The patient presents with polyuria, pyuria, and hematuria. Differential diagnoses include urinary tract infection, nephrolithiasis, glomerulonephritis, and genitourinary tumors. Evaluation includes urinalysis, urine culture and sensitivity, renal ultrasound, and cystoscopy if indicated. The case involves a young male with a history of neurosurgery who undergoes a water deprivation test consistent with central diabetes insipidus.

1. Approach to patient with
Polyuria
Pyuria
Hematuria
Tanvi Rakheja-141
Aditij Dhamija-143
Ankita Dhanuka-144

2. POLYURIA
• Polyuria is urine output more than
• Urinary Frequency – An increase in the number of times a person voids,
irrespective of net volume produced.
• Nocturia – Urinary frequency that is predominantly confined to night
time( i.e; while supine).
3L/DAY
Or
2L/m2
Or
40ml/kg/day

4. Clinical presentation

6. Basic Principle of Dynamic Tests in Endocrinology
• Stimulating or suppressing a particular hormonal axis and observing
the appropriate hormonal response.
• If a deficiency is suspected a stimulation test should be used whilst is
excess is considered likely , a suppression test is required.

7. Water Deprivation Test
• Principle –To raise plasma sodium to at least 145 meq/dl and plasma
osmolarity to at least 295 mosm/kg to stimulate enough ADH release
to cause maximum concentration of urine.
• If water deprivation alone not sufficient can be added with
intravenous 3%saline infusion for achieving the target end point.

9. Interpretation
• If Plasma Osmolarity >300mOsmol/kg
And : DIABETES INSIPIDUS
Urine Osmolarity <600 mOsmol/kg
• If Urine Osmolarity Increase by >50% after DDAVP : CENTRAL DIABETES INSIPIDUS
• If DDAVP does not concentrate the urine. : NEPHROGENIC DIABETES INSIPIDUS

12. PRIMARY POLYDIPSIA - Treatment
• Should not be treated with desmopressin .
• No effective treatment – counselling.
• Caution on using - thiazide diuretics or carbamazepine (Tegretol) that
impair urinary free water excretion directly or indirectly lead to dangerous
hyponatremia.

13. CENTRAL DIABETES INSIPIDUS - Treatment
• Desmopressin – A Synthetic Analogue of AVP
• IV or SC , Nasal , or Orally
• Onset of antidiuresis is rapid – 15 min to 60 min after
• Treatment rapidly reduces fluid intake and urine output to normal
,with only a slight increase in body water.

14. NEPHROGENIC DIABETES INSIPIDUS – Treatment
• Thiazide diuretic and /or amilorode in conjunction with a low sodium
diet and a prostaglandin synthesis inhibitors ( e.g., indomethacin).
• Side effects – hypokalemia and gastric irritation – amiloride or
potassium supplements and by taking medications with meals.

15. Case Scenario
• A 22 year old male presented with a 2 - year h/o of polyuria ,
daily urine output of 5 to 6L/day , h/o increased thirst present .
H/O of neurosurgical intervention for craniopharyngioma 2.5
years back .Hba1c 5.8 . Baseline Na+ = 139 , K+ = 4.0 , Ca = 9.8,
Creatinine = 0.8,serum osmolarity and urine osmolarity were
284 and 136 mosm/Kg. Patient was planned for water
deprivation test . On water deprivation urine and serum
osmolarity of 280 mosm/kg and 296mosm/kg and
desmopressin was given . Post desmopressin maximum urine
osmolarity was 600mosm/kg .What is the diagnosis ?

16. Answer : CENTRAL DIABETES INSIPIDUS
• H/o Craniopharyngioma
• Water Deprivation Test: On giving Desmopressin urine osmolarity
changes from 280 to 600mosm/kg.

