You will complete the Aquifer case,

Internal Medicine 14: 18-year-old female for pre-college physical

, focusing on the “Revisit three months later” for this assignment.

After completing the Aquifer case, you will present the case and supporting evidence in a PowerPoint presentation with the following components:

• Slide 1: Title, Student Name, Course, Date
• Slide 2: Summary or synopsis of Judy Pham’s case
• Slide 3: HPI
• Slide 4: Medical History
• Slide 5: Family History
• Slide 6: Social History
• Slide 7: ROS
• Slide 8: Examination
• Slide 9: Labs (In-house)
• Slide 10: Primary Diagnosis and 3 Differential Diagnoses – ranked in priority

Primary Diagnosis should be supported by data in the patient’s history, exam, and lab results.

• Slide 11: Management Plan: medication (dose, route, frequency), non-medication treatment, tests ordered, education, follow-up/referral.
• Slide 12-16: An evaluation of 5 evidence-based articles applicable to Ms. Pham’s case: evaluate 1 article per slide.

1. Include title, author, and year of article
2. Brief summary/purpose of the study
3. How did the study support Ms. Pham’s case?

Course texts will not count as a scholarly source. If using data from websites you must go back to the literature source for the information; no secondary sources are allowed, e.g. Medscape, UptoDate, etc. 

Slide 17: Reference List                                                                                                                                                                                                                                                                                                                                                                                                                                           

You will submit the PowerPoint presentation in the Submissions Area by the due date assigned. Name your Case Study Presentation SU_NSG6430_W7_A2_lastname_firstinitial

Internal Medicine 14: 18-year-old female for pre-college
physical
User: YULAK LANDA
Email: landayrn17@stu.southuniversity.edu
Date: April 5, 2021 2:48AM

Learning Objectives

The student should be able to:

Describe and recall the HEEADSS mnemonic approach to adolescent counseling.
Obtain a history that differentiates among etiologies of dysuria.
Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.
Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep,
and KOH stain.
Describe current recommendations for cervical cancer screening.
Discuss safe sexual practices and efficacy of common methods of contraception.

Knowledge

HEEADSSS Approach to Adolescent Counseling

The HEEADSSS approach to adolescent counseling addresses the main categories of Home/health, Education/employment, Eating
disorders, Activities, Drugs, Sexuality, Safety/violence, and Suicide/depression. View examples of screening questions for the
HEEADSSS history.
One of the nice qualities about the HEEADSSS approach is that it starts with less threatening issues and proceeds to more
personal questions, so the interviewer has a chance to establish rapport before exploring sensitive, intrusive topics. Be sure to ask
questions in a nonjudgmental way, and avoid questions that can be answered with “OK” or with a “Yes/No” (i.e., “Do you get along
with your mom and dad?”; “How are you doing in school?”; “Do you have any activities outside of school?”; “Do you do drugs?”;
“Are you sexually active?”; “Are you careful about being safe?”).
Remember to avoid making assumptions about a teen’s behaviors. For example, don’t assume that your patient is heterosexual,
sexually active, or even dating.

Adolescent Interview – Safety

Violence

The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual
abuse, date rape, and school violence are all common. In many urban communities, up to one in four students report carrying a
weapon to school. Family violence and dating violence cross all economic and social boundaries.
Injuries

For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are
more likely. It is important to address the use of seat belts and bike helmets with every adolescent.
Even though you address the safety issues most prevalent in the patient’s community first, do not skip any part of the history
based on assumptions about the patient’s ethnic background or economic status.

Recommended Vaccinations for Adolescents and Teenagers

Haemophilus
influenzae
type b

Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in
infants and young children, but it is not recommended after the age of five years.

Hepatitis B
Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and
hepatic carcinoma. The series of three injections is recommended for adolescents if they did not receive them
when younger.

There are two different human papillomavirus vaccines available. They vary in the number of strains of HPV they
protect against, ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is
recommended for girls and females 9-26 years old.

© 2021 Aquifer 1/10

https://medu-relier-production.s3.us-west-2.amazonaws.com/files/uploaded_pdfs/IM 14 – Sample HEEADSSS Screening Questions pdf

Human
papillomavirus

The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or
12 years of age. ACIP also recommends vaccination in males ages 13 – 21 who have not been vaccinated
previously or who have not completed the three-dose series. ACIP states that males aged 22 – 26 years may be
vaccinated, but does not recommend routine vaccination in this age group.

