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S2D: The Symptom to Diagnosis Podcast - Episode 19: Dysuria
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S2D: The Symptom to Diagnosis Podcast - Episode 19: Dysuria
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Language: EN.
Segment:0 .
[upbeat intro music] [upbeat intro music] [upbeat intro music]
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we're here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. We begin each episode with a case unknown to one of us, we then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand, we then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences, but, because protecting patient privacy is part of our oath, we never discuss actual patients, and most cases are composites. What are we talking about today, Scott?
DR. STERN: Today is dysuria, which actually means we'll talk a little bit about STDs, not to be confused with S2D, I just thought I'd point that out.
DR. CIFU: Interesting, though we call them STIs now.
DR. STERN: Oh, sorry, STIs, thank God.
DR. CIFU: Anyway, dysuria--
DR. STERN: [chuckles]
DR. CIFU: --sounds like an uncomfortable topic.
DR. STERN: It is.
DR. CIFU: Okay, do you have a case to present to me?
DR. STERN: I do, as a matter of fact, are you ready?
DR. CIFU: I am.
DR. STERN: Okay, 67-year-old man comes in with the chief complaints of some dysuria over the last four to five days, he notes even more dysuria-- -more than the dysuria is that he is voiding more often, and he doesn't know if he's had a fever, but he's felt warm the last couple of nights, he didn't take his temperature. His past medical history is pretty unremarkable, he's got hypertension, and his social history is that he's married and his only sexual contacts are with his wife.
DR. STERN: His medications include amlodipine.
DR. CIFU: Okay.
DR. STERN: So what would you like to know?
DR. CIFU: So, I think you're probably going to say no to all these things, but it sounds like no nausea, vomiting?
DR. STERN: Correct.
DR. CIFU: No back pain that he's complaining of?
DR. STERN: No back pain.
DR. CIFU: And he's pretty much, you know, normal with it when you're seeing him, doesn't look terribly sick.
DR. STERN: Right, yeah, totally.
DR. CIFU: Okay, and going back in time at 67, BPH symptoms, does he have problems with nocturia, hesitancy?
DR. STERN: Yeah he gets up like maybe once or twice a night for the last several years, more in the last four to five days, but that's kind of standard.
DR. CIFU: Okay, okay.
DR. CIFU: Urine stream not like what it was when he was 18?
DR. STERN: No, definitely not like what it was when he was 18.
DR. CIFU: [chuckles] Okay. You know, I think what we're going to have to work on in this podcast is to make dysuria seem interesting and not as straightforward as it often is. Certainly, older men presenting with some dysuria and maybe worsening LUTS, lower urinary tract symptoms, top of my differential would be cystitis, shockingly. And you know, young men very unusual for them to get UTIs, urinary tract infections, certainly as we get older and we don't do as good of a job emptying our bladder, that gets to be more common, and at some point you stop even working up why did he get it because you just assume it's BPH.
DR. CIFU: The four to five days and the fever, or whatever, febrileness, feverishness, make me maybe a little more concerned that it's something more than just a UTI, and the next thing that would come to my mind would be prostatitis, which I'm not sure it's a must-not-miss-diagnosis but it's kind of a must-not-miss-diagnosis, right? You don't want to leave that untreated, you don't want to leave any of this really untreated, but so I'd certainly be thinking about that, and my evaluation of this guy would include a prostate exam.
DR. CIFU: Really does not sound like he's got pyelonephritis, but I'd make sure that when I was examining him I'd whack on his costovertebral angles to make sure he's not real tender. Boy, you know, I guess I'd maybe ask more of a sexual history to make sure that this wasn't an STI, right? People can get STIs at any age, but it sounds like that's probably unlikely.
DR. CIFU: So it's not a terribly broad differential, but that's I think how I'd be starting out.
DR. STERN: Yeah, it sounds pretty good. I did have an 80-year-old patient once who came in with the clap much to my surprise, he could barely walk, but apparently sex was still on the game. All right, so you want to hear about his physical exam?
DR. CIFU: I do.
DR. STERN: All right, so, his temperature was 38, his blood pressure was 135/87, his pulse was 86, his respiratory rate was 16, you know, not shockingly, his cardiac and respiratory exams were unremarkable, his belly was soft, he did not have costovertebral angle tenderness, and on prostate exam he was exquisitely tender.
