Clinical Assessment

UTIs present with variable symptoms related not only to the site of infection but also to patient factors.

Cystitis

Cystitis commonly presents with one or more of dysuria, urinary frequency, haematuria, urgency and suprapubic discomfort, especially in the young adult woman.

Pyelonephritis

Pyelonephritis is characterised by fever, flank pain or tenderness with or without the symptoms of lower urinary tract infection. Studies reveal younger patients lacking a fever (defined as less than 37.8°C) to often have an alternative diagnosis such as PID, cholecystitis or renal colic [4]. Unusual presentations of pyelonephritis are often seen with pain in the epigastric area or either hypochondrium. The vast majority of patients with uncomplicated UTI will be systemically well.

The elderly merit special mention. They often have complicated UTIs and the symptoms and signs are often less well localised. They may be afebrile or have only a low grade fever. Verbalisation of their symptoms may be difficult because of acute confusion, as well as from existing medical conditions. The diagnosis should be considered in the elderly presenting with reduced level of consciousness, lethargy and generalised weakness [4].

The differentiation between cystitis and pyelonephritis is important in terms of resulting morbidity, choice of antibiotic and length of treatment. Pyelonephritis will most often require a 7-10 day course of antibiotics. It also always requires a renal ultrasound to be performed. This may be done acutely on admission or as part of follow-up after discharge.

It is difficult to be dogmatic regarding admission criteria. In a select group of immunocompetent patients who respond to initial treatment and can easily return to hospital, the outpatient management of pyelonephritis appears safe and cost effective [5]. The most common indications for admission are nausea and vomiting, comorbidity (especially pregnancy) and obviously severe sepsis or shock.