18. Classification of hematuria
• Macroscopic – microscopic
• Symptomatic- asymptomatic
• Transient- persistent
• According to act of void:
-Initial : Urethral origin
-Terminal : Bladder neck or prostate origin
-Total : Bladder or upper urinary tract origin

21. •Family history- hematuria, stones, htn, renal disease

23. •Urine dip stick analysis it is the most commonly used method of
testing the urine for blood is the urine test strip or dipstick, which
utilizes the peroxidase-like activity of hemoglobin to generate a color
change.
• Urine dipstick detects:
-Hb
-Myoglobin
-protein

24. Management
•Hematuria is a sign and not a disease so therapy should be directed to
the process causing it
•Asymptomatic hematuria generally does not require treatment
•Surgical intervention may be necessary with certain anatomic
abnormalities (eg, ureteropelvic junction obstruction, tumor)
•Patients with persistent microscopic hematuria should be monitored
every 6-12 months for the appearance of signs or symptoms indigative
of progressive renal disease

25. Case
•The a 48 year-old man had suffered for 2 days from a sore throat. He had a pink and
cloudy discolouration of his urine. He had difficulty in swallowing and was feverish.
He did not have dysuria and no increase or decrease in urinary frequency.
• He himself had 3 episodes of glomerulonephritis when aged 14, 21 and 28. Each
of these followed pharyngytis. There was no family history of renal disease.
• His urea was 7.3, creatinine was 167, and he had more than 100 red cells per ml
and ++ protein in his urine. Ultrasound studies indicated that his kidneys were of
normal size and cortical thickness, there was no hydronephrosis and the bladder
appreared to be normal. No renal tract calcification was seen on plain X-ray film.
• Immunohistochemistry showed that the glomeruli contained small but significant
mesangial deposits of immunoglobulin A

26. Diagnosis
IgA nephropathy

27. PYURIA

28. Pyuria is defined by the presence of any of the
following:
1. 10 or more white cells per cubic millimeter in a urine specimen
2. 3 or more white cells per high-power field of unspun urine
3. Positive result on Gram’s staining of an unspun urine specimen
4. Urinary dipstick test that is positive for leukocyte esterase.

29. Urine is cloudy due to presence of WBCs.
Symptoms of underlying disease.

30. Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495512/
Q. A 27-year-old woman presents to her primary care physician
with a report of urinating more frequently and pain with urination.
She denies blood in her urine, fevers, chills, flank pain, and vaginal
discharge. She reports having experienced similar symptoms a few
years ago and that they went away after a course of antibiotics. The
patient has no other past medical problems. Pertinent history
reveals she has been sexually active with her boyfriend for the past
4 months and uses condoms for contraception. She reports 2
lifetime partners and no past pregnancies or sexually transmitted
diseases. Her last menstrual period was 1 week ago.
What are the differential diagnoses and why?

31. Differential Diagnoses
UTI:
Points in favour:
Increased frequency, urgency, dysuria.
Points against:
No presence of suprapubic pain, discomfort, hesitancy, nocturia,
hematuria (not essential for diagnosing)

32. Vaginitis/cervicitis
Points in favour:
Female sex, age, recent sexual activity
Point against
No vaginal discharge

33. Pyelonephritis:
Essential to rule out in this case
Can be ruled out given the absence of fever and flank pain

34. Lab investigation for UTI
Not entirely necessary if high clinical suspicion – Can start empirical
treatment.
TMP-SMX 1 Tab BID for 3 days
Fluoroquinolones like ciprofloxacin, levofloxacin, norfloxacin
Nitrofurantoin

35. Investigations
• Urinalysis [>100,000 colonies per mL is significant bacteriuria]
• Microscopy may reveal RBCs, WBCs, casts, stones (some like struvite
may hint towards urea-splitting organisms like Proteus,
Pseudomonas]
• Urine Dipstick [Leukocyte Estrase – Specific for WBC and Nitrite –
Specific for nitrite reducing gram negatives like Proteus]
• Abdominal sonography, Urography, CT [Obstruction or calculi]
• Cystoscopy [Interstitial cystitis, urethral strictures, calculi]
• Culture

36. Method of Urine Collection
A clean-catch midstream specimen should be submitted to avoid
contamination from vaginal or penile microorganisms.
Patients should be given a 2% castile soap towelette and instructed
in appropriate specimen collection.
Men should cleanse the glans, retracting the foreskin first if
uncircumcised.
Women should cleanse the periurethral area after spreading the
labia. Identification of lactobacilli and epithelial cells from the
vagina suggest contamination.