DR. CIFU: Yeah, there you go. So, I think at this point I would send him for a UA, So, I think at this point I would send him for a UA, I would actually do a urine culture because I think I'm going to be treating him for prostatitis, which is going to be a long course of antibiotics, you know, probably a month's worth, and I'd want to make sure that I was treating him for the right thing while I'm treating him. I think these days we still start with fluoroquinolones for prostatitis, though we've sort of given those up because of, I think mostly because of adverse effects, for just plain old urinary tract infections, but I think they're still first-line for prostatitis, and then I'd kind of follow him closely to make sure he's getting better, and follow up on that culture to make sure I'm treating with the right thing.
DR. STERN: Good, all right, so we'll come back to him at the end then, what do you say?
DR. CIFU: Okay. So let's move on to the five key points, and I'd like to hear about five key points for diagnosing the cause of dysuria.
DR. STERN: [chuckles] Well, it's a little bit of a stretch to find five key points, but I think I've done it.
DR. CIFU: Good.
DR. STERN: The first is fairly obvious, and that's dysuria like so many of the other symptoms we've talked about, is almost always infectious, and it's usually one of several categories. It's either cystitis, pyelonephritis, prostatitis, an STD of some sort, or vaginitis.
DR. CIFU: I got nothing to say about that. I think it's true, I mean, when I think about other causes of dysuria, when I think about other causes of dysuria, often the cause is clear, you know, it's someone who's got a history of say, urethral stenosis, or just had cystoscopy, or is passing a stone and it's in their urethra, or it's just come out of their urethra, yeah, for the most part things that have irritated the urinary tract distally are infectious.
DR. STERN: Well, I mean, it's funny, it's one of the few things that's relatively straightforward from that point. So point two is actually, this might be the only time in the podcast where we're going to say we can make diagnoses often without any testing, and that is that cystitis, by far and away is the most common diagnosis, and it's often made just clinically. A woman comes in, a young woman who's sexually active comes in with classic urinary symptoms of frequency, and burning when she urinates, and often we'll make that diagnosis clinically, and even on the phone.
DR. STERN: And the reason we do that is, one, it turns out that those patients, those women, if they don't have vaginitis, if they don't have vaginal discharge, 90% of the time it's actually cystitis, and the UA is, shockingly enough, not sensitive enough to rule it out, probably that's in part because women have learned to drink a lot of water when they have cystitis, so you dilute out all the white cells and the bacteria that you're dipping for when you dip it.
DR. STERN: And actually the negative likelihood ratio of a negative leukocyte esterase and negative nitrate is only 0.3, so with that high of a pre-test probability, it kind of leaves you to say, "Okay, you've got classic symptoms, I'm going to go ahead and treat you."
DR. CIFU: So are you, ultra conservative, ultra risk averse Dr. Stern saying that we can do fewer tests?
DR. STERN: [chuckles] In this one case I'm going to go with that, but you may have trouble finding that in another podcast.
DR. CIFU: I did a little math here just to sort of highlight what you've just said, and it's really striking, I love sort of fiddling with test characteristics, you know, pre-test and post-test probabilities on occasion to kind of demonstrate the reality of what you just said, and so, if you have that woman, who's got as you said, dysuria, urinary frequency but without vaginal discharge, so someone you'd say, "I think this person has a UTI," you said they have a likelihood of 90%, okay, which is what I found too as far as kind of pre-test probability, prevalence, whatever.
DR. CIFU: And so, if you do a UA on that person, which has negative leuks and negative nitrites with that negative likelihood ratio of 0.3, that means your post-test probability after that is 73%, so still basically three out of four that person has a UTI despite that negative dip, so really the answer is don't even do the test.
DR. STERN: Just treat them.
DR. CIFU: Just treat them.
DR. STERN: [chuckles] Having said that though, point three is you need to know when to take pause, and so one of the things you always have to think about, is there any chance of this is pyelonephritis, because pyelonephritis requires different treatment, often intravenous, often for a longer course, so when should you think about that? Well, you should think about that, of course, if they have CVA tenderness, if they have rigors or they have fever.
