Adolescent Health Care: A Practical Guide

Chapter 25

Genitourinary Tract Disorders

Lawrence J. D'Angelo

Lawrence S. Neinstein

Genitourinary tract infections are common in adolescents. Those types most often diagnosed include cystitis, pyelonephritis, urethritis, and asymptomatic bacteriuria.

Cystitis

Epidemiology

  1. Over the course of a lifetime, cystitis is likely to occur three to five times more commonly in women than men. For adolescents, this difference may be as great as 50-fold!
  2. Ten percent to 20% of girls have at least one episode of acute cystitis during adolescence or young adulthood. Hooton et al. (1996) defined the annual incidence of a lower urinary tract infection (UTI) in female patients as 0.7 infections/person-year in a cohort of sexually active female university students. One infection appears to predispose an individual to more, with Foxman (1990) finding that 27% of young women had at least one recurrence within 6 months of the first infection, and 2.7% had a second recurrence in this same period.
  3. Risk factors for infection
  4. Females: Females are at greater risk than males because of a short urethra, which has close proximity to vaginal and rectal microorganisms. Risk factors for a UTI have been reported to include the following, although many of these risks are not well substantiated in the literature:
  • Poor perineal hygiene
  • –Infrequent cleansing
  • –Incorrect “wiping technique”
  • –Tight panty hose
  • Coitus and coital behaviors
  • –Diaphragm use (relative risk (RR) = 5.68 in subjects using a diaphragm five times a week)
  • –Coital frequency (RR = 4.81 in subjects reporting five coital episodes a week)
  • –Use of spermicide-coated condoms (odds ratio =5.65 for use more than twice weekly) (Fihn et al., 1996)
  • –Not voiding soon after intercourse (Strom et al., 1987)
  • Pregnancy
  • Nonsecretor of ABO blood group antigens (bind bacteria to vaginal epithelial cells)
  • Catheterization or instrumentation of the urethra
  • Anatomical abnormalities (e.g., urethral stenosis, neurogenic bladder, and nephrolithiasis)
  1. Males: Because UTIs in general and cystitis in particular are so much less frequent in males, risk factors and pathophysiology are less well understood. In non-sexually active male adolescents, bladder and renal infections are more likely to be a result of structural or functional abnormalities of the urinary tract. Additional factors in any male adolescent may include the following:
  • Blood group B or AB nonsecretor
  • P1blood group phenotype (epithelial cell receptors facilitate bacterial attachment)
  • Insertive anal intercourse
  • Sexual partner with vaginal colonization by uropathogens
  • Lack of circumcision (possibly by greater colonization of glans)

Microbiology

Females

The most common organism in female adolescents with acute cystitis is Escherichia coli (75%–90%). Staphylococcus saprophyticus is probably the second most common cause of UTI in young women (5%–15%). Other gram-negative organisms cause most of the remainder of the infections. In chronic or recurrent infections, Klebsiella species, enterococci,Pseudomonas aeruginosa, Enterobacter and Proteus species, Staphylococcus aureus, group B streptococcus, Streptococcus faecalis, and Serratia marcescens may play a more common role than in acute infections.

Males

Approximately three fourths of UTIs in male adolescents and young adults are due to gram-negative bacilli, but E. coli infections are not nearly as common as in girls. Gram-positive organisms, particularly enterococci and coagulase-negative staphylococci, account for approximately one fifth of infections. Trichomonas vaginalis is a rare cause of pyuria in men, usually involving an infection of the urethra or prostate. Gardnerella vaginalis can also occasionally cause infections in boys.

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Symptoms and Signs

Females

  1. Dysuria
  2. Frequency, hesitancy, and urgency
  3. Suprapubic pain
  4. Pyuria
  5. Hematuria

Symptoms caused by infections in the genitourinary tract are difficult to localize. For example, dysuria and dyspareunia in the female patient can be related to infections in the bladder, the urethra, or the vulva and vaginal tract. However, the location and timing of the dysuria is occasionally helpful. The dysuria associated with cystitis or urethritis is often described as internal pain and is usually worse when a patient initiates micturition. External pain or “terminal pain” (at the end of micturition) is more often associated with other conditions such as a vulvar inflammation, upper genital tract infection, or a herpes simplex infection.

Males

Apart from the preceding symptoms, male patients may also have symptoms associated with genitourinary infections in the prostate (perineal or rectal pain), epididymis (tender epididymis), or testicles (testicular pain and swelling).

