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iaskdumbquestions

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Urinalysis are not so straightforward when you're looking at a result and are the one responsible for choosing what to do with it. The more I see, the more I realize that unless it's a rip-roaring infection, and the clinical picture is hazy (or downright counterintuitive), I am not 100% confident what to do with UA results a good proportion of the time.

I've been reading about UA, but often it's the same explanation of what each component measures, but very little on putting it all together in a patient. So here I am, humbly asking for your help. Where can I learn more about UA interpretation?

What do I do with UA results that give me information I was not suspecting based on the clinical picture?

LE but no nitrites / LE and X number of WBC but no nitrites / blood in otherwise healthy adult / is there a cutoff for how many WBC are important with LE / etc etc etc

Obviously there are too many individual scenarios to game them all, but either way it's clear... I am not an expert on UA interpretation; but I need to be.

Thank you
 
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Anri of Astora

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For urinary tract infections, your clinical context (the presence of symptoms) will be the biggest factor in determining whether you send for a urine culture or treat. Remember we do not treat asymptomatic bacteriuria (unless in a pregnant woman).

For just the UA interpretation, some UTIs will present with LE but no nitrites so you don't need both present. Pyuria is also a high sensitivity test for infection.

For blood or protein, you will need to repeat the UA a few times. If still present with no underlying infection/Foley catheter/exercise, this will need an outpatient workup.
 
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PlutoBoy

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Urinalysis are not so straightforward when you're looking at a result and are the one responsible for choosing what to do with it. The more I see, the more I realize that unless it's a rip-roaring infection, and the clinical picture is hazy (or downright counterintuitive), I am not 100% confident what to do with UA results a good proportion of the time.

I've been reading about UA, but often it's the same explanation of what each component measures, but very little on putting it all together in a patient. So here I am, humbly asking for your help. Where can I learn more about UA interpretation?

What do I do with UA results that give me information I was not suspecting based on the clinical picture?

LE but no nitrites / LE and X number of WBC but no nitrites / blood in otherwise healthy adult / is there a cutoff for how many WBC are important with LE / etc etc etc

Obviously there are too many individual scenarios to game them all, but either way it's clear... I am not an expert on UA interpretation; but I need to be.

Thank you

This is a big topic but remember that persistent microscopic hematuria needs work up.

Pyuria with symptoms - treat.
 
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Moko

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The first thing I've been taught to look at is the presence of epithelial cells. If there's more than a few present, the UA could contain contaminants and I would be hesitant to interpret the result of any present bacteria, LE or nitrites. As others have mentioned, not all bacteria convert nitrates to nitrite, and nitrites may be falsely negative in polyuria. UTIs ultimately require the presence of symptoms to diagnose.

I also find urine specific gravity to be quite helpful, if the patient isn't on diuretics, and the sample is collected before significant fluid resuscitation in the ED. Hope this helps.
 
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PlutoBoy

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http://www.medscape.com/viewarticle/865175 just popped up in my email today. It has some discussion of common pitfalls of (mis)interpretation of UAs.

I assumed this was common knowledge?

I used to lose it when I inherited patients with chronic indwelling Foley catheters that were started on IV Fluconazole for "candida UTI".

I also agree that the diagnosis of AMS 2/2 UTI is one of the biggest myths if not outright lies perpetuated by the medical establishment but I guess people need a reason to get the patient admitted.
 

Raryn

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I assumed this was common knowledge?

I used to lose it when I inherited patients with chronic indwelling Foley catheters that were started on IV Fluconazole for "candida UTI".

I also agree that the diagnosis of AMS 2/2 UTI is one of the biggest myths if not outright lies perpetuated by the medical establishment but I guess people need a reason to get the patient admitted.
A lot of things are "common knowledge" when you're done with training. I have no idea what stage the OP is at, but the medscape article seemed like a decent enough starting point.

And yes, misdiagnosis is a problem. So maybe common knowledge isn't so common?
 
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HoosierdaddyO

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This thread popped up and I thought it was kind of convenient bc of a few questions that came my way!!

Say a patient has no UTI like Symptoms but the urine is as follows:
Neg Nitrites
+LE
30 WBCs
30 RBCS
No Bacteria
No WBC clumps

Are you treating this or no in an otherwise healthy male?!

Can gross hematuria and other pathologies give a sterile pyuria? And are you treating once again without symptoms?!
 

Redpancreas

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This thread popped up and I thought it was kind of convenient bc of a few questions that came my way!!

Say a patient has no UTI like Symptoms but the urine is as follows:
Neg Nitrites
+LE
30 WBCs
30 RBCS
No Bacteria
No WBC clumps

Are you treating this or no in an otherwise healthy male?!