Influenza

The influenza vaccine is recommended for everyone who is at least age six months. It is usually administered in
September through December when the influenza season is imminent.

The H1N1 strain, or “swine” influenza, the predominant strain circulating in the U.S. over the past several years,
has high rates of morbidity and mortality among children and adolescents.

Meningococcal
The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12
years during the routine preadolescent immunization visit with a booster dose at age 16 and is recommended for
all previously unvaccinated adolescents aged 11-18 years.

MMR
MMR is recommended in adults who have not been previously vaccinated as children. An exception to this
recommendation is the case of pregnant females. Pregnant females should not be vaccinated with MMR because
of a risk of fetal transmission since it is a live virus vaccine.

Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.

Tetanus,
diphtheria,
acellular
pertussis

The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria, and pertussis. It
contains acellular pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that
caused high fever and neurologic symptoms when given to older children and adults. Tdap, which was licensed in
2005, is the first vaccine for adolescents and adults that protects against all three diseases.

Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred
timing between 11 and 12 years. If a patient has received a Td booster, then waiting at least 5 years between Td
and Tdap is encouraged because the incidence of side effects is lower.

The exception to this rule is the case of type III hypersensitivity reactions. Type III hypersensitivity reactions
(Arthus reactions), which are characterized by immune complex deposition in blood vessels, can rarely be seen
following receipt of vaccines containing tetanus toxoid or diphtheria toxoid. These reactions are characterized by
severe pain, swelling, and sometimes necrosis at the injection site and occur between 4 and 12 hours following
vaccination. It is recommended that patients who have had such a type III hypersensitivity reaction avoid
receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.

Varicella

The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had
chickenpox or have not received the vaccine.

Varicella was added to the list of standard childhood vaccines in 1995. Two doses are required, with the first
administered at 12-15 months of age and the second at 4-6 years of age. There is also a combination measles,
mumps, rubella, and varicella vaccine (MMRV) available.

Hepatitis A Hepatitis A vaccination is effective in preventing hepatitis A virus infection. The series of two to three injections(depending on the type of vaccine) is recommended for adolescents if they did not receive them when younger.

When a Pelvic Examination Is Indicated

Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65.
There is recent evidence that screening for cervical cancer in females less than 21 years of age leads to potentially unnecessary
procedures and more harm than benefit. The frequency of cervical cancer screening with the Papanicolaou (Pap) test for
immunocompetent individuals with previously normal tests is once every three years or, for females ages 30 – 65 years, screening
with high-risk human papillomavirus (HPV) testing alone or in combination with cytology every five years.

STI Screening Recommendations

Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.
Test results for most STIs, such as gonorrhea, chlamydia, HIV etc. must be reported to the public health department.

© 2021 Aquifer 2/10

Most Common Causes of

Cystitis

E. coli causes a majority of all cases of uncomplicated urinary tract infections.
Other common organisms include Klebsiella pneumonia, Proteus mirabilis and Staphylococcus saprophyticus.

Differentiating Cystitis from

Pyelonephritis

It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

Cystitis Pyelonephritis

Clinical
manifestations

dysuria, frequency, urgency,
suprapubic pain, and/or
hematuria

may or may not have symptoms of cystitis together with fever (> 38 C) and other
systemic symptoms, such as chills, flank pain, costovertebral angle tenderness,
and nausea/vomiting

Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)

Treatment

short-course antibiotic
therapy (three days);

hospitalization usually not
required

at least seven days of treatment;

hospitalization may be required

Dysuria in Males

Disease Presentation Diagnosis

UTI and
cystitis

Isolated acute cystitis is rare in males because their longer
urethra hinders bacteria from reaching the bladder, and prostatic
fluid has antibacterial properties.

Most males with acute cystitis have functional or anatomic
abnormalities, and need further evaluation.

Symptoms of lower and upper tract infections are the same in
males and females.

Midstream culture and sensitivity of the
urine

Urethritis

Usually sexually transmitted gonococcal and/or chlamydia
infection.

Gonococcal urethritis is more likely in males with acute symptoms
and purulent urethral discharge.