DR. STERN: It turns out that 93% of people with pyelonephritis have fever, and fever is very uncommon with cystitis, so if you see fever, you need to step back and say, "Boy, I'm going to treat and evaluate this as though they have pyelonephritis," but be careful. You know, the converse is not true, and what I mean by that is, most people who have pyelonephritis also have lower urinary tract symptoms, because the pathophysiology of pyelonephritis is usually an ascending infection, that is, it started in the bladder and then moved up the ureters, and then went into the kidney, so often these patients have had multiple days of lower urinary tract symptoms, then got febrile, then had back pain.
DR. STERN: So, if you have any of those things, fever, back pain, et cetera, boy, you should move on and think about pyelo.
DR. CIFU: I think those are great points. You know, on the one hand it's not hard especially on the phone, to ask those extra questions, you know, "Do you have fever, do you have back pain?" I've actually had people actually do their own CVA tenderness, you know--
DR. STERN: [chuckles]
DR. CIFU: --which is kind of easy,
DR. CIFU: and if I hear them jump or go "whoa" when they do it, I know I should assess them more. And then it is true, actually I have to say I didn't really know or haven't really thought about the fact that most people with pyelo have urinary tract symptoms, but it is true, you know, there's some minority I guess who don't, and so, I think we get in the habit of sometimes, thinking of, maybe it sounds like it's my mistake, of thinking about pyelo not having urinary tract symptoms, but of course they do, right?
DR. CIFU: And so you just shouldn't be confused by that.
DR. STERN: Right, totally.
DR. CIFU: Okay, number four.
DR. STERN: Well, this is really one of the few pivotal points in dysuria, which is really you have to separate out women that have a vaginal discharge and some form of vaginitis from women that have cystitis, and some form of vaginitis from women that have cystitis, and it turns out if women have a vaginal discharge, the likelihood ratio for cystitis drops to 0.2, so now the differential is really completely different, and it includes STDs including chlamydia, GC, trichomoniasis, includes bacterial vaginosis, candidiasis, and atrophic vaginitis, so the workup is totally different.
DR. CIFU: Right.
DR. STERN: And typically the workup includes a pelvic exam and a wet prep of the vaginal discharge, and there's a variety of things you can look for, I'll just list them quickly because they're so exciting, you can do a positive whiff test for bacterial vaginosis which smells like fish, a curd-like discharge really suggests candida vaginitis. You can do a wet prep looking for clue cells which are lots of bacteria around the white cells which can be seen in bacterial vaginitis, or motile trichomonads and trichomoniasis, a KOH prep can help show budding yeast or mycelia, you can also do a nucleic acid amplification test for trichomoniasis, and finally for GC and chlamydia, of course you can do a urine test, and it turns out that urine tests and cervical cultures have all about the same likelihood ratio, so any of those is completely fine.
DR. STERN: If you are worried about discharge, the last thing we say is you do have to check for cervical motion tenderness, because PID is in this differential, and that's a really much more serious illness that you can't overlook.
DR. CIFU: That was kind of boring.
DR. STERN: Sorry.
DR. CIFU: [chuckles] One thing I want--
DR. STERN: That wasn't very nice, I mean, what am I supposed to do? It's a list of things!
DR. CIFU: [chuckles] No, it got across the information, I wasn't saying it was bad, it was just a little dull to listen to. One thing that maybe I'll throw out here which I think you'll be very interested in, we talked back when we did dyspnea, we talked about that Schwartzstein paper, where they worked on figuring out if different types of dyspnea actually felt different.
DR. STERN: Right.
DR. CIFU: Wouldn't it be interesting to do a study to see in women, if dysuria from cystitis actually felt different from dysuria from bacterial vaginosis, I would expect it does.
DR. STERN: I think you should start that study right away, I will be happy to send all my patients with this complaint to you and you can sort it, how's that?
DR. CIFU: Okay. Number five, I hope this is not a boring lesson.
DR. STERN: This is much briefer,
DR. STERN: which is that in men who have a penile discharge, of course that's also a different animal and you have to think about STDs, GC, and chlamydia in particular.
DR. CIFU: All right. I should have mentioned as you say that when you think about the case, you know, when you're thinking about prostatitis in older men who tend to have less risky sexual behavior, let's say, overwhelmingly, what you're going to find is, you know, Gram-negatives, the same things that cause cystitis, in younger men with maybe higher risk, there's a more diverse array of organisms that could cause their prostatitis.