Differential Diagnosis of Acute Dysuria

The most common complaint arousing suspicion of cystitis is dysuria. Dysuria may be a symptom of infection elsewhere in the urinary tract or infection of the genital tract, particularly in adolescents (Demetriou et al., 1982). The following are considerations in the differential diagnosis of cystitis and dysuria:

Females

Table 25.1 lists the pathogens, incidence of pyuria and hematuria, urine culture findings, and signs and symptoms of acute dysuria in women.

  1. Acute vaginitis and possible associated Skene glands infection secondary to Chlamydia trachomatis, Neisseria gonorrhoeae,or herpes simplex virus.
  2. Vulvovaginitis due to Candidaor Trichomonas.
  3. Local dermatitis: Includes irritation from chemicals and other agents such as soap, contraceptive agents and foams, and feminine hygiene products.
  4. Subclinical pyelonephritis: Some females with only dysuria have an upper UT These infections may be more difficult to eradicate. There are no reliable and simple methods to distinguish them from lower UTIs.
  5. Acute urethral syndrome: The presence of frequency and dysuria in women with urine cultures showing between 102and 105 colony-forming units (CFU)/mL has been termed theacute urethral syndrome or the dysuria–pyuria syndrome. However, studies have shown that many women with symptomatic cystitis have fewer than 105 CFU/m Therefore, this lower figure of 102 CFU/mL may be the appropriate microbiological criteria for determining the presence of a UTI. Kunin et al. (1993) reevaluated acute urinary symptoms and “low-count” bacteriuria (>102–104 CFU/mL) in women. E. coli and S. saprophyticus were the only microorganisms statistically associated with urinary tract symptoms and pyuria. This revision of bacterial counts has lessened or eliminated the need for a discrete acute urethral syndrome or dysuria–pyuria syndrome. The small group of symptomatic women with no growth on urine culture deserves evaluation for urinary or genital tract infections with C. trachomatis, Mycobacterium tuberculosis, herpes simplex virus, Candida, or T. vaginalis.

TABLE 25.1
Differential Diagnosis of Acute Dysuria in Women

Condition

Pathogen

Pyuria

Hematuria

Urine Culture

Signs, Symptoms

From Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med 1993;329:1329, with permission.

Cystitis

Escherichia coli, Staphylococcus saprophyticus, Proteus, Klebsiella sp

Usually

Sometimes

102 to >105

Acute onset, severe symptoms, dysuria, frequency, urgency, suprapubic or low back pain, suprapubic tenderness

Urethritis

Chlamydia trachomatis, Neisseria gonorrhoeae,herpes simplex virus

Usually

Rarely

<102

Gradual onset, mild symptoms, vaginal discharge or bleeding, lower abdominal pain, new sexual partner, cervical or vaginal lesions on examination

Vaginitis

Candida spTrichomonas vaginalis

Rarely

Rarely

<102

Vaginal discharge or odor, pruritus, dyspareunia, external dysuria, no frequency or urgency, vulvovaginitis on examination

Males

In males, the major diseases in the differential diagnosis of cystitis and dysuria include the following:

  1. Urethritis (secondary to sexually transmitted organisms including N. gonorrhoeae, trachomatis, T. vaginalis,and others)
  2. Prostatitis
  3. Irritation from agents such as spermicidal foam
  4. Trauma (usually associated with masturbation)

