DiagnosisAssociated symptomsAdditional historyPhysical examinationLaboratory and other test results
CystitisFrequency, urgency, may have gross hematuriaRecent sexual intercourse, risk factors present (see Table 2)15 to 20% have suprapubic tenderness; no costovertebral angle tendernessUsually positive for pyuria and sometimes also positive for bacteriuria and nitrite
Subclinical pyelonephritisFrequency, urgency, may have gross hematuriaRisk factors present (see Table 5)May have suprapubic tenderness; no costovertebral angle tendernessUsually positive for pyuria and sometimes also positive for bacteriuria and nitrite; positive renal cortical scintigraphy, urine culture usually > 105 colony-forming units per mL of urine
Acute pyelonephritisNausea, emesis, fever, sepsis, back/flank painMay have had concurrent or preceding cystitis symptoms (see Table 5)Costovertebral angle tenderness, deep right or left upper quadrant tendernessPyuria usually present with casts of white blood cells; obtain urine culture and sensitivity
Interstitial cystitisFrequency, urgency, gross hematuria (20%)Often middle-aged; longstanding symptoms with negative culturesNo costovertebral angle tenderness; may have suprapubic tendernessUrinalysis negative for white blood cells or bacteria; positive for glomerulations on cystoscopy
VaginitisExternal irritation, vaginal discharge or pruritus, dyspareunia; no hematuriaPremenstrual exaggeration of symptoms; sexual activity or recent antibiotic exposure or post-menopausal and not receiving estrogen replacement therapyVaginal discharge, inflamed vaginal mucosa (absent in bacterial vaginosis), inflamed cervix (Trichomonas), vaginal atrophy (postmenopausal)Positive potassium hydroxide or vaginal saline preparation; elevated pH (bacterial vaginosis or Trichomonas)
Genital herpesDysuria, fever, headache, myalgias, neck pain, vulvar pain, photophobiaSexually active; may have vaginal dischargeGrouped vesicles usually on cervix or pubic area, but may be vaginal; tender inguinal adenopathyViral culture optional
UrethritisUsually asymptomatic; if symptoms develop, they are usually delayed (>1 week)History of unprotected sexual exposureNo suprapubic pain unless associated with pelvic inflammatory disease; rarely, visible urethral dischargeUrethral swab positive for white blood cells; obtain Gram stain to detect intracellular gram-negative diplococci and DNA probe for Chlamydia and gonorrhea