GENITOURINARY INFECTIONS





Acronyms



Bacterial vaginosis (BV)

Overview

  • Epidemiology: BV is prevalent in 20 - 25% of young women and 15% of pregnant women
  • Risk factors: Douching, sexual intercourse, lack of vaginal lactobacilli, IUD, uncircumcised male partners, and the penile microbiota
  • Pathology: In BV, the normal vaginal flora (Lactobacillus sp) is replaced with high concentrations of G. vaginalis, Ureaplasma, Mycoplasma, and numerous fastidious or uncultivated anaerobes. The cause of the shift in vaginal microbiota is not well-understood.
  • Symptoms: Vaginal discharge and a fishy malodor. However, most women with BV are asymptomatic.
  • Recurrence: Recurrence is common after treatment, with more than 50% of women experiencing reinfection within 12 weeks. The 2025 StepUp study found that treating male partners with oral and topical antibiotics reduced recurrence rates.

Diagnosis

  • Diagnosis can be made in a lab with a gram stain or with PCR tests that detect the presence of G. vaginalis, A. vaginae, and mobiluncus species
  • A wet mount of vaginal discharge can be performed to look for the diagnostic clue cells, which are squamous epithelial cells covered with coccobacilli in the absence of rods
  • Home vaginal pH tests are widely available, and they can help provide clues to the type of infection. BV typically occurs at a pH ≥ 4.7, while yeast infections occur at the normal vaginal pH of < 4.7.

Treatment overview

  • Treatment is only recommended for women with symptoms
  • The 2025 StepUp study found that treating male partners with oral and topical antibiotics reduced recurrence rates in women. Past studies that only treated male partners with oral therapies did not demonstrate reduced recurrence.
  • Women who do not respond to treatment may actually have desquamative inflammatory vaginitis [1,10]

Treatment regimens

2021 CDC recommendations
Other

Studies

RCT
StepUp - Male-Partner Treatment to Prevent Recurrence of Bacterial Vaginosis, NEJM (2025) [PubMed abstract]
  • Design: Randomized, open-label trial (N=164 couples | length = 12 weeks) in couples in which a woman had bacterial vaginosis and was in a monogamous relationship with a male partner
  • Treatment:
    • Partner-treatment group: Females and males received metronidazole 400 mg twice daily for 7 days. Males also received 2% clindamycin cream applied to penile skin twice daily for 7 days.
    • Female-only group: Females received metronidazole 400 mg twice daily for 7 days
    • Females with a contraindication to oral metronidazole could receive intravaginal metronidazole or clindamycin
  • Primary outcome: Recurrence of bacterial vaginosis within 12 weeks, defined by both the presence of at least three Amsel criteria and a Nugent score of 4 to 10, within 12 weeks. All women were tested for BV during follow up at day 8, week 4, week 8, week 12, and as needed for symptoms.
  • Results:
    • Primary outcome: Partner-treatment group - 35%, Female-only group - 63% (p<0.001)
  • Findings: The addition of combined oral and topical antimicrobial therapy for male partners to treatment of women for bacterial vaginosis resulted in a lower rate of recurrence of bacterial vaginosis within 12 weeks than standard care.
RCT
Vaginal Lactobacillus Crispatus vs Placebo to Prevent Recurrent Bacterial Vaginosis, NEJM (2020) [PubMed abstract]
  • Design: Randomized placebo-controlled trial (N=228 | length = 12 weeks) in women diagnosed with BV who were treated with vaginal metronidazole gel
  • Treatment: Lactobacillus crispatus (Lactin-V) powder (2×109 CFU) intravaginally once daily for 4 days then twice weekly vs Placebo powder
  • Primary outcome: Recurrent bacterial vaginosis on testing done at 4, 8, and 12 weeks
  • Results:
    • Primary outcome: Lactobacillus crispatus - 30%, Placebo - 45% (p=0.01)
  • Findings: The use of Lactin-V after treatment with vaginal metronidazole resulted in a significantly lower incidence of recurrence of bacterial vaginosis than placebo at 12 weeks.
RCT
Bioadhesive Clindamycin 2% Gel (Xaciato) vs Placebo for Bacterial Vaginosis, Obstet Gynecol (2022) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=307 | length = 30 days) in women with bacterial vaginosis
  • Treatment: Clindamycin 2% vaginal gel (Xaciato) one 5g intravaginal dose vs Placebo gel
  • Primary outcome: Clinical cure, defined as resolution of three of four Amsel's criteria, at the test-of-cure visit (day 21–30)
  • Results:
    • Primary outcome: Clindamycin intravaginal gel - 70.5%, placebo - 35.6% (p<0.001)
  • Findings: A new, single-dose clindamycin vaginal gel was highly effective, with excellent safety, in women disproportionately affected by bacterial vaginosis, with Nugent scores of 7-10 at study entry.

