Is It Just a UTI?

ABSTRACT&COMMENTARY

Source: Berg E, et al. High prevalence of sexually transmitted diseases in women with urinary tract infections. Acad Emerg Med 1996;3:1030-1034.

In a three-month retrospective study of women 12-45 years old who were discharged from the ED with a sole diagnosis of urinary tract infection (UTI), Berg et al sought to determine the prevalence of occult sexually transmitted disease (STD). Only patients who had a pelvic examination with cultures were included. Documented symptoms, signs, and laboratory results were reviewed to determine whether any parameters could be discovered that would differentiate those patients with an STD from those without one. STD was defined as gonorrhea, chlamydia, or trichomoniasis.

One hundred forty-eight women met the inclusion criteria by age and diagnosis, but only 94 of them had documented pelvic examination and culture results. Of those 94, an impressive 53% had an STD (10% gonorrhea, 22% chlamydia, and 33% trichomoniasis—some patients had more than one entity). There was no difference between those patients positive for STD and those negative for STD with regard to historical, physical, or laboratory examination results.

The authors conclude that a high-risk group for unrecognized STD has been identified. They assert that this group cannot be recognized by clinical or laboratory findings, and suggest consideration of empirical treatment of these STD pathogens in women in this age range with an ED diagnosis of UTI.

COMMENT BY RICHARD A. HARRIGAN, MD

We see this patient so often in our ED: a young woman with nonspecific genitourinary complaints and a urinalysis consistent with a UTI. Does this patient need a pelvic examination? I think it is necessary in certain populations, not only because UTI and STD can be difficult to differentiate by history and abdominal examination alone, but because there is a link between frequency of sexual intercourse and UTI.1 But what about the patient who has "obvious" UTI symptoms—can a UTI just be a UTI? The answer is still unclear. In this study by Berg et al, there is evidence that some patients are presumed to just have a UTI—54 of the 148 patients in this age range with the diagnosis of UTI did not have a pelvic examination with cultures. Maybe those patients were the ones with "obvious" UTIs, or maybe those patients had missed occult STDs—who knows? If the former is true, the study population is biased; that is, perhaps patients were more likely to have a pelvic examination if their physicians thought they were more likely to have a pelvic infection and/or the working diagnosis of UTI were less secure. This would inflate the occult STD rate in this study. It could be argued that there was significant suspicion on the part of the treating physicians that the patient might have concomitant STD because cultures were sent on all those patients; the working diagnosis was in actuality not solely "UTI," but "UTI, R/O STD."

The authors readily acknowledge the need for a prospective study. They also reveal that their study lacked the power to decisively discern which symptoms could differentiate patients with STD from patients without STD. This study highlights the fact that STD and UTI are interrelated—they may coexist and they are difficult to differentiate due to overlapping symptomatology. For now, it is safer to be thorough and examine the patient fully. In this population, it is still unclear when a UTI is just a UTI.

Reference

1. Hooten TM, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996;335:468-474.