Proteinuria can be:
• Transient – occurs commonly especially in children and usually
resolves within a few days often associated with fever, exercise
or stress. In older patients may be due to CHF.
• Intermittent – frequently associated with postural changes.
Commonly occurs in upright position in young adults and rarely
exceeds 1g/day. Resolves spontaneously in about half of
patients and not associated with disease. If normal renal
function evaluate no further.
• Persistent – usually due to glomerular cause with >2g
protein/day of which major component is albumin. Some may
also coexist with haematuria.
Blood - Hematuria
RBC: The exact definition of microscopic
hematuria is debated, but is generally
defined as >3 RBC/HPF (40×).
• Positive test indicates
• False positive readings
most often due to
Hematuria vs. Hemoglobinuria and
• absence of RBC's on the microscopic examination
Hemoglobin vs. Myoglobin
• Hemoglobin usually is bound and is too large to pass
through the glomerular filter. If the renal threshold is
exceeded, the hemoglobin can pass into the urine.
Myoglobin on the other hand, is not bound and freely
passes through the glomerular filter.
• Free hemoglobin may be present from trauma, from a
transfusion reaction, or from lysis of RBCs (RBCs will lyse
if the pH is <5 or >8).
• There may be myoglobin present because of a crush
injury, burn, or tissue ischemia.
• Glucose - Identified ay Glycosuria
• Ketones - Identified as Ketonuria
• Glycosuria (excess
sugar in urine) generally
• Blood sugar above renal
threshold (10mmol/l or
180mg/dl) will appear in
• Dipstick will detect
glucose in the urine in
the range of 50 mg/dl to
• This is specific to
glucose and no other
sugar such as galactose
• acetone, aceotacetic acid, beta-hydroxybutyric acid
• Glomeruli freely filter ketones and the tubules then resorb them
completely. If the tubular resorptive capacity is saturated, then
the ketones are incompletely resorbed, resulting in ketonuria.
• Ketonuria does not signify renal disease, but rather excessive
lipid or defective carbohydrate metabolism.
• Dipstick tests are semiquantitative and only detect acetone and
acetoacetic acid. Reagent strips contain nitroprusside that does
not react with beta-hydroxybutyric acid.
• Ketonuria may be caused by starvation, insulinoma, diabetic
ketoacidosis, persistent hypoglycemia, high fat low carbohydrate
diets, and glycogen storage disease.
• Ketonuria most commonly it is a sign of
impaired insulin function (uncontrolled
• The finding of ketones in the urine may
signal an urgent medical situation, as
these compounds raise the acidity of
the blood (metabolic ketoacidosis) can
cause coma and even death if
Liver diseases and haemolytic
• Urobilinogen - Identified as
• Bilirubin - Identified as Bilirubinuria
Conjugated bilirubin vs.
• Urine normally contains no bilirubin and only
very little urobilinogen.
• Urobilinogen its concentration in urine is
• Unconjugated bilirubin is water insoluble
and bound to albumin does not appear in
• conjugated bilirubin is water
solubleappear in urine.
Bilirubin and Urobilinogen
- Dipstick It is very sensitive and detects as little
as 0.05 mg/dl of bilirubin resulting in color
change to pink.
- false negative results are obtained if urine is
tested after prolonged exposure, since bilirubin
degenerates with exposure to light.
- False positive results are obtained if there is
contamination with stool or if the temperature
of the reagent strip is elevated.
Bilirubin and Urobilinogen
• Low Urobilinogen+Low Bilirubin =
Congenital enzymatic defect/ drugs that acidify
urine, such as ammonium chloride or ascorbic
• Low Urobilinogen+High bilirubin = biliary
• High Urobilinogen+High bilirubin =