Epididymitis

Overview

  • Epidemiology - there are approximately 600,000 cases of epididymitis in the U.S. each year, with peak incidences occurring between the ages of 16 - 30 and 51 - 70.
  • Pathology - epididymitis may be caused by infectious agents and noninfectious processes. Bacterial agents typically reach the epididymis through retrograde ascent; one exception is tuberculosis, which seeds the epididymis through hematogenous spread. Urinary pathogens such as E. coli are most common in boys < 14 years and men > 35, while gonorrhea and chlamydia predominate in sexually-active young adults. Chronic epididymitis, defined as ≥ 6 weeks, may be caused by M. tuberculosis and other granuloma-inducing processes (e.g. sarcoidosis). Nonbacterial causes of epididymitis include trauma, postprostatic biopsy and postvasectomy epididymal inflammation, sarcoidosis, Behcet disease, enterovirus and adenovirus (in children), and vasculitis.
  • Risk factors - risk factors for epididymitis include sexual activity, insertive anal intercourse, bladder outlet obstruction (ex. BPH), recent prostate biopsy, and urinary tract instrumentation or surgery
  • Symptoms - epididymitis typically presents with localized pain in the posterior testicle that can radiate to the lower abdomen. Symptoms such as fever, urinary frequency, hematuria, penile discharge, and dysuria may be present. Testicular torsion is a urologic emergency that can present with similar symptoms. Torsion is most commonly seen in boys 12 to 18 years old and is rare after age 35.
  • Diagnosis - diagnostic testing includes urinalysis, culture, and nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia. Empiric treatment is recommended [1,2,14,17]

Treatment regimens (2021 CDC)

Epididymitis likely caused by gonorrhea or chlamydia
  • Ceftriaxone 500 mg IM (1000 mg if ≥ 330 lbs) single dose + Doxycycline 100 mg twice daily for 10 days ($-$$ for both meds)
Epididymitis likely caused by enteric or urinary tract pathogen
Epididymitis that may be caused by gonorrhea, chlamydia, and/or enteric organisms (insertive anal intercourse)
  • Ceftriaxone 500 mg IM (1000 mg if ≥ 330 lbs) single dose + Levofloxacin 500 mg once daily for 10 days ($-$$ for both meds)

Prostatitis

Overview

  • Epidemiology - there is no reference standard for diagnosing prostatitis, so epidemiologic data is based on patients with typical symptoms. In studies, the prevalence of prostatitis ranges from 2.2 - 9.7%, with acute bacterial prostatitis being more common in younger patients (< 35 years) and chronic prostatitis predominating in older men.
  • Etiology - acute prostatitis is typically caused by gram-negative bacteria, including Escherichia coli, Enterobacter, Serratia, Pseudomonas, Proteus, and Klebsiella. Gonorrhea and chlamydia are also seen, particularly in sexually-active young men. In chronic prostatitis (symptoms > 3 months), gram-negative bacteria still predominate, but other etiologies should be considered, including gram-positive bacteria (e.g. Enterococci), atypical pathogens (e.g. M. tuberculosis, Candida spp), and noninfectious causes.
  • Symptoms - prostatitis is marked by inflammatory symptoms (e.g. urinary frequency, urgency, dysuria), obstructive symptoms (e.g. hesitancy, poor stream, incomplete emptying), and pain in the pelvis and/or rectum that is poorly localized. Sexual dysfunction (e.g. ejaculatory discomfort, hematospermia) is also common. In acute bacterial prostatitis, systemic symptoms may be present, including fever, nausea, and tachycardia.
  • Diagnosis - there is a lack of professional consensus on what defines a diagnosis of prostatitis. Prostatic fluid is difficult to obtain, and an etiologic agent is identified in less than 10% of cases. Urinalysis and mid-stream urine culture are recommended in all patients. Sexually-active men should be tested for gonorrhea and chlamydia. The prostate may be tender and swollen on exam; however, digital rectal exams are uncomfortable for most patients, making these findings difficult to discern. Prostatic massage with a 4-glass test (Meares-Stamey test) is cumbersome and rarely performed. PSA levels are elevated in 60% of men with acute bacterial prostatitis, but they are not recommended for diagnostic purposes. [3,4,15,16]