Chlamydia is likely when dysuria is present alone or with minimal
discharge. Males with chlamydia infection may be asymptomatic.

Recommended that patients be treated presumptively for both
gonorrhea and chlamydia, pending results.

Herpes simplex virus is a rare cause of urethritis, but may be
suggested by the history of penile lesions.

Diagnosis can be made on a Gram
stain of a urethral swab.

Leukocytes and Gram-negative
intracellular diplococci confirm the
diagnosis of gonorrhea.

White cells without organisms
suggest non-gonococcal urethritis
(NGU) which is usually chlamydia
but can also be Trichomonas
vaginalis.

Because many outpatient offices
are not equipped to do Gram stains,
NAAT testing of the urethra or urine
is becoming the preferred diagnostic
test for gonorrhea and chlamydia.

Prostatitis

Acute prostatitis

Presents with UTI symptoms of fever, chills, dysuria, dribbling, and
hesitancy, and is caused by Gram-negative rods
(Enterobacteriaceae, Pseudomonas, Proteus), Gram-positive
organisms (Enterococcus, S. aureus), and sexually transmitted
agents such as Neisseria gonorrhoeae and Chlamydia
trachomatis.

Prostate is edematous and very tender on digital rectal
examination.

Chronic prostatitis

Diagnosis can be difficult to make and
may require submitting urine specimens
gathered following prostatic massage for
microscopic urinalysis and culture.

© 2021 Aquifer 3/10

Characterized by lower urinary tract symptoms, perineal
discomfort, pain with ejaculation, and occasionally deep pelvic
pain that radiates to the back. The symptoms are often subtle and
sometimes may be absent, and the physical exam may be normal.

This diagnosis should be considered in males with recurrent UTIs
without risk factors.

Epididymitis

Patients with epididymitis present with dysuria, frequency,
urgency, and unilateral testicular pain.

Fever and rigors may be present and there may be redness and
tenderness of the entire affected testicle.

Testicular torsion should be considered in all cases, especially
when the patient is an adolescent and the onset is sudden.

Epididymitis in males < 35 years is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae; in those > 35, enteric
Gram-negative rods (Escherichia coli) are the most common
causes.

If the diagnosis is questionable, color
duplex doppler scanning should be
obtained immediately.

Factors that Contribute to Complicated Urinary Tract Infections

Anatomic or
functional
abnormalities of
the urinary tract

Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine,
promoting bacterial growth and causing complicated infections.

Hospital-acquired
Hospital-acquired urinary tract infections are considered complicated because patients are more
susceptible to developing infections with antibiotic-resistant organisms that are found in the hospital
environment.

Immunosuppressed
or recently treated
with antibiotics

Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to
have complicated infections.

Male
Urinary tract infections in males are complicated because they are commonly associated with bladder
outlet obstruction, instrumentation, or other urologic abnormalities. However, a small number of adult
males can develop uncomplicated UTIs. Risk factors associated with these infections are homosexuality,
intercourse with a urinary tract-infected female partner, and lack of circumcision.

Pregnant Urinary tract infections in pregnant females are considered complicated because they can progress to andcan induce preterm labor.

Urinary catheter or
recent
instrumentation

Urinary tract infections in patients with urinary catheters or recent instrumentation are considered
complicated because they introduce external pathogens into the urinary tract and, in the case of indwelling
catheters, provide a nidus for bacterial growth.

Birth Control Options

Percentage of females experiencing an unintended pregnancy within the first year of use: United States

Method Typical use Perfect use

No method 85 85

Spermicides 29 18

Withdrawal 27 4

Fertility awareness-based methods 25

Standard days method 5

© 2021 Aquifer 4/10

Two day method 4

Ovulation method 3

Sponge

Parous females 32 20

Nulliparous females 16 9

Diaphragm 16 6

Condom

Female (Reality) 21 5

Male 15 2

Combined pill and progestogen-only pill 8 0.3

Evra patch 8 0.3

NuvaRing 8 0.3

Depo-Provera 3 0.3

Combined injectable (Lunelle) 3 0.05

IUD

ParaGard (copper T) 0.8 0.6

Mirena (LNG-IUS) 0.2 0.2

Implanon 0.05 0.05

Female sterilization 0.5 0.5

Male sterilization 0.15 0.10

Adapted from WHO Medical eligibility criteria for contraceptive use (2009)
Male latex condoms: when correctly used with each episode of intercourse are the best protection against sexually
transmitted infections.
IUDs: can be considered for females at low risk of acquiring sexually transmitted infections, since sexually transmitted
infections may require removal of the IUD. Females with a history of PID can safely use the IUD with appropriate counseling.
IUDs can be used as long as the female is not planning a pregnancy for at least one year, since attempting a pregnancy
would require IUD removal. Females who have never been pregnant can safely use the IUD.
Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the
risk of pregnancy by at least 75%.