DR. STERN: Right, exactly, sure. And in the old days when we had Gram stain material in the clinics before Clio weighed in and said that was a bad idea, you could actually Gram stain these and see Gram-negative diplococci. [Dr. Cidu] Right, but then you'd get blue stains on your white coat.
DR. STERN: You might but that would show you're a real doctor.
DR. CIFU: Okay, let's finish up the case, you got anything else to tell me?
DR. STERN: Yeah, so he had a urinalysis done and that was negative, and he was treated on long course of antibiotics and he got better, so, what is your interpretation of all that?
DR. CIFU: I think he had prostatitis and I think you got him better. Did you check a PSA on that visit just for kicks?
DR. STERN: No, that would have been a mistake as you know. So just to make that point, prostate cancer almost never causes dysuria, and anything that inflames the prostate can raise the PSA, so if you made the mistake of getting a PSA in a patient like this, you're often going to find it's very high, very elevated, it's very non-specific, that'd be a mistake, and you should definitely repeat it in one to two months.
DR. CIFU: The converse of that is if you are following a PSA on someone, and you've gotten, I don't know, in 2018 their PSA was 2.0, in 2020 it was 2.4, and in 2021 it's 97.8, they probably have prostatitis rather than prostate cancer.
DR. STERN: It's true, you and I have talked about that before and when we see giant jumps in the PSA that are very quick, we often think that it's infectious, many of those people are better, you just repeat it, but don't lose track of it, if you do that, you better make sure you repeat it.
DR. CIFU: Right, right. Okay, so now we're going to move on to fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge, Scott, why don't you start us off?
DR. STERN: Well, you were asking about whether or not the dysuria complaint could be helpful diagnostically, and I didn't find that, but what I did find is, curd-like discharge on a vaginal exam has a likelihood ratio of 130 for yeast infection, so if I have a woman who complains about that, fine, I'm just frankly treating her, I have to say.
DR. CIFU: That's a serious likelihood ratio. Mine is pretty good but not quite as high, so, the whiff test which is smelling the discharge, and if it smells fishy or an amine scent is how it's also described, whatever the hell that means, has a likelihood ratio as high as 22, and I think the "as high" is that you need to have been taught what the smell is so you can actually know it, and that's for bacterial vaginosis if I didn't say that.
DR. STERN: Great, and the last one I have isn't really a physical finding, but it's worth pointing out that if you did do a UA and the leukocyte esterase is positive, it has a likelihood ratio of anywhere from 12 to 48 for cystitis.
DR. CIFU: So, leuks negative, not terribly helpful, leuks positive, quite helpful.
DR. STERN: But I'd be careful, again, if they have vaginitis, of course it's a different animal, right?
DR. CIFU: Absolutely, absolutely. Okay, common misconceptions?
DR. STERN: Yeah, the urine nitrate is not as specific as people would think, likely due to secondary vaginal contamination by bacteria, and the likelihood ratios are only anywhere from 3 to 30. Similarly, actually the UAs will often report out whether or not they see bacteria but to those of us who have actually looked at UAs in the old days, bacteria on a non-stained specimen is a dot that's floating around, I don't believe that that has very much diagnostic value either.
DR. CIFU: I'm with you, I'm with you. I think my misconception is the prostate massage, this was something that people were talking about when I was in medical school decades ago, and that's something that should be a thing of the past. You know, in someone who has prostatitis, massaging their prostate is basically cruel and unusual punishment, it may also, you know, there are at least reports of that you're basically squeezing out endotoxin, you might make the person worse, and you really do not need an aggressive prostate massage to get a positive UA, or to get culture results, there's no evidence that that increases the yield, and the whole idea that I'm going to do a UA before and after prostate massage, I mean, that's just craziness I think before we had modern microbiological techniques.
DR. STERN: But it's worth pointing out just to emphasize, you did do the prostatic exam, so you're distinguishing the prostatic exam from prostatic massage, you need the prostate exam to make the diagnosis.
DR. CIFU: Absolutely.
DR. STERN: The other trick to this trade I find on the prostate exam is, obviously a lot of men are uncomfortable when you do a rectal examination, so the way I do this is very specific, which is I tell the man what I'm going to do, "I'm going to insert a gloved finger in your rectum, you're going to feel uncomfortable, and then I'm going to wait a second, and then I want you to tell me when I actually push on the prostate if that hurts," so that I can distinguish the general discomfort from a rectal exam from whether the prostate's inflamed.