Treatment regimens

Acute prostatitis
Chronic prostatitis

Pyelonephritis

Overview

  • Symptoms of pyelonephritis include urinary urgency and frequency, dysuria, fever, flank pain, nausea, and vomiting
  • Most healthy patients with manageable nausea can be treated as outpatients
  • E. coli is found in up to 95% of cases. Other less common pathogens include Klebsiella pneumoniae and Staphylococcus saprophyticus. [5,6]

Treatment regimens (2011 IDSA)

First line
Alternative regimens
  • Sulfamethoxazole-trimethoprim 800/160 mg twice a day for 14 days ($)
    • If this regimen is used empirically, then also give Ceftriaxone 1000 mg IM one time dose
  • Oral cephalosporins are not as effective as the other choices. If one is used, then also give Ceftriaxone 1000 mg IM one time dose

Urinary tract infection, Adults

Overview

  • Epidemiology: It is estimated that 50% of women will have a UTI at some point in their lives. Recurrence is common, with 25% of women having another UTI within 6 months of their first one. UTIs are much less common in males, but as men age and benign prostatic hyperplasia (BPH) becomes more prevalent, the risk increases.
  • Symptoms: Dysuria, urinary frequency, hematuria, urgency, and suprapubic pain and pressure
  • Risk factors:
    • Women: sexual activity, diaphragms and spermicides, changes in vaginal flora (e.g., menopause), family history, diabetes
    • Men: advanced age, prostate enlargement, uncircumcised, diabetes, urologic procedures
  • Pathology: E. coli accounts for up to 95% of cases. Other pathogens include Klebsiella pneumoniae, Enterococcus species, and Staphylococcus saprophyticus.
  • Diagnosis: Urine culture is considered the gold standard for diagnosis. A positive urinalysis for leukocyte esterase or nitrites has a sensitivity of 75% and a specificity of 82%.
  • Asymptomatic bacteriuria: With the exception of pregnant women and patients undergoing urological procedures, asymptomatic bacteriuria should not be treated [5,6,11]

Treatment regimens

IDSA 2011 recommendations
Other

Recurrent UTIs

  • For women with ≥ 3 UTIs in 12 months, preventative therapy may be tried
  • Imaging studies (e.g. ultrasounds, CT scans) and urologic referrals have low yield in women and are not recommended
  • For continuous antibiotic therapy, a six-month trial is recommended. After 6 months, stop and observe. About 50% of women will return to recurrent UTIs. Antibiotics may be restarted if needed.
    • Measures that may help prevent recurrent UTIs include:
      • Reduction in intercourse
      • Avoid spermicides
      • Urinate after intercourse
      • Drink more fluids - one study found that drinking an additional 1.5 liters/day reduced recurrent UTIs [PMID 30285042]
      • Avoid douching
      • Wipe front to back
      • Avoid tight-fitting underwear
      • Cranberry juice, capsules, or tablets - conflicting results in studies [PMID 23076891, 21148516, 22305026, 27787564, 37068952,]
      • Topical estrogen in postmenopausal women
      • D-mannose - a placebo-controlled trial (N=598) published in 2024 did not find d-mannose 2 grams daily to be effective at preventing recurrent UTIs. [PMID 38587819]
      • Methenamine hippurate 1 gram twice daily was found to be noninferior to antibiotic prophylaxis in an open-label trial that allowed crossovers [PMID 35264408]
    • NOTE: None of these interventions have been conclusively proven to reduce infections [5,6]

Prophylactic therapy for recurrent UTIs

Postcoital (single dose)
Continuous (try for 3 - 6 months, then reevaluate)