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Diagnosis

  1. History
  2. In females, are there symptoms suggestive of vulvovaginitis, such as an abnormal vaginal discharge or vaginal itching? With a vaginal infection, symptoms of frequency and urgency are less common. In males, is there a history of sexual exposure, past urinary tract problems, or trauma?
  3. Does the patient use any medications or irritants such as douches, feminine hygiene products, strong soaps, bubble bath, or contraceptive products that could cause a local dermatitis? Is there a history of mechanical irritation including frequent masturbation?
  4. Is the teen sexually active? If so, sexually transmitted diseases (STDs), including a cervicitis or urethritis caused by trachomatis, N. gonorrhoeae,or T. vaginalis, become a concern.
  5. Are there signs of upper genitourinary tract disease? Fever and flank pain suggest acute pyelonephritis.
  6. Are there factors suggestive of a subclinical pyelonephritis, such as underlying urinary tract disease, diabetes mellitus, urinary infections in childhood, three or more previous UTIs, or acute pyelonephritis in the past?
  7. Physical examination
  8. In both sexes, an examination of the abdomen and flank for tenderness should be performed. In addition, the genital area should be examined for a local dermatitis.
  9. In girls, a pelvic examination should be considered if the teen is sexually active or if there is history of a vaginal discharge.
  10. In boys, the physical examination should include inspection and palpation of the genitals to check for urethral discharge, meatal erythema, inflammation of the glans penis, penile lesions, an enlarged or tender epididymis or testis, or inguinal lymphadenopathy. A rectal examination is necessary if a diagnosis of prostatitis is under consideration.
  11. Laboratory studies
  12. Microscopic examination of urine
  • The presence of one or more bacteria/oil immersion field of uncentrifugedurine has an 80% to 95% correlation with bacteriuria in which the bacteria count is 105/m This examination may also be performed on a gram-stained specimen of unspun urine.
  • A count of more than ten organisms/oil immersion field on a centrifugedunstained sediment also correlates with positive culture results. Pyuria with five or more leukocytes/high-power field of urine sediment on spun urine has a poorer correlation. Sources of error with the latter include variable volumes of urine, variable time and speed of centrifugation, and inconsistent resuspension volume. However, analysis of unspun urine for leukocytes in a counting chamber does give reproducible results and is significant if the count is > ten leukocytes/mm3. Urine should be examined within 2 hours of collection. Presence of pyuria is a good indicator that antibiotic therapy will be necessary. A positive finding with a leukocyte esterase dipstick has a sensitivity of approximately 75% to 96% and specificity of 94% to 98% in detecting pyuria associated with an infection.
  1. Urine culture
  • A bladder or renal infection is usually characterized by a urine culture with a colony count of >100,000 CFU/mL of a typical urinary pathogen. However, it is now well established that a colony count of >100 CFU/mL of a pure culture of an organism indicates an infection in the presence of symptoms and pyuria. A urine culture is not mandatory for the diagnosis and treatment of a female adolescent with signs and symptoms of a UTI, particularly with a first episode. If therapy fails, if the infection represents a reoccurrence within the 3 months of an initial infection, or if the patient is a male, a culture is recommended. Cultures are also indicated for female patients with pyuria without bacteriuria.
  • In patients who become asymptomatic with therapy, posttreatment cultures are unnecessary. Follow-up cultures are indicated for patients with acute pyelonephritis, a complicated infection, or during pregnancy.
  1. Culture alternatives: Several rapid culture kits available for office use include:
  • Dipslide: Best studied and most reliable kit culture technique. The test is inexpensive and yields high sensitivity and specificity rates (generally <1% false-positive and false-negative results).
  • Filter-paper techniques yield false-negative rates of 3% to 20% and false-positive rates of 2% to 23%.
  • Several other chemical tests use nitrate glucose oxidase or catalase to detect the presence of bacteriuria. These tests are neither highly sensitive nor specific.
  1. Other tests
  2. Females: In girls, three infections within 1 to 2 years may be an indication for a more complete evaluation of the patient's urinary tract, which may include a renal ultrasound and a voiding cystourethrogram. However, in postpubertal female young adults with uncomplicated cystitis, evaluation after recurrent episodes is unlikely to reveal significant abnormalities that would change either therapy or prognosis. Figure 25.1 is a flow diagram for the evaluation of women with internal dysuria.
  3. Males: Although some authorities recommend a full investigation after the first infection, this is probably of greater importance in the young child or infant. In male adolescents, an investigation with more invasive tests is probably not indicated after the first infection, unless there is evidence in the history or physical examination of a possible renal abnormality or if there is no response to therapy. This is particularly true for male adolescents who are sexually active. Krieger et al. (1993) evaluated acute UTI in healthy university men. The incidence was 5 per 10,000 men per year. Of this group of men, 92% responded to a single course of antibiotics. None of them had neurological or anatomical abnormalities, and all the radiographic findings were normal. The major risk factor was a history of sexual activity in the previous month.

Recurrent Infections in Female Adolescents

Approximately 20% of young women will have recurrent infections. Most of these adolescents and young

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women do not have anatomical or functional abnormalities of the urinary tract. However, recurrent cystitis within 3 months of the original infection should call for a urine culture. Those female patients with a relapse (recurrent infection with original pathogen within 2 weeks of completion of therapy) should also have their urine cultured and in either case should have careful follow-up. Continued infections should result in an evaluation for an occult source of infection or urological abnormality.

 

FIGURE 25.1 Flow diagram for the evaluation of women with internal dysuria. STD, sexually transmitted disease; UTI, urinary tract infection. (From Holes KK. Lower genital tract infection in women: cystitis, urethritis, vulvovaginitis, and cervicitis. In: Holmes KK, Mardh PA, Sparling PF et al., eds. Sexually transmitted diseases. New York: McGraw-Hill, 1990, with permission.)