Can gross hematuria and other pathologies give a sterile pyuria? And are you treating once again without symptoms?!

The clinical context is important. Why was the patient admitted and what was the UA obtained for? Why are there WBCs and RBCs? Any issues to warrant looking at a sediment? Any recent foley placement? Does the patient have an indwelling foley?

1.) I personally like to let it reflex to culture out of interest mainly. For one, if the colony count is low, you generally don't treat it anyways. Also, if it’s Staph Aureus, you may want to do some further chart review and make sure patient hasn't had fevers in the past. I've yet to catch endocarditis from Staph in the urine but I've heard stories from ID attendings. I like to know about Pseudomonas or ESBL as well.

2.) In an otherwise asymptomatic male who’s not confused, isn’t having any symptoms, isn’t planning any urological procedures soon, doesn’t have a renal transplant history, or any altered anatomy, I wouldn’t opt to treat asymptomatic bacteruria unless you have a compelling reason to.

3.) You could also be a CYA hospitalist and retrospectively think of a symptom to warrant treatment and write it down as another problem that you’ve addressed. Three days of ceftriaxone shouldn’t hurt, right?
 
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Chemist0157

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This thread popped up and I thought it was kind of convenient bc of a few questions that came my way!!

Say a patient has no UTI like Symptoms but the urine is as follows:
Neg Nitrites
+LE
30 WBCs
30 RBCS
No Bacteria
No WBC clumps

Are you treating this or no in an otherwise healthy male?!

Can gross hematuria and other pathologies give a sterile pyuria? And are you treating once again without symptoms?!
Why was it checked?

Inpatient? Outpatient? Foley?

Casts?

Normal creatinine?

Smoker?

Does he have gross gross hematuria, or is that a separate question from the clinical scenario?

If I see a healthy male in clinic with normal creatinine but persistent hematuria, I can ask questions to think about Alport’s. Could be IgA nephropathy or thin basement membrane disease. They don’t buy themselves biopsies unless there is proteinuria or abnormal creatinine. They probably see urology to rule out a bleeding lesion, especially if older and smoker.

Edit - diagnostic US or CT could be helpful to look for stone too.
 
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obiwan

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3.) You could also be a CYA hospitalist and retrospectively think of a symptom to warrant treatment and write it down as another problem that you’ve addressed. Three days of ceftriaxone shouldn’t hurt, right?

No patient should go through a hospitalization without empiric coverage for a UTI with ceftriaxone ........
 
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HoosierdaddyO

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Ok well imagine that urinalysis in the setting of a 5mm kidney stone at the uvj… who is otherwise not septic, with normal vitals, who is denying any fever or chills. Not displaying any UTI like symptoms (ie Dysuria, increased frequency)… but does have gross hematuria most likely secondary to the kidney stone.

Would you be treating that urine that is negative for bacteria, negative for nitrites, and no WBC clumps with limited to no concerned for sepsis?! Patient also has a cr of 0.8 and BUN of 9 with no other systemic symptoms?!
 

gutonc

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Ok well imagine that urinalysis in the setting of a 5mm kidney stone at the uvj… who is otherwise not septic, with normal vitals, who is denying any fever or chills. Not displaying any UTI like symptoms (ie Dysuria, increased frequency)… but does have gross hematuria most likely secondary to the kidney stone.

Would you be treating that urine that is negative for bacteria, negative for nitrites, and no WBC clumps with limited to no concerned for sepsis?! Patient also has a cr of 0.8 and BUN of 9 with no other systemic symptoms?!
That's easy then...I wouldn't empirically treat.

No bugs and no nitrites are encouraging for no UTI. I'd probably send off the UCx just to make myself feel better, but he's bleeding and has an inflammatory process due to the stone, which can easily explain the reds and whites. LE is just a surrogate for WBCs.
 
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mszzeta

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This should be basic training in internal medicine or family medicine. What you mostly need to pay attention is WBC, RBC, protein and bacteria. You need to know most proteinuria is from glomerular disease. RBC can be from both glomerular or any course of the urinary tract. Asymptomatic bacteria (with or without commitment RBC/WBC) usually dose not need treatment unless in special situations (pregnancy, certain GU procedures)

Proteinuria that you don't think due to HTN or DM -> nephrology
UTI symptoms + abnormal urinalysis -> antibiotics
Hematuria with dysmorphic red blood cells or cast (however, many urinalysis test do not report this) -> nephrology
Persistent hematuria without dysmorphic red blood cells -> urologist. Can order ultrasound first
asymptomatic with bacteria, lots of WBC and RBC -> most of the time nothing
High creatinine -> nephrologist
 
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