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A Clinical Dilemma: Does She Really Have a UTI?

Authors propose an algorithm for the evaluation and treatment of women with urinary tract infections.

These authors conducted a Medline search for studies that examined the accuracy of history and physical examination in predicting whether a nonpregnant woman has an uncomplicated urinary tract infection (UTI). The exclusion of studies that included patients who had complicated UTIs or lived in a nursing home narrowed the analysis down to 9 studies.

The probability of UTI was approximately 50% among women who presented with symptoms of possible infection. The most powerful predictive signs and symptoms were vaginal discharge and vaginal irritation, both of which significantly decreased the likelihood of UTI (likelihood ratio, 0.3 and 0.2, respectively). Historical symptoms that significantly increased the probability of UTI included dysuria (LR, 1.5), frequency of urination (LR, 1.8), hematuria (LR, 2.0), and back pain (LR, 1.6). The only physical finding that significantly increased the probability of infection was costovertebral angle tenderness (LR, 1.7).

Comment: Each year, nonpregnant women make approximately 7 million ambulatory visits for possible UTIs. It is amazing that in only 9 qualified studies have investigators attempted to analyze the accuracy of history and examination in predicting this common clinical scenario!

Based on this analysis, the authors propose an algorithm for the evaluation and treatment of women who present with possible UTIs. Basically, for uncomplicated patients with vaginal discharge and without back pain or fever, they recommend sexually transmitted infection (STI) testing, pelvic exams, and urine cultures. A previous systematic review showed that symptomatic women with negative dipstick tests still had a 20% probability of infection; therefore, antibiotic treatment in this scenario is withheld until a UTI is confirmed on culture. Given the prevalence of STIs, it seems prudent to perform STI testing and pelvic exams in patients with UTI symptomatology and vaginal symptoms, and to strongly consider pelvic exams and testing in patients with other factors that increase the likelihood of STIs (e.g., young age, history of gonorrhea or chlamydia, recent change of sexual partner).

— Ann J. Davis, MD

Published in Journal Watch Women's Health July 23, 2002

Citation(s):

Bent S et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002 May 22/29; 287:2701-10.

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• Medline abstract (Free)