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pyuria (leukocyturia)

Pus in the urine. Defined as 10 or more leukocytes/mL, determined from fresh unspun urine by microscopy using a hemocytometer chamber. Also: > 3-5 leukocytes/hpf older women with urinary tract infection: 180 leukocytes/HPF older women with asymptomatic bacteriuria: < 60 leukocytes/HPF Etiology: - urinary tract infection - sterile pyuria: [5] - genitourinary tuberculosis - sexually-transmitted disease - bacterial infection: - gonorrhea, Chlamydia trachomatis, syphilis, mycoplasma, - trichomoniasis - viral infection: HPV, HSV2, Herpes zoster, advanced HIV1 - fungal infections - Candida albicans most common - renal tubulointerstitial disease - glomerulonephritis - acute interstitial nephritis (AIN) - acute renal transplant rejection - interstitial cystitis [3] - renal calculi - bladder tumors - inflammatory disorders - interstitial cystitis - prostatitis - urethritis - balanitis - allergic reactions - eosinophiluria - acute urethral syndrome or dysuria-pyuria syndrome in women - common in patients with indwelling catheter (foley) - cannot be used to indicate infection Epidemiology: - 14% of women & 3% of men have sterile pyuria [5] Laboratory: - pyuria alone inadequate for predicting bacteriuria [6] - urine WBC count > 25 cell/hpf is optimal cutoff to detect bacteriuria [6] - testing for sexually-transmitted disease as indicated - sterile pyuria - tuberculin skin testing vs quantiferon - urine acid-fast bacilli smear & urine culture for tuberculosis [8,9] Radiology: - abdominal &/or pelvic imaging for evaluation of febrile or otherwise symptomatic patients Differential diagnosis: 1) increased numbers of leukocytes (> 20/hpf) are found in most diseases of the urinary tract 2) > 30/hpf suggests acute infection a) repeated sterile cultures suggest tuberculosis or nephritis b) gross pyuria suggest rupture of urinary tract abscess c) leukocyte casts suggest renal origin 3) sterile pyuria Management: - pyuria without bacteriuria - specific evaluation for sexually transmitted infection [5] - evaluation for tuberculosis [5] - antibiotics do not improve symptoms of delirium in elderly with pyuria or bacteriuria without systemic signs of infection or genitourinary symptoms Notes: - leukocytes are rapidly lysed in hypotonic or alkaline urine; 50% lyse after 2-3 hours of standing at room temperature.

Interactions

disease interactions

Related

eosinophiluria leukocyte (white blood cell)

General

sign/symptom

References

  1. Clinical Diagnosis & Management by Laboratory Methods, 19th edition, J.B. Henry (ed), W.B. Saunders Co., Philadelphia, PA. 1996, pg 438
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 544
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Dieter RS. Sterile pyuria: a differential diagnosis. Compr Ther. 2000 Fall;26(3):150-2. Review. PMID: 10984817
  5. Wise GJ, Schlegel PN Sterile Pyuria. N Engl J Med 2015; 372:1048-1054 PMID: 25760357 http://www.nejm.org/doi/full/10.1056/NEJMra1410052
  6. Cheng B et al. Correlation of pyuria and bacteriuria in acute care. Am J Med 2022 Sep; 135:e353. PMID: 35580716 https://www.amjmed.com/article/S0002-9343(22)00350-3/fulltext
  7. Bilsen MP et al. Current pyuria cutoffs promote inappropriate urinary tract infection diagnosis in older women. Clin Infect Dis 2023 Jun 16; 76:2070 PMID: 36806580 PMCID: PMC10273372 Free PMC article https://academic.oup.com/cid/article/76/12/2070/7048393
  8. Muneer A, Macrae B, Krishnamoorthy S, Zumla A. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019 Oct;16(10):573-598 PMID: 31548730 Review.
  9. Jacob JT, Nguyen TM, Ray SM. Male genital tuberculosis. Lancet Infect Dis. 2008 May;8(5):335-42. PMID: 18471778
  10. Stall NM, Kandel C, Reppas-Rindlisbacher C, et al. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc. 2024 Jun 19. PMID: 38895992 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18964