DR. CIFU: Sounds good.
DR. STERN: Okay, so my last common misconception is, the UA is not as diagnostic on prostatitis as you might hope, that's actually the truth is what I'm saying, the UA is not often diagnostic, because the prostate isn't meant to communicate with the urethra except during ejaculation.
DR. CIFU: Right.
DR. STERN: And so men can have a negative UA during prostatitis, and it does not rule out the diagnosis.
DR. CIFU: Right, absolutely. I have a pet peeve--
DR. STERN: Go ahead.
DR. CIFU: --I'll throw out.
DR. STERN: It's not surprising, actually.
DR. CIFU: My pet peeve is when people sort of do everything they can to avoid doing a pelvic exam. You know, a lot of the things we do in the office are not terribly pleasant for both doctor and patient, we don't do them because they're pleasant, we do them because they're useful. And so there are times that you absolutely do not need a pelvic exam, you know, we gave those ridiculous likelihood ratios for curd-like discharge for yeast infection, and the whiff test for bacterial vaginosis, if you get a history and the person says, "I think I have a candidal yeast infection," and tells you they have curd-like discharge, you should just treat that.
DR. CIFU: But if you treat it and then they call you a week later and they say, "I still have vaginal discharge," the right thing to do is to have that person come in, do the pelvic exam, actually assess them and figure out what you're treating, because you don't want to give another course of Diflucan when actually what they need is treatment for chlamydia.
DR. STERN: Absolutely, agreed.
DR. CIFU: Period.
DR. STERN: All right, pearls.
DR. STERN: Should we go on to pearls? I'm going to start.
DR. CIFU: Go.
DR. STERN: So the first pearl
DR. STERN: I think is pretty obvious, but any patient who has an STI, also needs to be evaluated for syphilis and HIV, and the test of choice for syphilis is usually not an RPR, because the RPR can be negative in both early syphilis, in patients who have very high titers, and also in latent syphilis, so, typically we start with a treponemal test rather than a non-treponemal test.
DR. CIFU: That's actually flipped back and forth over the course of our career.
DR. STERN: It has, but this is where it started out for me, and this is where we are today again.
DR. CIFU: Aren't you smart--
DR. STERN: I don't know if you were trained somewhere in that interim period where they didn't know how they were training physicians.
DR. CIFU: So, yes, if someone has an STI you should check them for chlamydia, gonorrhea, HIV, RPR, you should check them for chlamydia, gonorrhea, HIV, RPR, do you know what you should not test them for?
DR. STERN: Tell me.
DR. CIFU: You should not test them for HSV antibodies, that drives me crazy.
DR. STERN: Right. Why do that?
DR. CIFU: Why do that? You know, most human beings have antibodies to HSV-1 or 2, You know, most human beings have antibodies to HSV-1 or 2, if they don't have symptoms, you're just creating a stressful conversation, it makes me nuts.
DR. STERN: Yeah, I've never done that, I've resisted. Even I've resisted, so we should have a term for when Scott doesn't want to do a test.
DR. CIFU: [chuckles] Wrong. [both chuckle]
DR. CIFU: Okay.
DR. STERN: You have a pearl?
DR. CIFU: I have a pearl, this is a shocking one. When you have someone with dysuria, you know, we've joked around a lot that dysuria is generally very simple, but you should take a complete history, because you can learn a lot from associated symptoms, right? Ask about vaginal symptoms, discharge, dyspareunia, ask about prostate symptoms, you know, our case today had hesitancy. Perineal pain is another thing that people will tell you about, certainly ask about systemic symptoms.
DR. CIFU: You know, our guy had, what? Some night sweats?
DR. STERN: Felt warm. Yeah.
DR. CIFU: Yeah, some sort of febrile symptoms, ask about those because those may really turn up something interesting that you say, "Wow, I really thought this is cystitis, but there may be a little bit more going on and I should look into it before I just give three days of Bactrim."
DR. STERN: Right, right. Imagine that, you wanted to take a history!
DR. CIFU: [chuckles] Yeah.
DR. STERN: Now you sound like the old timer.
DR. CIFU: I've got history, I've got pelvic exam, I'm going crazy.