Pyelonephritis

Pyelonephritis is an infection of the renal pelvis and medulla. Risk factors for pyelonephritis are similar to those for UTI but also include maternal history of UTI and diabetes (Scholes et al., 2005). There are approximately 250,000 cases of acute pyelonephritis each year, resulting in >100,000 hospitalizations. Women are five times more likely than men to be hospitalized. Most infections occur from bacterial ascent through the urethra and bladder.

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The clinical and laboratory manifestations usually include the following:

  1. Symptoms of acute cystitis
  2. Fever
  3. Costovertebral tenderness
  4. Elevated leukocyte count and erythrocyte sedimentation rate
  5. Urinalysis revealing leukocytes and bacterial casts
  6. Positive urine culture result

The range of symptoms varies from mild flank pain to those of septicemia. Most cases of acute pyelonephritis in young women are caused by E. coli infection (>80%). Pyuria and gram-negative bacteria are usually present on examination of the urine. Urine culture specimens should always be obtained. Blood culture specimens should also be obtained from those whose diagnosis is uncertain, from immunosuppressed patients, from those in whom a hematogenous source is suspected, or from those who are ill enough to be hospitalized. If fever and flank pain persist after 72 hours of treatment, then cultures should be repeated and ultrasonography or computed tomography should be considered to evaluate for an abscess. Additional indications for imaging studies include recurrent pyelonephritis, persistent hematuria, or poor response to treatment. Indications for hospitalization include persistent vomiting, suspected sepsis, uncertain diagnosis, and urinary tract obstruction. Other relative indications include anatomical urinary tract abnormalities, immunocompromised status, and inadequate access to follow-up care.

Treatment of Genitourinary Infections

  1. Acute, uncomplicated infections in females (usually caused by organisms such as E. coli, S. saprophyticus, Proteus mirabilis, Klebsiella pneumoniae,and others): A growing number of urinary tract pathogens have begun to develop resistance to commonly used antibiotics, particularly trimethoprim-sulfamethoxazole and amoxicillin. Resistance to the latter and its clinical failure rate are now so high that amoxicillin is no longer considered an appropriate “first choice” antibiotic, even if combined with clavulanate (Hooton et al., 2005). Local resistance patterns should be consulted before prescribing any antibiotics as first-line treatment of UTIs. Assuming appropriate sensitivity of organisms:
  2. No complicating factors: Use a 3-day oral regimen of one of the following:
  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours) or trimethoprim (100 mg every 12 hours)
  • Cefpodoxime (200 mg every 12 hours)
  • Nitrofurantoin (100 mg every 6 hours)
  • In older adolescents (older than 16 years), a 3-day regimen of a quinolone would also be appropriate. Appropriate regimens include the following:
  • –Norfloxacin (400 mg every 12 hours)
  • –Ciprofloxacin (250 mg every 12 hours)
  • –Ofloxacin (200 mg every 12 hours)
  1. For patients with potentially complicating problems such as diabetes, sickle cell disease, a history of a previous UTI, or symptoms for >1 week, use a 7-day regimen of a previously mentioned medication.
  2. Pregnancy: Use a 7-day regimen of the following:
  • Nitrofurantoin (100 mg four times a day)
  • Cefpodoxime (200 mg every 12 hours)
  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours)
  1. 3-day course versus single-dose antibiotics: Although there was great interest in the possibility of treating uncomplicated UTIs in women with a single dose of antibiotics, a 3-day course of antibiotics appears to ensure greater success than the single-dose antibiotic regimens in a number of studies. The exception to this may be the use of fosfomycin in a single 3-g dose for infections in women older than 18 years (minimum age approved).
  2. 3-day course versus longer course of antibiotics: Michael et al. (2006) evaluated ten trials in children up to age 18. There was no significant difference in the frequency of positive urine cultures between the short (2–4 days) and standard duration oral antibiotic therapy (7–14 days) for UTI at 0 to 10 days after treatment and at 1 to 15 months after treatment. There was also no difference in the development of resistant organisms. A 2005 meta-analysis by Katchman et al. (2005) addressed this question in adults with UTIs. Antibiotic therapy for 3 days was similar to prolonged therapy in achieving symptomatic cure for cystitis; however, the prolonged treatment was slightly more effective in obtaining bacteriological cure both short-term (RR = 1.37) and longer term (RR = 1.47). If elimination of bacteriuria is important in an adolescent, a longer treatment time than 3 days, could be considered.
  3. Acute, uncomplicated pyelonephritis in female patients (usually caused by organisms such as E. coli, P. mirabilis, K. pneumoniae, S. saprophyticus): Avoid amoxicillin and first-generation cephalosporins because 25% to 35% of organisms are resistant to these antibiotics.
  4. Mild to moderate illness with no nausea or vomiting: Initial outpatient oral therapy is acceptable in adolescents with a community-acquired infection not associated with severe systemic symptoms or known complications. Oral therapy can include any of the following, with each regimen administered for 10 to 14 days.
  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours)
  • Cefpodoxime (200 mg every 12 hours)
  • Quinolones that can be utilized in older adolescents and young adults:
  • –Norfloxacin (400 mg every 12 hours for 10–14 days)
  • –Ciprofloxacin (500 mg every 12 hours for 10–14 days)
  • –Ofloxacin (200–300 mg every 12 hours for 10–14 days)
  • –Levofloxacin (500 mg daily for 10–14 days)
  1. Severe pyelonephritis or other complicated UTI requiring hospitalization (e.g., patients with diabetes, sickle cell disease, or immunodeficiency): Parenterally administered antibiotics, including one of the following:
  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours)
  • Ceftriaxone (1–2 g/day)