Studies

RCT
Seven vs Fourteen Days of Antibiotic for Afebrile Male UTI, JAMA (2021) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=272 | length = 28 days) in men prescribed 7 - 14 days of ciprofloxacin or trimethoprim/sulfamethoxazole for afebrile UTI
  • Treatment: After receiving their prescribed antibiotic for 7 days, patients were randomized to continue their antibiotic or switch to placebo for days 8 - 14. Ciprofloxacin was prescribed in 57% of patients and trimethoprim/sulfamethoxazole in 43%.
  • Primary outcome: Resolution of the initial UTI symptoms by day 14 after completion of active antibiotic treatment
  • Results:
    • Primary outcome: Seven days - 93%, Fourteen days - 90% (seven days noninferior)
  • Findings: Among afebrile men with suspected UTI, treatment with ciprofloxacin or trimethoprim/sulfamethoxazole for 7 days was noninferior to 14 days of treatment with regard to resolution of UTI symptoms by 14 days after antibiotic therapy. The findings support the use of a 7-day course of ciprofloxacin or trimethoprim/sulfamethoxazole as an alternative to a 14-day course for treatment of afebrile men with UTI.
RCT
Nitrofurantoin vs Fosfomycin for UTI, JAMA (2018) [PubMed abstract]
  • Design: Randomized controlled trial (N=513 | length = 28 days) in women with uncomplicated UTI
  • Treatment: Nitrofurantoin 100 mg three times a day for 5 days vs Fosfomycin 3000 mg one time
  • Primary outcome: clinical response in the 28 days following therapy completion, defined as clinical resolution (complete resolution of symptoms and signs of UTI without prior failure), failure (need for additional or change in antibiotic treatment due to UTI or discontinuation due to lack of efficacy), or indeterminate (persistence of symptoms without objective evidence of infection)
  • Results:
    • Primary outcome: Nitrofurantoin - 70%, Fosfomycin - 58% (p=0.004)
  • Findings: Among women with uncomplicated UTI, 5-day nitrofurantoin, compared with single-dose fosfomycin, resulted in a significantly greater likelihood of clinical and microbiologic resolution at 28 days after therapy completion
RCT
Norfloxacin vs Diclofenac for UTI, BMJ (2017) [PubMed abstract]
  • Design: Randomized controlled trial (N=253 | length = 3 days) in women with uncomplicated UTI
  • Treatment: Norfloxacin 400 mg once daily for 3 days vs Diclofenac 75 mg once daily for 3 days
  • Primary outcome: resolution of symptoms at day 3 (72 hours after randomization and 12 hours after intake of the last study drug)
  • Results:
    • Primary outcome: Norfloxacin - 80%, Diclofenac - 54% (p<0.001)
  • Findings: Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.
RCT
Fosfomycin vs Ibuprofen for UTI, BMJ (2015) [PubMed abstract]
  • Design: Randomized controlled trial (N=484 | length = 28 days) in women with UTI
  • Treatment: Fosfomycin 3000 mg one time vs Ibuprofen 400 mg three times a day for 3 days
  • Primary outcome: number of all courses of antibiotic treatment on days 0 - 28 (for UTI or other conditions) and burden of symptoms on days 0 - 7
  • Results:
    • Primary outcome (antibiotic courses during follow-up): Fosfomycin - 40 courses, Ibuprofen - 94 courses (p<0.001)
    • Women who received antibiotics during follow-up for UTI: Fosfomycin - 12%, Ibuprofen - 31% (p<0.001)
  • Findings: Two thirds of women with uncomplicated UTI treated symptomatically with ibuprofen recovered without any antibiotics. Initial symptomatic treatment is a possible approach to be discussed with women willing to avoid immediate antibiotics and to accept a somewhat higher burden of symptoms.