DR. STERN: Man, man, man.
DR. STERN: All right, so mine is an unusual pearl, but if you should see it, I want you to be aware of it which is, you have to really worry if somebody has a staph aureus UTI. I did see this one time and I was caught off guard, most pyelonephritis is due to an ascending infection, and those are almost always Gram-negatives, if you get somebody who has pyelonephritis with staph aureus, its likely cause was it was hematogenous and went from somewhere else to the kidney, rather than our standard ascending infection, and then you need to find out where it came from.
DR. STERN: Did they have endocarditis and they were seeding their kidney, did they have osteomyelitis and they were seeding their kidney? Something else is going on, and it shouldn't just be said, "Oh, it's pyelonephritis due to staph aureus."
DR. CIFU: Yeah, this is another piece of data that I have never been able to find, I would love to know, of people with endocarditis, what percent have completely clean urinalysis? Because I bet it's very low. You know, it may be from actual bacterial seeding of the kidneys, where you're seeing white cells, or you're actually seeing staph in the urine, or it might be glomerulonephritis from complement deposition or whatever.
DR. CIFU: I think it's my anecdotal clinical experiences that people with at least acute bacterial endocarditis and probably subacute bacterial endocarditis as well, have something active in their urinary sediment.
DR. STERN: I think that's true. Where I got burned was a patient who came in who had back pain and fever, and the first diagnosis that came to mind was pyelo, and then she grew staph aureus, and we didn't initially look to see where else it was coming from, and she had a serious infection elsewhere.
DR. CIFU: Interesting, so she grew staph aureus from the urine and then it was only later that--
DR. STERN: Right, exactly, and so that's the clue, if you see that scenario, you should really think again.
DR. CIFU: That's a good one, and if you haven't done blood cultures, you've probably have started the person on antibiotics for their pyelo, you might not get positive blood cultures.
DR. STERN: You might not, although you might because it's staph and you're not covering staph.
DR. CIFU: Yeah, yeah, true.
DR. STERN: Your turn, pearl.
DR. CIFU: Pearl, so elderly patients may present atypically with a UTI, I think that's not really a surprise to any of us, but I've certainly-- you know, it mostly comes from families who get so aware of this because a grandmother or an elderly spouse ends up in the hospital once with urosepsis and is confused or delirious, and then the person will be just a little bit off at home, and they'll call you and they'll say, "We're worried she has a UTI," and I'm always very impressed with the insight into that, and it's true, very often will not present with dysuria or frequency but something else.
DR. STERN: I mean, elderly patients in general, they just so often present atypically, right?
DR. CIFU: Yeah, yeah.
DR. STERN: Well, we've got so many pearls here it's like a strand. But anyway my next one is-- [chuckles] -we've already alluded to this, that women with a self-reported history of curd-like discharge should really be treated for yeast infections, and reevaluated if they don't get better.
DR. CIFU: Okay. Pyelo.
DR. STERN: Go ahead.
DR. CIFU: So, you already mentioned treatment of pyelo, treatment of pyelo, longer course of antibiotics, very often, even if you're not admitting the person, a first dose of intravenous antibiotics before oral antibiotics, if people are sick, if people are not trustworthy, those are people you're going to admit to the hospital for treatment. The other sort of subgroup of pyelonephritis patients which require more than antibiotics, are people who have pyelonephritis and a stone, and you might find that out because the person's presenting with more stone symptoms, but ends up being febrile with white cells in their urine, it might be that that person has pyelo but also has a lot of blood, and then you image them and you find out that they have a stone.
DR. CIFU: So, any person - I always call it pus under pressure - who has an infection that's not able to drain by itself, so that might be pyelonephritis, it might be ascending cholangitis of a gallstone, it might be just a plain old abscess somewhere, antibiotics are not enough, you have to release the pressure. And so in those people they generally need say, stenting of the ureter, get that stone out of there, let the pus run out, continue the antibiotic treatment, get them better.
DR. STERN: Which actually gets to a question that's coming clinically which is, how often and when you image someone who has pyelonephritis? So, being the nervous Nellie that I am I tend to have a low threshold, but I think the standard recommendations are if they don't look septic is to give them 48 hours on systemic therapy, and if they're not improving, to image them, what's your approach?