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  • Ciprofloxacin (200–400 mg every 12 hours)
  • Gentamicin (1 mg/kg every 12 hours [with or without ampicillin])
  • Ticarcillin/clavulanate (3.1 g every 8 hours)
  • Imipenem (500 mg every 8 hours)

Use these until fever has resolved for 24 to 48 hours and then treat with oral antibiotics for 14 days using one of the following (limit use of quinolones in patients younger than 16 years):

  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours)
  • Cefpodoxime (200 mg every 12 hours)
  • Norfloxacin (400 mg every 12 hours)
  • Ciprofloxacin (500 mg every 12 hours)
  • Ofloxacin (200–300 mg every 12 hours)
  1. Pregnancy: Hospitalization is highly recommended, with parentally administered antibiotics, including one of the following:
  • Ceftriaxone (1–2 g/day)
  • Aztreonam (1 g every 8–12 hours)
  • Gentamicin (1 mg/kg every 12 hours)

Use these until fever has resolved for 24 to 48 hours and then treat with oral antibiotics for 14 days, using one of the following:

  • Cefpodoxime proxetil (200 mg every 12 hours)
  • Trimethoprim-sulfamethoxazole (160/800 mg every 12 hours)
  1. Recurrent infections: Recurrent cystitis in female patients should be managed by either continuous prophylaxis, postcoital prophylaxis, or therapy initiated by the patient.
  2. Continuous prophylaxis: Use one of the following:
  • Trimethoprim (100 mg daily)
  • Trimethoprim-sulfamethoxazole (40/200 mg daily)
  • Nitrofurantoin (50–100 mg daily)
  • Norfloxacin (200 mg daily)
  • Cephalexin (250 mg daily)
  1. Postcoital prophylaxis: Use one of the following:
  • Trimethoprim-sulfamethoxazole (40/200 mg)
  • Nitrofurantoin (50–100 mg)
  • Cephalexin (250 mg)
  1. Patient-administered therapy: An alternative to prophylaxis in the compliant individual is self-medication initiated at the time the symptoms appear, with a 3-day regimen (Gupta et al., 2001). Patient-initiated therapy is best for individuals with only one or two episodes per year.
  2. Nonantibiotic measures: Nonantibiotic prevention of recurrent UTIs includes the following:
  • Voiding after intercourse
  • Discontinuing use of a diaphragm
  • Emptying the bladder frequently
  • Acidifying the urine
  1. Treatment of UTIs in male patients: Less information is known about short-term or single-dose therapy in males. Male patients should probably receive a 7- to 10-day course of antibiotics. However, in less compliant male patients, a 3-day regimen of trimethoprim-sulfamethoxazole or a quinolone such as norfloxacin in age-appropriate patients could be used.
  2. Cautions and contraindications
  3. Fluoroquinolone antibiotics are not approved for use in adolescents younger than 16 years and should not be used in pregnancy.
  4. Trimethoprim-sulfamethoxazole is not approved in pregnancy but has been widely used.
  5. Gentamicin should be used with great caution in pregnancy because of the possibility of toxicity to the eighth nerve of the developing fetus.
  6. Local resistance patterns will influence the ultimate choice of antibiotics.

Asymptomatic Bacteriuria

The prevalence of asymptomatic bacteriuria (reproducible growth of >105 CFU/mL) ranges from approximately 1% to 7%. There is a tendency toward spontaneous cure. However, women with this condition are at increased risk of an overt UTI (8% in the week after documented bacteria in the urine [Hooton et al., 2000]), and in individuals whose infection begins in childhood, there is a suggestion that their infection can lead to renal impairment. Asymptomatic bacteriuria during pregnancy is a risk factor for the development of acute pyelonephritis, for lower fetal birth weight, and for a higher incidence of prematurity. Treatment is mainly indicated for the following individuals:

  1. Those who are pregnant
  2. Male patients
  3. Female patients with either an underlying renal tract abnormality or an immunocompromising disease

Treatment should be with appropriate antibiotics selected on the basis of culture sensitivities.

