Renal colic mimics
- Some mimics of renal colic that may arrive at the ED include: upper UTI’s, ectopic pregnancies, ovarian torsion, adnexal masses, testicular torsion, acute aortic syndromes, renal artery aneurysms, renal infarction, splenic infarction, bowel obstruction, diverticulitis, appendicitis, biliary colic, cholecystitis, acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.
- Focused history and physical exam are paramount due to the multitude of structures in the area and potentially dangerous conditions that may mimic renal colic.
- Flank pain and hematuria are the hallmarks of renal colic, however, the presentation is variable.
- Diagnosis can be confirmed with CT scan, which will show most other potential items in the differential if the scan is negative for a stone.
UTI Myths and Misconceptions
- UTI is a clinical diagnosis, not a laboratory one. Dysuria plus urinary frequency in the absence of symptoms of STI is diagnostic.
- Most patients with a clinical picture consistent with a lower UTI do not require urine tests.
- The indications for urine tests for suspected lower UTI include immunocompromised patients, history of multiple courses of antimicrobial therapy, history of antibiotic resistance and history of multiple drug allergies.
- While bacteria seen on microscopy is predictive of a positive culture, it is not necessarily diagnostic of a UTI as the positive culture could represent a contaminant or asymptomatic bacteriuria.
- A common pitfall is treating non-pregnant patients with asymptomatic bacteriuria with antibiotics. Asymptomatic bacteriuria is very common in all age groups and is often misdiagnosed as a UTI.
- Do not routinely treat catheterized patients found to have pyuria or candida in their urine.
- A common pitfall is to assume that the cause of altered level of awareness in an elderly is a UTI upon finding pyuria or bacteriuria on urinalysis leading to premature closure and missing a more serious diagnosis.
- Imaging is not routinely required for patients suspected clinically of pyelonephritis.
- Cranberry juice, direction of wiping and voiding post intercourse are not effective in preventing recurrent UTIs
- 3-5 days duration of therapy is sufficient for the vast majority of lower UTI
Myth 1: The Urine Is Cloudy and Smells Bad. My Patient Has a UTI
Myth 2: The Urine Has Bacteria Present. My Patient Has a UTI. Also See Myth 8
Myth 3: My Patient’s Urine Sample Has >5 Squamous Epithelial Cells per Low-Power Field and the Culture is Positive. Because the Culture is Positive, I Can Disregard the Epithelial Cell Count and Treat the UTI
Myth 4: The Urine Has Positive Leukocyte Esterase. My Patient Should Have a Urine Culture Performed, Has a UTI, and Needs Antibiotics
Myth 5: My Patient Has Pyuria. They Must Have a UTI
Myth 6: The Urine Has Nitrates Present. My Patient Has a UTI
Myth 7: All Findings of Bacteria in a Catheterized Urine Sample Should Be Diagnosed as a UTI
Myth 8: Patients with Bacteriuria Will Progress to a UTI and Should Therefore Be Treated
Myth 9: Falls and Acute Altered Mental Status Changes in the Elderly Patient Are Usually Caused by UTI
Myth 10: The Presence of Yeast or Candida in the Urine, Especially in Patients with Indwelling Urinary Catheters, Indicates a Candida UTI and Needs to Be Treated
- If the child is unwell, culture them as you think is appropriate and treat.
- In well appearing children, UTI does not seem to cause long term renal problems and the risk of sepsis is incredibly low.
- In well appearing children, there does not appear to be a difference between starting antibiotics for UTI on the first day of fever or on day number 5.
- Given the rate of asymptomatic bacteriuria, you should anticipate a high rate of false positive urine cultures.
- Therefore, it makes sense to wait until at least the fifth day of fever before testing for UTI. This will result in fewer urines being sent and fewer false positives (because many fevers will resolve before day 5), but does not seem to be associated with any harm
- There does not seem to be any value in routine imagining of children with a first time UTI. Selective imagining based on history and physical makes more sense, but even then it is not clear that imaging changes management.