Urinary tract infection, Pediatric

Overview

  • Epidemiology - UTIs are the most common bacterial infection in children. Approximately 8% of girls and 2% of boys have a UTI during the first 8 years of life. The incidence for males is around 5.3% during the first 6 months and drops to 2% after the age of one. In females, the opposite is true, as their risk goes from 2% during the first 6 months to 11% after one year.
  • Pathology - most UTIs occur when bacteria ascend the urethra and reach the bladder. Infections confined to the bladder typically lack systemic symptoms (e.g. fever) and are easily eradicated with antibiotics. Infections that ascend the ureters and reach the kidneys usually cause fever, and in children, can be a sign of underlying urinary tract abnormalities, including vesicoureteral reflux, which is a risk factor for recurrent infections. Recurrent febrile UTIs can lead to renal scarring and loss of kidney function. The most common cause of UTIs in children is E. coli (up to 90%). Other less common pathogens include Proteus Mirabilis, Klebsiella species, Pseudomonas Aeruginosa, and Enterococcus.
  • Symptoms - infections confined to the bladder cause dysuria, frequency, enuresis, hematuria, suprapubic pain/pressure, and urgency. Infections that reach the kidneys are marked by fever, chills, flank pain, nausea, vomiting, and in severe cases, sepsis and shock.
  • Diagnosis - collecting good urine samples in young children can be challenging. A two-step approach that can minimize invasive procedures involves first obtaining a urine sample from a clean-catch or plastic bag attached to the patient and performing a urinalysis on it; the risk of contamination with these methods is high (50 - 60% for a bag, 26% for clean-catch), but they can be used to rule out a UTI. If the urinalysis is negative, a bladder infection is unlikely, and a culture does not need to be performed. If the urinalysis is positive, a new urine specimen should be obtained through catheterization or suprapubic bladder aspiration; these methods have a much lower risk of contamination so that a UTI can be definitively diagnosed. In toilet-trained children, midstream samples after careful cleaning of the genitalia are acceptable. The presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen is consistent with a UTI.
  • Genitourinary tract evaluation - febrile UTIs in children can be a sign of anatomical abnormalities; therefore, imaging of the GU tract is recommended in some cases. Children 2 months to 2 years with first febrile UTI should have a renal and bladder ultrasound, which will find irregularities in about 15% of cases. Voiding cystourethrography (VCUG) is the gold standard for diagnosing vesicoureteral reflux, but it is invasive and exposes the patient to radiation. Recommendations for performing VCUG vary, but the following high-risk features are typically listed as indications: (1) abnormal findings on ultrasound consistent with VCUG (e.g. hydronephrosis, scarring) (2) UTI not caused by E. coli, (3) recurrent febrile UTI, (4) UTI with complicated clinical course (e.g. sepsis). A recent study evaluated the utility of VCUG in infants (0 - 3 months) with first febrile UTI. See pediatric UTI studies for more. [7,8,12]

Vesicoureteral reflux (VUR)

  • Vesicoureteral reflux (VUR) is a condition where urine is able to flow up the ureter from the bladder. Under normal conditions, a valve at the junction of the ureter and bladder prevents the retrograde flow of urine. VUR is associated with recurrent febrile UTIs that lead to renal scarring and loss of kidney function. VUR is graded on a scale of I (mild) to V (severe).
  • The treatment of VUR is controversial, and in many cases, the condition resolves spontaneously as the child grows. Treatment options for more severe disease include surveillance, antibiotic prophylaxis, surgical repair, and endoscopic injection of bulking agents. Studies comparing surgery to antibiotic prophylaxis have found no significant difference between the two. [PMID 1433585, 11343739, 2888509] Studies comparing antibiotic prophylaxis to none have had mixed results. In a placebo-controlled trial enrolling children 2 to 71 months with grade I - IV reflux, prophylaxis with sulfamethoxazole-trimethoprim halved the risk of recurrent UTI over 2 years but had no effect on renal scarring. [PMID 24795142]. A similar two-year study in infants aged 1 to 5 months with grade III - V reflux found that antibiotics reduced the incidence of first UTI but had no effect on renal scarring or GFR. [PMID 37702442] In both studies, prophylaxis increased the prevalence of antibiotic-resistant bacteria. [7,8,9]

Treatment

Typical regimens
  • Sulfamethoxazole-trimethoprim 6 - 12 mg/kg/day (trimethoprim component) given in 2 divided doses for 7 - 14 days ($)
  • Augmentin 20 - 40 mg/kg/day given in 3 divided doses for 7 - 14 days ($)
  • Cefixime 8 mg/kg/day (max 400 mg/day) given once daily for 7 - 14 days ($)
  • Cefpodoxime 10 mg/kg/day (max 400 mg/day) given in 2 divided doses for 7 - 14 days ($$)
  • Cefuroxime 20 - 30 mg/kg/day (max 1000 mg/day) given in 2 divided doses for 7 - 14 days ($)
  • Cephalexin 50 - 100 mg/kg/day (max 2000 mg/day) given in 4 divided doses for 7 - 14 days ($)
Other