Nongonococcal Urethritis

Nongonococcal urethritis (NGU) is an infectious inflammation of the urethra characterized by dysuria and by a mucopurulent penile discharge. As its name implies, it is unassociated with infection by N. gonorrhoeae. Asymptomatic infections are quite common.

Etiology

  1. C. trachomatis:There is clear evidence that certain genotypes cause approximately 40% to 50% of the cases of NGU.
  2. Ureaplasma urealyticum:Reliable data implicate this organism as a cause of approximately 20% to 30% of additional cases of NGU.
  3. In the remainder of cases, the cause is uncertain: Other possibilities include Mycoplasma genitalium, G. vaginalis, herpes simplex virus, S. saprophyticus, E. coli, and T. vaginalis.

Epidemiology

  1. Incidence: Extremely common among sexually active men. In the United Kingdom, it is the most frequently recorded STD and this would probably be true in the United States if all jurisdictions required reporting of NGU and chlamydial infection. It is estimated that 3 to 4 million cases occur yearly in the United States.
  2. Transmission: Sexual contact

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Clinical Manifestations

  1. Discharge: Usually scanty or moderate, watery discharge; some patients have no discharge, whereas others have copious, purulent discharge, which usually starts 8 to 14 days after contact.
  2. Dysuria
  3. Rarely, hematuria
  4. Complications of untreated infection include epididymitis, prostatitis (rare), and Reiter syndrome (very rare).

Diagnosis

  1. Clinical history
  2. Gram stain of urethral discharge
  3. More than five polymorphonuclear cells/oil immersion field indicates urethritis.
  4. The lack of intracellular gram-negative diplococci suggests NGU.
  5. Urine
  6. A leukocyte count of more than ten cells/high-power dry field of the urine sediment from the first 10 to 15 mL of a urine stream indicates urethritis.
  7. A leukocyte esterase dipstick test result is positive.
  8. The urine sediment test, although often unnecessary if a discharge is present, is helpful in determining the presence or absence of urethritis.
  9. Urethral culture if Gram stain result of the discharge is negative; culture or nonculture technique for gonorrheal and chlamydial infection

Therapy

  1. Recommended regimen
  2. Doxycycline (100 mg orally twice daily for 7 days) or
  3. Azithromycin (1 g orally in a single dose)
  4. Ofloxacin (400 mg orally twice daily for 7 days)
  5. Alternative regimens
  6. Erythromycin base (500 mg given orally four times daily for 7 days) or
  7. Erythromycin ethylsuccinate (800 mg orally four times daily for 7 days)
  8. For a patient who cannot tolerate high-dose erythromycin schedules: Use one of the following regimens:
  • Erythromycin base (250 mg given orally four times a day for 14 days)
  • Erythromycin ethylsuccinate (400 mg orally four times a day for 14 days)

Note that patients with persistent or recurrent objective signs of urethritis after adequate treatment of themselves and their partners warrant further evaluation for less common causes of urethritis. In addition, in some individuals with persistent infections, a longer (14–21 days) course of antibiotics may be effective. Finally, sexual partners must be treated.

Prostatitis

Etiology

Prostatitis is an inflammatory reaction confined to the prostate gland. In adolescents, prostatitis is an unusual condition. Acute prostatitis in adolescents is usually caused by an infection, which probably started as a urethral infection and reached the prostate through the reflux of infected urine into the prostatic ducts or by lymphogenous or hematogenic spread. Although it is often assumed that STDs, and particularly infection with N. gonorrhoeae and C. trachomatis, cause a large percentage of the cases of acute prostatitis in adolescents and young adults, evidence to support this is inadequate. Coliform bacteria, S. saprophyticus, Mycoplasma hominis, U. urealyticum, and T. vaginalis, have also been implicated as causative agents. In one study of 409 patients with prostatitis—boys age 19 years and older—the most frequent organism isolated was U. urealyticum (de la Rosette et al., 1993). The cause or causes of noninfectious prostatitis and chronic prostatitis are even more unclear.