37. Other methods of urine collection
Suprapubic aspiration
Catheter

38. Patient characteristics Most common causative microorganism(s) Laboratory tests
Uncomplicated UTI
Premenopausal, healthy female (not
pregnant)
Escherichia coli, Staphylococcus
saprophyticus, other
(Enterococcus, Proteus, Klebsiella, Citrobacte
r, etc)
Not necessary unless uncertain by history
(use urine dipstick) and/or possible STI (also
perform appropriate tests for STIs)
Complicated UTI
Pregnant female E coli, Group B Streptococcus
Urinalysis and culture; address other
modifiable factors and use prevention
strategies if able
Catheter-associated UTI
E coli, other Enterobacteriaceae
(Klebsiella, Serratia, Enterobacter, Pseudom
onas, Enterococcus,
and Proteus), Citrobacter, Acinetobacter, M
organella, gram-positive bacteria, yeast
Structural or functional urinary tract
abnormality
Immunosuppressed
Male
Elderly
Diabetic
Recent antibiotic use
Instrumentation of urinary tract
Prolonged symptoms (>7 days) at
presentation
Pyelonephritis Organisms similar to uncomplicated UTI Urine culture, blood cultures
Table 1.
Common Causative Organisms and Indicated Laboratory Tests for Patients With Uncomplicated and Complicated Urinary Tract Infections (UTIs).
Abbreviation: STI, sexually transmitted infection.

39. Asymptomatic Bacteriuria
The diagnosis of asymptomatic bacteriuria requires both:
(1)The urine is culture-positive (≥105 CFU/mL or ≥102 CFU/mL in
catheterized patients)
(2)The patient does not have symptoms or signs of a UTI
Asymptomatic bacteriuria is only treated in some groups of
patients, including those who are pregnant or undergoing urologic
procedures, as it otherwise does not correlate with symptomatic
disease or complications.

40. What is the most common organism
implicated in UTI?

41. Escherichia coli

42. Complications of UTI if left untreated
Acute kidney injury – Permanent damage and fibrosis
Renal or Perinephric abscess(es)
Struvite Stones

43. Urine is sent for investigation
How do you proceed?

44. Sterile Pyuria
Sterile pyuria is the persistent finding of white cells in the urine in
the absence of bacteria, as determined by means of aerobic
laboratory techniques (on a 5% sheep-blood agar plate and
MacConkey agar plate).

45. Can we exclude infection entirely?
Obviously, no.
Sterile pyuria can be due to infectious or non-infectious causes.

47. Management of patient with sterile pyuria
Look at other symptoms:
1. Patient with pelvic pain, urinary symptoms and urethral symptoms
2. Patient with fever, systemic symptoms, urinary symptoms, or back,
abdominal, or pelvic pain

48. Patient with pelvic pain, urinary symptoms
and urethral symptoms
Evaluate for STD, Prostatitis and PID.
If not detected, evaluate for:
Urinary stone
Foreign body
Bladder tumour
Interstitial cystitis
Schistosomiasis

49. Gonorrhea and Chlamydia
Diagnosed by Nucleic Acid Amplification Test
Treat with Ceftriaxone (250mg IM) + Azithromycin (1g orally single
dose) or Doxycline (100mg twice orally for 7 days)
Genital Herpes
Diagnosed by identification of vesicular lesions, cell culture, PCR
Treat with Acyclovir 400mg orally 3 times a day (7-10 days) or
Valcyclovir (1g orally twice a day for 7 days)

51. Patient with fever, systemic symptoms, urinary
symptoms, or back, abdominal, or pelvic pain
Reassess for bacterial infection by means of aerobic and anaerobic
culture
If bacteria detected – Treat
Otherwise,
Evaluate for genitourinary tuberculosis and fungal infections (candida,
aspergillus, cryptococcus, blastomycosis, coccidiomycosis,
histoplasmosis) – More likely in immunocompromised individuals

52. Genitourinary TB
Investigations
CB-NAAT
Urine culture
PCR Assay
CT-urography
Intravenous pyelography
Management
First line drug therapy for 3-6 months based or Rif resistance
Rifampicin + Isoniazid + Pyrazinamide + Ethambutol

53. Fungal infections
Coexisting conditions like DM, Immunosuppression, AIDS, etc
Microscopic examination of fungus is done and fungal cultures are
taken along with biopsy from bladder and prostate
Treatment are antifungals – Fluconazole, Posaconazole, echinocandins,
amphotericin-B.
For schistosomiasis – Praziquantel
For Trichomoniasis – Metronidazole/Tinidazole