Urinary Tract Infection — History and Physical — Clinical Pathway: All Settings

Urinary Tract Infection (UTI) Clinical Pathway — All Settings

History and Physical Exam

Assess for symptoms suggestive of UTI as well as alternative sources of fever.

Children < 24 Months

  • Often present with fever alone, with or without other non-specific symptoms
  • Appropriate to screen this age group based on risk factors, especially when there is no other source of fever identified (UTICalc  )

Older Children and Adolescents

More likely to have symptoms suggestive of UTI.

History
  • Fever:
    • Presence
    • Duration
    • Height of fever
  • Risk Factors for UTI in Children < 24 Months:
    • History of UTI
    • No alternative source
    • Temperature > 39°C
    • Female or uncircumcised male
    • Fever > 2 days
    • Age < 12 mos
    • Use UTICalc   to estimate probability of UTI in 56 days to 24 mos with fever
  • Alternative Fever Source:
    • Alternative source is included in UTI risk prediction, UTICalc  
    • Children with definitive source of fever were typically excluded from occult UTI prediction studies due to low expected risk.
    • Consider the following when assessing alternative fever source:
      • Possible fever source
        • New upper respiratory infection
        • Acute gastroenteritis
        • Acute OM
      • Definitive Fever Source
        • Viral disease with pathognomonic findings:
          • Bronchiolitis (lower respiratory findings present)
          • Coxsackie (hand, foot, and mouth disease)
          • Parvovirus (fifths disease)
          • Herpes simplex virus (gingivostomatitis)
          • Varicella zoster virus
          • Epstein-Barr virus (mononucleosis)
          • Measles
        • Bacterial:
          • Group A Streptococcal pharyngitis
          • Acute purulent otitis media
          • Sinusitis
          • Pneumonia
          • Cellulitis, abscess, lymphadenitis
          • Septic arthritis, osteomyelitis
          • Meningitis
        • Fever Clinical Pathway, All Settings
  • Symptoms Suggestive of UTI:
    • More commonly identified in older children, adolescents:
      • Dysuria, frequency, urgency, hematuria
      • Abdominal pain, nausea, vomiting
      • New incontinence
      • Flank pain, back pain
  • Assess:
    • Hydration status, I/O
    • History of recurring fever without identifiable source, FUO
    • History of UTI
    • Constipation
    • Dysfunctional voiding by history
    • FH of vesicoureteral reflux (VUR) or renal disease
    • Recent antibiotic use
    • GU abnormality, recent GU surgeries
    • Other pertinent disease
    • Adolescents:
Physical Exam
  • VS, growth
  • Overall appearance, signs of sepsis
  • Suprapubic, flank tenderness
  • Abdominal mass, palpable bladder, palpable stool
  • Evidence of spinal lesion
    • e.g., hair tuft, lipoma, sacral dimple
  • GU abnormality
    • e.g., labial adhesions, signs of vulvovaginitis or FB, phimosis