Diagnosis

  1. In acute bacterial prostatitis, symptoms include the following:
  2. Pain: Penile/scrotal, suprapubic, perineal, groin, or back pain or pain that occurs during ejaculation
  3. Bladder symptoms: Frequency, dysuria, and hesitation
  4. Systemic symptoms: Chills, fever, and malaise
  5. Other symptoms: Hematospermia and hematuria
  6. In nonacute prostatitis, the symptoms are less dramatic and may include frequency, urgency, and dysuria.
  7. The only method for documenting prostatitis is the segmental culture technique.
  8. Four specimens are collected, including the following:
  • First-voided 10-mL urine
  • Midstream urine
  • Prostatic secretions during prostatic massage
  • First-voided 10 mL after prostatic massage
  1. In individuals with bacterial prostatitis, the third and fourth specimens should grow more colonies than the first two. The presence of more leukocytes in the first specimen suggests urethritis, and growth primarily in the second specimen suggests cystitis. However, because the meaning and interpretation of this test are not standardized and the test is time consuming, expensive, and uncomfortable, it should not be performed routinely in adolescents.

Treatment

In the acutely inflamed prostate gland, antibiotics have good penetration; however in adolescents with recurrent prostatic infections, treatment is hampered by the lack of good antibiotic penetration. The best antibiotic choices for empirical treatment of prostatic infections include the following:

  • Trimethoprim-sulfamethoxazole (160/800 mg every 2 hours for 7 days) or
  • Ofloxacin (400 mg every 12 hours for 7 days) or
  • Doxycycline (100 mg every 12 hours for 7 days) or
  • Erythromycin (500 mg every 6 hours for 7 days)

If symptoms persist, more aggressive attempts to obtain specific diagnostic samples need to be undertaken, including the segmental culture technique described above.

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Hematospermia

Bloody ejaculate is an unusually reported condition which can occur in male adolescents. The adolescent may notice a reddish discoloration of his semen either after masturbation or on removing a condom after intercourse. This condition may cause extreme anxiety or feelings of guilt. The teen may be concerned about a malignancy or fear that his behavior has caused the condition. In adolescents, the condition is usually either idiopathic and self-limited or related to an infection such as a gonococcal or chlamydial urethritis. Apart from evaluation for a UTI, prostatitis, or sexually transmitted urethritis, an extensive investigation is not required unless the condition is persistent and the initial findings are negative.

Web Sites

For Teenagers and Parents

http://familydoctor.org. Good general reference for a range of health problems, including UTIs.

http://youngwomenshealth.org/resourcenter.html. Comprehensive site for young women's health issues.

http://womenshealth.gov/faq/Easyread/uti-etr.htm Patient-friendly government handout on UTIs.

http://my.webmd.com/content/article/1680.50565. WebMD article on UTIs.

http://www.drreddy.com/uti.html. Good explanation for teens and parents.

http://www.mayohealth.org. Mayo Clinic site on UTIs. Search for UTIs.

For Health Professional

http://www.urologychannel.com/uti/index.shtml. Discussion of urinary tract health issues, including UTIs.

http://www.niddk.nih.gov/health/urolog/pubs/cpwork/cpwork.htm. National Institutes of Health information on prostatitis.

http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/. National Institutes of Health information on urinary tract infections.

References and Additional Readings

Abrahamsson A, Hansson S, Jodal U, et al. Staphylococcus saprophyticus urinary tract infections in children. Eur J Pediatr 1993;152:69.

Ansbach RK, Dybus KR, Bergeson R. Uncomplicated E. coli urinary tract infection in college women: a retrospective study of E. coli sensitivities to commonly prescribed antibiotics. J Am Coll Health 1995;43:183.

Bergeron MG. Treatment of pyelonephritis in adults. Med Clin North Am 1995;79:619.

Bonny AE, Brouhard BH. Urinary tract infections among adolescents. Adolesc Med Clin 2005;16:149.

Brumfitt W, Hamilton-Miller JM. A comparative trial of low dose cefaclor and macrocrystalline nitrofurantoin in the prevention of recurrent urinary tract infection. Infection1995;23:98.

Davison IM, Sprott MS, Selkon JB. The effect of covert bacteriuria in schoolgirls on renal function at 18 years and during pregnancy. Lancet 1984;2:651.

Demetriou E, Emans SJ, Masland RP Jr. Dysuria in adolescent girls: urinary tract infection or vaginitis? Pediatrics 1982;70:299.

Fihn SD, Boyko EJ, Normand EH, et al. Association between use of spermicide-coated condoms and Escherichia coli urinary tract infection in young women. Am J Epidemiol1996;144:512.

Fletcher MS, Herzberg Z, Pryor JP. The aetiology and investigation of haemospermia. Br J Urol 1981;53:669.

Foxman B. Recurring urinary tract infection: incidence and risk factors. Am J Public Health 1990;80:331.

Gupta K, Hooton TM, Roberts PL, et al. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001;135:9.

