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Urinary Tract Infection, Women: Stephen Bent, MD, discusses the clinical examination for urinary tract infections in women.
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Urinary Tract Infection, Women: Stephen Bent, MD, discusses the clinical examination for urinary tract infections in women.
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Upload Date:
2022-02-28T00:00:00.0000000
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News & Perspectives section. Today, this JAMAevidence podcast will focus on a condition that affects millions of people each year, especially women, mainly urinary tract infections. Our guest expert is Dr. Stephen Bent. Dr. Bent, why don't you introduce yourself to our listeners? >> Thank you, Joan. My name is Steve Bent and I'm an Assistant Professor of Medicine at the University of California San Francisco. And I split my time between clinical practice and conducting clinical research.
>> What do we know about the prevalence of urinary tract infections in adult women, and are there important demographic characteristics? >> Yes, there are. Probably the most important thing to know is that urinary tract infections are very common, and they affect many millions of women each year in the United States. You can really think about two groups. They're most common in young, sexually active women. And in this group, approximately half of women each year have a urinary tract infection. They're somewhat less common in post-menopausal women where approximately one in ten or about 10% have a urinary tract infection each year.
>> Which symptoms increase the diagnostic probability of urinary tract infections in women? >> Well, I think it's first important to note that the probability of urinary tract infection is very high in someone who presents for an evaluation for urinary tract infection. So if you take all women who come to be seen for a possible urinary tract infection, about half or 50% will have a true urinary tract infection. And then, among the group that present for an evaluation, there are really four important symptoms to remember.
And those are dysuria or painful urination, frequency, and hematuria. Those all increase the likelihood of urinary tract infection. And then the fourth one is the absence of vaginal discharge because if a woman is reporting vaginal discharge, that suggests that they have a sexually transmitted disease and not a urinary tract infection. So those are really the four important ones to remember. >> Which history and physical examination findings are helpful when diagnosing UTIs? >> Well, the physical exam is not particularly informative.
The main things to remember about that are that, if a woman reports vaginal discharge, then the finding of vaginal discharge on pelvic exam suggests that it's not a urinary tract infection. And then the other is costovertebral angle tenderness. So if a woman is having back pain with palpation, that suggests there may be upper tract involvement and the woman may be having pyelonephritis, which is a more serious condition. But if you look at the overall, the most important clinical features to remember about urinary tract infection are, first, that the probability is very high in women who present for an evaluation.
That if they have dysuria, frequency, and hematuria, those all modestly increase the chances of urinary tract infection. And then if they also report no vaginal discharge, that substantially increases the chance of a urinary tract infection. If you combine all those symptoms, so if a woman who comes in and says that they have dysuria and frequency, but not vaginal discharge, their likelihood of an infection is about 90%. So you can really make a very clear diagnosis just from those symptoms and historical findings.
>> You mentioned that discharge indicates that it's not. Are there other findings that don't point you in that direction? >> That decrease the likelihood of infection? >> Yes. >> That's a very good question. And the history of symptoms and the physical exam are actually useful for ruling in infection, but it's actually harder to rule out infection in a woman who presents with typical symptoms. Because remember that the probability of infection is 50%, so to lower someone's probability of not having a UTI, you really have to perform a urine culture to be confident that they don't have a urinary tract infection.
>> How accurate are self-diagnoses? >> That's a really interesting question. It's actually only been addressed by one study, but in that study, it was a very powerful predictor of urinary tract infection. So if you could only ask one question, this would really be the question to ask, and that is, have you ever had a urinary tract infection before and does this feel like your prior urinary tract infection? And if a woman says yes, if they've had the infection before, then their chances of having an infection if they say they have one now is about 80%.
So as we sort of clinically suspect, women have a very good sense of knowing what their prior infections were like and, if they say they have one now, there's a very good chance that they do, indeed, have another urinary tract infection. >> Dr. Bent, would you please describe for our listeners the reference standard test for UTIs? >> The dipstick test is commonly used in office settings, but this is not a true reference standard test. It's a test that's convenient that can be done in the office. And when it's positive it strongly suggests urinary tract infection, but it doesn't have perfect sensitivity or specificity.
It's not particularly good at ruling out infection in a woman with typical symptoms. The true reference or gold standard test is the urine culture, which is easy to perform but the downside is the results aren't available for anywhere from one to several days. So usually, you have to make a treatment decision prior to the results of the reference standard test, the culture. >> Is there anything else that JAMAevidence users should know about UTIs? >> Yeah, I think that really the take home message is that clinicians can think about two groups of patients who present for an evaluation of urinary tract infection.
The first would be otherwise healthy young women who present with relatively typical signs and symptoms of urinary tract infections. So frequency and dysuria with no vaginal discharge. These women have a very high probability of urinary tract infection and can probably be treated empirically. The second group would be women who do not meet this first category and that includes women that have any complicated features, so things like pregnancy, other significant diseases like diabetes, or a prior history of pyelonephritis.
Or women who have signs and symptoms that suggest that some other disease might be present, such as vaginal discharge or if they have back pain or fever. And then this second group, because it's not as likely that they have urinary tract infection, they really need a more thorough evaluation with a full physical exam, possibly a pelvic exam, and also urine culture to really formally establish a diagnosis. >> Thank you, Dr. Bent, for this overview of urinary tract infections. And for more information, JAMAevidence subscribers can consult Dr. Bent's article on "Making the Diagnosis of UTIs in Women" which was originally published in the Rational Clinical Examination.
This has been Joan Stephenson of JAMA interviewing Dr. Stephen Bent about urinary tract infections for JAMAevidence.