DR. CIFU: Just that, if they're getting better, you don't need to do it, unless there's suspicion, unless there's a history that sounds like, "It sounds more like a stone than pyelo," right, because for the most part, you don't see pyelo and a stone, you see pyelo or you see a stone.
DR. STERN: True, absolutely.
DR. CIFU: And there's really interesting debate, which I sort of love the progression of this about imaging for stones, because you know, you and I grew up in a time, that if someone came in with really good symptoms of a kidney stone and had blood in their urine, you were done, that's your diagnosis, and then we got crazy about CTs being so good for diagnosing stones that everybody gets CTs now, which you don't need.
DR. CIFU: And there was a terrific New England Journal article a few years ago, took place in the emergency room, and instead of trying to just overcome people's desire to image and just say, "You don't have to image," what they did is they actually randomized people to a CT or to an ultrasound, okay? Now, an ultrasound's not a great test for a stone, right? You may see obstruction, hydronephrosis, but it's hard to see a stone in the urine--
DR. STERN: Right, for sure.
DR. CIFU: --with an ultrasound,
DR. CIFU: but so sort of what he was was doing is, say we're going to randomize these people to a not so good test, it's probably not really doing anything, but at least it doesn't cost a lot have radiation, give contrast, and then they follow those people out to just see was there a difference in outcome, and there was no difference in outcome.
DR. STERN: So you have a young person who comes in with severe flank pain, and if they have blood then you're not imaging them?
DR. CIFU: I'm not, I'm giving them Flomax, I'm telling him to push fluids, and I'm telling him to call me in a few days.
DR. STERN: Okay, well. Huh. That's all I have to say, you know me, I'm going to image them, I need to know.
DR. CIFU: That's nuts, that's nuts, you know what they have! Right? And they're going to pass their stone by themselves, and the only thing that you would find which would make you act faster, was if they had like a huge stone that wasn't going anywhere, but they're still not going to have that out for a few days.
DR. STERN: Okay.
DR. CIFU: You, Dr. Stern are trying to break the American healthcare system. [chuckles]
DR. STERN: I am, I am, single-handedly. I am. Okay, my last pearl is, we've been talking about UTIs like for the most part benign, but you have to remember that urosepsis actually accounts for 25% of all cases of sepsis. So you have to really listen to that history, and you should think about urosepsis in any patient who has urinary tract symptoms with any of the following, high fevers, frankly shaking chills, there's some data that's from old literature that suggested that a third of people who rigor, that is physically shake, have bacteremia, hypotension, and in the elderly of course obtundation or metabolic acidosis.
DR. CIFU: That's a terrific point, it's one of those things that you get very comfortable with, but you have to recognize that things can go badly, and we've all seen people just do terribly, and get incredibly sick incredibly fast with urosepsis. I've heard you quote that rigoring data before, I love that, and I think it lines up nicely with clinical experience.
DR. STERN: Since I get afraid when I see somebody rigor, I just saw someone today who was rigoring, it scares me to death.
DR. CIFU: Yeah. The only time I've ever truly had rigor since I've been like a grownup, was a time I had a community-acquired pneumonia, and all the other times I've had fevers, whatever, I felt terrible, but you know--
DR. STERN: I had it with campylobacter.
DR. CIFU: Yeah.
DR. STERN: There you go.
DR. STERN: That's the end of our personal medical history for today. [both chuckle]
DR. CIFU: I'm going to throw out one more just about urine cultures, we've talked about young women with UTIs, never culture those people, often you don't even get a UA, on the other hand, if you have someone, a man with cystitis, a woman with complicated or recurrent infections, you should get cultures on that person, because you want to know what you're treating, you want to know that you're treating it appropriately, and you kind of want the data in case that person gets another infection to say, you know, is this, what's the terminology?
DR. CIFU: Is this recurrent or is this untreated--
DR. STERN: Complicated?
DR. CIFU: Yeah, okay. Okay, well, we hope you found this episode of S2D, the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our book Symptom to Diagnosis: An Evidence-Based Guide takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places, on your mobile device, and also available and fully searchable via the Access Medicine website available worldwide from McGraw Hill.
DR. CIFU: The music for the S2D podcast is courtesy of Dr. Maylyn Martinez.
DR. STERN: Thank you. [upbeat outro music] [upbeat outro music]