Holmes KK, Stamm W. Lower genital tract infection in women. In: Holmes KK, Sparling PE, Mardh PA et al., eds. Sexually transmitted diseases, 3rd ed. New York: McGraw-Hill, 1999.

Hooton TM, Scholes D, Gupta K, et al. Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in women. A randomized trial. JAMA 2005;293:949.

Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996;335:468.

Hooton TM, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med 2000;343:992.

Hooton TM, Winter C, Tiu F, et al. Randomized comparative trial and cost analysis of 3-day antimicrobial regimens for treatment of acute cystitis in women. JAMA 1995;273:41.

Joly-Guillou ML, Lasry S. Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis, and prostatitis.Drugs 1999;57:743.

Katchman EA, Milo G, Paul M. Three-day vs longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis. Am J Med 2005;118:1196.

Komaroff AL. Urinalysis and urine culture in women with dysuria. Ann Intern Med 1986;104:212.

Krieger JN, Ross SO, Simonsen JM. Urinary tract infections in healthy university men. J Urol 1993;149:1046.

Kunin CM, White LV, Hua Hua T. A reassessment of the importance of “low count” bacteriuria in young women with acute urinary symptoms. Ann Intern Med 1993;119:454.

Latham RH, Running K, Stamm WE. Urinary tract infections in young adult women caused by Staphylococcus saprophyticus. JAMA 1983;250:3063.

Leigh DA. Prostatitis—an increasing clinical problem for diagnosis and management. J Antimicrob Chemother 1993;32 (Suppl A):1.

Lipsky BA. Prostatitis and urinary tract infection in men: what's new; what's true? Am J Med 1999;106:327.

Merrick MV, Notghi A, Chalmers N, et al. Long-term follow-up to determine the prognostic value of imaging after urinary tract infections. Part 1: reflux. Arch Dis Child1995;72:388.

Merrick MV, Notghi A, Chalmers N, et al. Long-term follow-up to determine the prognostic value of imaging after urinary tract infections. Part 2: scarring. Arch Dis Child1995;72:393.

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Michael M, Hodson EM, Craig JC, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2006;1.

Millar LK, Wing DA, Paul RH, et al. Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial. Obstet Gynecol 1995;86:560.

Ohkawa M, Yamaguchi K, Tokunaga S, et al. Ureaplasma urealyticum in the urogenital tract of patients with chronic prostatitis or related symptomatology. Br J Urol 1993;72:918.

Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician 2005;71:933.

de la Rosette JJMCH, Hubregtse MR, Meuleman EJH, et al. Diagnosis and treatment of 409 patients with prostatitis syndromes. Urology 1993;41:301.

Rouse DJ, Andrews WW, Goldenberg RL, et al. Screening and treatment of asymptomatic bacteriuria of pregnancy to prevent pyelonephritis: a cost-effectiveness and cost-benefit analysis. Obstet Gynecol 1995;86:119.

Scholes D, Hooton TM, Roberts PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005;142:20.

Semeniuk H, Church D. Evaluation of the leukocyte esterase and nitrite urine dipstick screening tests of bacteriuria in women with suspected uncomplicated urinary tract infections. J Clin Microbiol 1999;37:3051.

Sheffield JS, Cunningham FG. Urinary tract infection in women. Obste Gynecol 2005;106:1085.

Sheinfeld J, Schaeffer Al, Cordon-Cardo C, et al. Association of the Lewis blood-group phenotype with recurrent urinary tract infections in women. N Engl J Med 1989;320:773.

Silber TJ, Kastrinakas M. Hematospermia in adolescents and young adults. Pediatrics 1986;78:708.

Smellie JM, Rigden SP, Prescod NP. Urinary tract infection: a comparison of four methods of investigation. Arch Dis Child 1995;72:247.

Stapleton A, Latham RH, Johnson C, et al. Postcoital antimicrobial prophylaxis for recurrent urinary tract infection: a randomized, double-blind, placebo-controlled trial. JAMA1990;264:703.

Stein GE. Comparison of single-dose fosfomycin and a 7-day course of nitrofurantoin with uncomplicated urinary tract infection. Clin Ther 1999;21:1864.

Strom BL, Collins M, West SL, et al. Sexual activity, contraceptive use, and other risk factors for symptomatic and asymptomatic bacteriuria: a case-control study. Ann Intern Med1987;107:816.

Weir M, Brien J. Adolescent urinary tract infections. Adolesc Med (State Art Rev) 2000;11:293.

Zhanel GG, Harding GKM, Guay DRP. Asymptomatic bacteriuria: which patients should be treated? Arch Intern Med 1990;150:1389.