Management

First-Line Empiric Therapy for Cystitis

In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.
In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a
poor choice for empiric therapy.
In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%.
Therefore, these have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these
antibiotics vary by geographic region and can exceed 20% in some areas.

© 2021 Aquifer 5/10

Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas
resistance rates exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant organisms (sometimes referred to as "collateral damage") and there are several “black box” warnings on fluoroquinolones due to some serious side effects. Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are not eligible to receive recommended first-line agents. Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there are less data with these agents. The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate, second-generation cephalosporins (cefaclor), third-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances first-generation cephalosporins (cephalexin and cefadroxil). In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug-drug interactions, recent antibiotic use, and renal function, among others.

Recommended Dosing and Duration for Cystitis Therapy

Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has
similar efficacy to that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other
recommended first-line agents have different recommended durations. See the table below for recommended durations of first-
line agents.
First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.

Drug Dose and interval Duration

Trimethoprim-sulfamethoxazole 160/800 mg q 12 hours 3 days

Nitrofurantoin monohydrate
macrocrystals 100 mg q 12 hours 5 days

Fosfomycin trometamol 3 gm in a single dose 1 dose

Recommended Therapy for Pyelonephritis

In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic
urinalysis. Definitive antibiotic choice should be based on the results of the urine culture.
For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the
local resistance rates are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be given for pyelonephritis. Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism is known to be susceptible. Two-week regimens are generally advised when using trimethoprim- sulfamethoxazole. If trimethoprim-sulfamethoxazole is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be given before starting the course of trimethoprim- sulfamethoxazole. Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained.

Who Should Be Hospitalized For Pyelonephritis

Patients who cannot maintain oral hydration or cannot take oral medicines should be hospitalized, as should those who have
social circumstances or other factors that hinder adherence to therapy.
Patients who appear septic, who are hemodynamically unstable, and who have any complicating factors should also be
hospitalized.
In many cases, people with diabetes should be hospitalized for parenteral therapy because they have worse outcomes, and
diabetics have an increased risk of complications such as emphysematous pyelonephritis or abscess.
Pregnant females should be hospitalized, because pyelonephritis is associated with an increased incidence of fetal
complications and premature delivery.

Preventing Recurrent UTIs

1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis
and urine culture. Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical
irritation, or urethritis.

2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating
infections. These predisposing factors should be treated if present.

3. In patients without predisposing factors, some clinicians attempt behavioral and lifestyle modification. Because sexual
activity is associated with recurrent infections, doctors often recommend that females void before and after sexual
intercourse. This, and advice to wipe “front to back,” increase fluid intake (including cranberry juice), and avoid full
bladders, have not been proven to reduce the recurrence of infection, but they are benign maneuvers, and still make sense

© 2021 Aquifer 6/10

to many clinicians.
4. For post-menopausal females, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection.
5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at

least two in six months, antibiotic prophylaxis may be considered.
Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do
not differ significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than
continuous prophylaxis with similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise,
patient-initiated treatment upon developing symptoms can represent a cost-effective management strategy if infections are not
severe and not frequent.
The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns
of the patient’s prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by
observation for reinfection.

Recommended Chlamydia Therapy

First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline
100 mg twice daily. The one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin
are considered alternative treatment agents and require seven days of therapy.

Studies

Cervical Cancer Screening Guidelines

Age Recommendation

Under
21 Females under the age of 21 should not be tested, regardless of sexual activity.

21-29 Females between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique.HPV testing should not be used in this age range unless it is prompted by an abnormal Pap result.

30-65 There are three options for screening females between the ages of 30 to 65: 1. “Co-testing” with the Pap test and a high-risk HPV test every five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years.

