Bacteriuria vs Urinary Tract Infection
Bacteriuria is defined as bacteria in the urine in a patient who is asymptomatic, whereas symptomatic bacteria in the urine is termed urinary tract infection. Bacteriuria is not usually treated unless the patient is pregnant, immunocompromised or scheduled to undergo a genitourinary procedure, whereas urinary tract are treated with antibiotics.
History
Additional history that would be beneficial for the assessment would include last pelvic exam, and any history of change in color, consistency or volume of vaginal secretions. Medications that the patient is currently taking to assess if any of the medications are immunosuppressive medications in addition to the patient history of menstruation, menstrual frequency or menopause, Postmenopausal women may be at higher risk for colonization due to a loss of an acidic vaginal pH. (Crader, M. F. 2020). Past medical history of renal calculi as they can colonize with bacteria, history of frequency of daily urination to assess and history of tobacco use to assess for bladder cancer risk and process used for urine sample to verify clean catch. Additionally personal hygiene habits such as use and frequency of use of feminine napkins, use of feminine hygiene products such as douche that can change the pH of the vagina and inquiry about personal practices of use of sexual lubricants and after intercourse.
Diagnostic Studies
Verifying that the urine specimen has an order for culture would be the first diagnostic study; a culture of the bacteria detected will help guide potential treatment options, additional tests to add on to the urine sample would be urine cytology to screen for bladder cancer if there is a strong history of tobacco use. Vaginal exam with vaginal and urethral smears and culture given the reports of recent marriage and thus new sexual partner to test for STDs. Ultrasound can be useful to assess for abscess or suspected renal calculi in the bladder or urethra.
References
Crader, M. F. (2020, November 19). Bacteruria – StatPearls – NCBI Bookshelf. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482276/
Merck Manuals. (2020c). Bacterial Urinary Tract Infections. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/genitourinary-disorders/urinary-tract-infections-utis/bacterial-urinary-tract-infections?query=Asymptomatic%20Bacteriuria
Case #2: 23-year-old woman
Differential Diagnosis
Possible inflammatory causes for 23-year-old woman reoccurring symptoms could be urethritis, sexually transmitted infections, and vaginitis. Urethritis is inflammation of the urethra that is commonly caused by bacterial or viral source, the most common bacteria for urethritis N. gonorrhoeae, C. trachomatis and Mycoplasma genitalium, and viral causes are commonly HPV, HSV and CMV. Sexually transmitted infections that cause the symptoms include Gonorrhea, Chlamydia, Trichomoniasis and Herpies simplex, given the information that the recurrent infections started after marriage there is possibility of STI due to introduction of a new sexual partner and previous treatment for acute cystitis may have helped with the infection but subsequent sexual encounters reintroduced the infectious agent. Vaginitis is a bacterial infection with symptoms of discharge, odor irritation and itching that can also cause dysuria. The most common causes of vaginosis include candidiasis, and trichomoniasis.
Possible non-inflammatory causes for 23 year old womans reoccurring symptoms include non-inflammatory causes could be urethral anatomic abnormalities, local trauma, and endometriosis. Urethral anatomical abnormalities such as strictures or diverticulum can cause reflux of urine and recurrent urinary infections, however most common anatomical abnormalities are present at birth and this is usually diagnosed in childhood in patients with a family history or urethral anatomical abnormalities. Local trauma such as genitourinary instrumentation or surgery, pelvic irradiation, foreign body presence, horseback or bicycle riding Michels, T., & Sands, J. (2015). Endometriosis of the bladder can cause acute flank pain, microscopic hematuria, dysuria, increased frequency, and urgency when the endometrial tissue grows within the bladder wall. Bladder endometriosis is extremely rate, with an occurrence rate of 1-2% of women who have endometriosis.
Diagnostic Tests
Urine culture and sensitivity could help determine if there is a bacterial cause of the recurrent dysuria if it is of a infectious nature. A pelvic exam with assessment for discharge, odor, and screening with vaginal and urethral smears and culture for possible vaginosis or sexually transmitted infections. For diagnosis of anatomical abnormalities or endometriosis of the bladder an cystoscopy would be required to visualize the causative nature of the symptoms.
Recurrent Lower UTIs
Common causes of recurrent UTIs in women include use of spermicides for contraception, new sexual partner, and voiding dysfunction. Many other factors have been thought to predispose women to RUTIs, such as voiding patterns pre- and post-coitus, wiping technique, wearing tight undergarments, deferred voiding habits and vaginal douching; nevertheless, there has been no proven association (Scholes D et all 2000).
Renal Failure
Acute kidney failure also known as acute renal injury (AKI) is an sudden decrease in renal function and is defined as one or more of the defining criteria of rise in serum creatinine of at least 0.3 mg/dL, serum creatinine >1.5 times the baseline value or urine volume of < 0.5mL/kg per hour for 6 hours. The cause of acute kidney injury can be subdivided into 3 causes, prerenal, intrarenal and post renal. Prerenal is associated with decreased renal profusion that is related to volume depletion or decreased arterial pressure that causes the glomular filtration rate to decrease.
Intrarenal AKI results from an ischemic or nephrotoxic cause such as prolonged hypotension or exposure to a nephrotoxic substance or medication that cause an acute inflammation of the glomeruli.
Postrenal AKI is due to a blockage or obstruction of urinary flow and is seem most often in prostate hypertrophy in men. Patients with acute kidney injury are more likely to develop chronic kidney disease in the future. They are also at higher risk of end-stage renal disease and premature death( Goldberg R, Dennen P 2008).