Over
65

Females older than 65 who have had negative Pap tests are unlikely to have abnormal Pap tests with repeat testing so
should no longer be screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing
continues after the age of 65.

These guidelines apply to females without medical conditions or exposure that place them at a higher risk of cervical cancer.
Females in the following groups should be screened more frequently (e.g. annually):

those with HIV infection
those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids)
those with diethylstilbestrol (DES) exposure before birth

HPV vaccines target only certain genotypes of HPV. The 9-valent Gardasil-9 includes seven genotypes that cause cervical cancer
(types 16, 18, 31, 33, 45, 52 and 58) and two genotypes that most commonly cause genital warts (types 6 and 11). The
quadrivalent Gardasil includes the most common genotypes to cause cervical cancer (types 16 and 18) and the two genotypes
that most commonly cause genital warts (types 6 and 11). But recipients of either vaccine are still at risk of developing cervical
cancer. Therefore, they should receive age-appropriate screening as discussed above. However, they are at a decreased risk
because types 16 and 18 are the cause of cervical cancer in a majority of cases.
Liquid-based cytology is a method where cervical cells are suspended in a vial of liquid preservative instead of spread from a
brush and spatula onto a glass slide. There are fewer unsatisfactory specimens with liquid Paps, and testing for HPV can be done
on fluid from the vial, if warranted. However, there are more false-positive results with liquid Pap, which can result in needless
referrals for colposcopy.

Recommended Pelvic Exam Tests in the Setting of Suspected STIs

Microscopic examination of
slide with drop of vaginal
discharge and normal saline

The saline-prepped or “wet mount” slide allows for diagnosis of Trichomonas and bacterial
vaginosis.

Microscopic examination of
slide with drop of vaginal
discharge and potassium

The potassium hydroxide slide is used to visualize budding yeast and hyphae that are seen
with candida vaginal infections.

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hydroxide

Nucleic acid amplification
testing (NAAT) for N.
gonorrhea and C. trachomatis

The best way to test for chlamydia and gonorrhea during a pelvic exam is nucleic acid
amplification testing (NAAT) for N. gonorrhea and C. trachomatis. NAAT is a sensitive and
specific assay and has replaced culture methods. It can be used on urine specimens as well.

Smelling a slide with a drop of
vaginal discharge and
potassium hydroxide

Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test.
The production of a fishy odor indicates a positive test. A positive whiff-amine test is seen in
bacterial vaginosis.

Tests not indicated:

Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of
Neisseria gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid
testing.
Smelling a slide with normal saline is not useful.

What to Look for on Wet Mount Slides

In the case of trichomoniasis, wet mount slides reveal trichomonads, which are flagellated protozoans. The treatment is a
single dose of 2 grams of metronidazole.
Clue cells can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of
abnormal vaginal discharge in females of childbearing age, is a condition characterized by reduced numbers of normal
vaginal lactobacilli and overgrowth of other vaginal bacteria. Clue cells are epithelial cells entirely covered with these
bacteria, giving the perimeter a “furlike” appearance. The treatment of BV is a course of metronidazole 500 mg twice daily
for seven days.
It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis,
and atrophic vaginitis.

Diagnostic Tests for Cystitis

Microscopic urinalysis

Pyuria, defined as at least two to five leukocytes per high-powered field in a spun urine specimen, is present in almost all females
with cystitis, and evaluation of midstream urine for white blood cells is the most valuable lab test for urinary tract infection. If
white cells are not present in the urine, an alternative diagnosis should be considered.
Urine dip stick

In ambulatory settings, urine dipstick testing has largely replaced microscopy to confirm the diagnosis of urinary tract infection
(UTI), because it is cheaper, faster, and more convenient. Dipsticks detect the presence of leukocyte esterase and nitrite and have
comparable accuracy to microscopic urinalysis in the diagnosis of cystitis. However, they may be negative in low-colony count
infections (less than 104 colonies/mL). Therefore, patients should also have a microscopic urinalysis performed.
Tests not indicated for diagnosis of cystitis

Microscopic evaluation of the urine for bacteriuria is generally not recommended for acute cystitis because bacteria in low
quantities (less than 104 colonies/mL) are difficult to find, even with Gram stain.
Urine culture is not cost-effective and not necessary in females with cystitis, because the causative organisms and antibiotic
sensitivities are predictable, and the results of the culture are not immediately available. There are certain situations when
obtaining a urine culture is useful, such as in patients with refractory symptoms or those with history of urinary tract
infections with antibiotic-resistant organisms.

Indications for Imaging or Urologic Evaluation in a Patient with a UTI

Imaging studies and urologic referral are not indicated in the routine evaluation of young females with cystitis or pyelonephritis
because they rarely uncover abnormalities that require treatment. However, in certain groups, further evaluation is recommended
to exclude anatomic abnormalities and complications of pyelonephritis.

Isolation of Proteus can be associated with urologic (struvite) stones so may require imaging, especially in patients with
recurrent or refractory infections despite adequate antibiotic treatment.
Recurrent pyelonephritis should prompt imaging to rule out nephrolithiasis or other urologic anomalies.
Patients with pyelonephritis who remain febrile and show no clinical improvement within 72 hours on appropriate antibiotic
therapy should have imaging to rule out obstruction or renal or perinephric abscesses. The presence of these complications
often requires drainage and longer courses of antibiotics.
Patients with suspected abnormality of the urinary tract.

CT scan or renal ultrasound is recommended as a first step to rule out nephrolithiasis or obstruction prior to urologic evaluation in
these circumstances.
Urologic evaluation, including cystoscopy, should also be performed in those with persistent hematuria after infection has been
eradicated.

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https://medu-relier-production.s3.amazonaws.com/files/SIMPLE-14-1zy3KMEwWBAmB9ibV-eZWaOocRg4zdVAuHVfBQ2EYbUQl1a8EZL/compressed/images/251991

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Clinical Reasoning

Differential of Dysuria, Urinary Frequency, and Hematuria

Most Likely Diagnoses

Cervicitis
with
urethritis

Several sexually transmitted infections, such as chlamydia, gonorrhea, and trichomoniasis can cause
cervicitis with concomitant urethritis and dysuria similar to that seen here.

Symptoms that occur gradually over several weeks are more likely with a sexually transmitted urethritis.

Cystitis

Cystitis is an inflammation of the bladder caused most commonly by bacterial infection.

A non-specific term often used interchangeably with cystitis is “urinary tract infection.” Urinary tract
infection can denote infection of any portion of the urinary tract, including the kidneys (pyelonephritis) or
urethra (urethritis).

Hematuria, urinary frequency, and dysuria are all common features of cystitis.

Urinary frequency and dysuria can also be seen with urethritis, but hematuria is rarely seen with that
condition. The presence of hematuria points to cystitis rather than urethritis in this patient.

Note that fever is not seen with cystitis. When fever is present in the setting of urinary symptoms,
pyelonephritis should be considered.

Pelvic
inflammatory
disease

Pelvic inflammatory disease, often called PID, is the name for a spectrum of disorders of the upper female
genital tract, including endometritis, tubo-ovarian abscess, and salpingitis.

Often sexually transmitted infections are the source of PID, which can lead to infertility if not treated.

Females with PID may have subtle symptoms, and physical exam findings of cervical motion tenderness
and uterine or adnexal tenderness are important diagnostic features of PID.

In addition to vaginal discharge, abdominal and pelvic pain are common in PID—more so than with the
other diagnoses.

Fever is variably present in PID, and is more likely in severe cases.

Less Likely Diagnoses

Bacterial
vaginosis

Bacterial vaginosis is a condition marked by increased malodorous vaginal discharge.

It is caused by an imbalance of naturally occurring vaginal flora.

It is not an inflammatory condition, therefore pain and burning are rarely seen.

Sexual activity is a risk factor for bacterial vaginosis, but there is no clear evidence that it is transmitted
sexually.

Candidiasis

Candidiasis is an often-neglected cause of dysuria and is perceived as pain or burning when urine comes in
contact with an inflamed perineum or labia.
A vaginal yeast infection may cause inflammation of the perineum and the urethral orifice, called “vaginitis,”
that leads to dysuria. This so-called “external dysuria” is most common with candida and trichomonas
vaginitis, but it is also present in patients with genital ulcers from herpes simplex and in irritant vaginitis
from soaps, hygiene products, condoms, and spermicides.
Urinary frequency, urgency, or hematuria are symptoms related to the bladder and urethra. When present,
they speak against the diagnosis of vaginitis.

Interstitial
cystitis

Interstitial cystitis, also known as painful bladder syndrome, is a chronic pain syndrome characterized by
frequency, urgency, and dysuria.

However, it is less likely to present with hematuria and is less likely to have such an acute onset.

Nephrolithiasis Although nephrolithiasis can cause hematuria, it usually does not present with dysuria or urinary frequency.

Pyelonephritis

Pyelonephritis is an infection of the kidney or upper urinary tract.
Dysuria may be present, but is rarely the only symptom.
Symptoms that suggest the diagnosis of pyelonephritis are flank pain, fever, chills, nausea, vomiting, and
prostration, none of which is present here.
Fever is usually present with pyelonephritis, but not always, so a lack of fever argues against this diagnosis.

© 2021 Aquifer 9/10

References

Albert X, Huertas I, Pereiró II, Sanfélix J, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women.
Cochrane Database Syst Rev. 2004; 3:CD001209.

Final Recommendation Statement: Cervical Cancer: Screening – US Preventive Services Task Force.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2.
Accessed December 2, 2019.

Goldenring J, Rosen D. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21:64.

Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and
Infectious Diseases. Clin Infect Dis 2011;52:e103-e120. DOI: 10.1093/cid/ciq257.

Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and
Infectious Diseases.Clin Infect Dis 2011;52:e103-20. DOI: 10.1093/cid/ciq257.

Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women.
Arch Intern Med 2007;167:2207-12. DOI: 10.1001/archinte.167.20.2207.

Hooton TM. Recurrent urinary tract infection in women. Int J Antimicrob Agents.2001;14:259-268.

Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. General Recommendations on Immunization: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1-60.

Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for cervical cancer: a decision analysis for the U.S. Preventive Services
Task Force. Agency for Healthcare Research and Quality, Publication No. 11-05157-EF-1. Published May 2011. Accessed December 2,
2019.

Qaseem A, Snow V, Shekelle P, Hopkins R Jr, et al. Screening for HIV in health care settings: a guidance statement from the American
College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150(2):125-31. DOI: 10.7326/0003-4819-150-2-200901200-
00300.

World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: Reproductive Health and Research, World Health
Organization; 2009

© 2021 Aquifer 10/10

https://www.ncbi.nlm.nih.gov/pubmed/15266443

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2

https://www.ncbi.nlm.nih.gov/pubmed/21292654

https://doi.org/10.1093/cid/ciq257

https://www.ncbi.nlm.nih.gov/pubmed/21292654

https://doi.org/10.1093/cid/ciq257

https://www.ncbi.nlm.nih.gov/pubmed/17998493

https://doi.org/10.1001/archinte.167.20.2207

https://www.ncbi.nlm.nih.gov/pubmed/11295405

https://www.ncbi.nlm.nih.gov/pubmed/21293327

https://www.ncbi.nlm.nih.gov/books/NBK92546/

https://www.ncbi.nlm.nih.gov/pubmed/19047022

https://doi.org/10.7326/0003-4819-150-2-200901200-00300

• Internal Medicine 14: 18-year-old female for pre-college physical

Learning Objectives
Knowledge
HEEADSSS Approach to Adolescent Counseling
Adolescent Interview – Safety
Recommended Vaccinations for Adolescents and Teenagers
When a Pelvic Examination Is Indicated
STI Screening Recommendations
Most Common Causes of Cystitis
Differentiating Cystitis from Pyelonephritis
Dysuria in Males
Factors that Contribute to Complicated Urinary Tract Infections
Birth Control Options
Management
First-Line Empiric Therapy for Cystitis
Recommended Dosing and Duration for Cystitis Therapy
Recommended Therapy for Pyelonephritis
Who Should Be Hospitalized For Pyelonephritis
Preventing Recurrent UTIs
Recommended Chlamydia Therapy
Studies
Cervical Cancer Screening Guidelines
Recommended Pelvic Exam Tests in the Setting of Suspected STIs
What to Look for on Wet Mount Slides
Diagnostic Tests for Cystitis
Indications for Imaging or Urologic Evaluation in a Patient with a UTI
Clinical Reasoning
Differential of Dysuria, Urinary Frequency, and Hematuria
References