Prophylactic therapy for vesicoureteral reflux

Studies

RCT
Five Days vs Ten Days of Augmentin for Febrile UTI, Pediatrics (2024) [PubMed abstract]
  • Design: Randomized controlled trial (N=142 | length = 30 days) in children aged 3 months to 5 years with noncomplicated febrile UTI
  • Treatment: Amoxicillin-clavulanate 50 + 7.12 mg/kg/day orally in 3 divided doses for 5 or 10 days
  • Primary outcome: Recurrence of a urinary tract infection within 30 days after the completion of therapy
  • Results:
    • Primary outcome: Five days - 2.8%, Ten days - 14.3% (diff -11.51%, 95%CI [-20.54 to -2.47])
  • Findings: This study demonstrates that a 5-day course is noninferior to a 10-day course of oral amoxicillin-clavulanate.
RCT
Standard Course (10 days) vs Short Course (5 days) of Antibiotics for UTI, JAMA Pediatrics (2023) [PubMed abstract]
  • Design: Randomized controlled control (N=664 | length = 14 days) in children aged 2 months to 10 years with UTI exhibiting clinical improvement after 5 days of antibiotic therapy
  • Treatment: Subjects were evaluated after 5 days of antibiotic therapy, and those exhibiting clinical improvement were randomized to another 5 days of antibiotic therapy (standard course) or 5 days of placebo (short course). Subjects were treated with amoxicillin-clavulanate, cefixime, cefdinir, cephalexin, or trimethoprim-sulfamethoxazole.
  • Primary outcome: Treatment failure, defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14)
  • Results:
    • Primary outcome: Standard course - 0.6%, Short course - 4.2% (p<0.05)
  • Findings: In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment.
OBS
Avoidance of voiding cystourethrography in infants younger than 3 months with Escherichia coli urinary tract infection and normal renal ultrasound, Archives of Disease in Childhood (2017) [PubMed abstract]
  • Design: Cohort study (N=122) in infants aged 0 - 3 months with a first febrile UTI undergoing renal ultrasound and VCUG
  • Primary outcome: Risk factors for high-grade vesicoureteral reflux (VUR) defined as grade ≥ III
  • Results: The probability of high-grade VUR was 3% in the presence of urinary E. coli infection. Adding a normal renal US finding decreased this probability to 1%. However, in the presence of non-E. coli bacteria, the probability of high-grade VUR was 26%, and adding an abnormal US finding increased further this probability to 55%.
  • Findings: In infants aged 0 - 3 months with a first febrile UTI, the presence of E. coli and normal renal US findings allow to safely avoid VCUG. Performing VCUG only in infants with UTI secondary to non-E. coli bacteria and/or abnormal US would save many unnecessary invasive procedures, limit radiation exposure, with a very low risk (<1%) of missing a high-grade VUR.
OBS
Association Between Uropathogen and Pyuria, Pediatrics (2016) [PubMed abstract]
  • Design: Retrospective cohort study (N=1181) in children evaluated in the ER with symptoms of UTI who had paired urinalysis and urine cultures
  • Primary outcome: Association between pyuria and uropathogens
  • Results: Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis.
  • Findings: We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.

Yeast infection (vulvovaginal candidiasis)

Overview

  • An estimated 75% of women have at least one yeast infection during their lifetime, and 40 - 45% will have ≥ 2 episodes
  • Symptoms of a yeast infection include vaginal itching, soreness, pain with intercourse, painful urination, redness, and thick, white, curdy discharge
  • Yeast infections are typically caused by Candida albicans

Diagnosis

  • Definitive diagnosis is made by observing hyphae or pseudohyphae on a wet preparation. 10% KOH solution improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae.
  • A large number of home vaginal pH tests are available. Yeast infections typically occur at the normal vaginal pH which is < 4.7 while bacterial vaginosis occurs at a vaginal pH ≥ 4.7.

Recurrent yeast infections

  • Recurrent vulvovaginal candidiasis is defined as ≥ 4 episodes in 1 year. It may be treated with prolonged episodic therapy or maintenance therapy. 30 - 50% of women will have recurrent disease after maintenance therapy is discontinued.
  • See treatment recommendations below

Treatment overview

  • Creams and suppositories are oil-based and might weaken latex condoms
  • Yeast infections are not acquired through sexual intercourse and sex partners should not be treated

Treatment regimens (2015 CDC)

Over-the-counter
  • Clotrimazole (Lotrimin®) - cream; use as directed ($)
  • Miconazole (Monistat®) - cream, vaginal suppository; use as directed ($)
  • Tioconazole - cream; use as directed ($)
Prescription
  • Butoconazole 2% cream (Gynazole®) - one applicatorful of cream (approximately 5 grams of the cream) intravaginally for one dose ($$)
  • Terconazole cream (Terazol®)
    • 0.4% cream 5 grams intravaginally for 7 days ($)
    • 0.8% cream 5 grams intravaginally for 3 days ($)
    • 80 mg vaginal suppository, one suppository daily for 3 days ($)
  • Fluconazole 150 mg one time dose ($)
  • Ibrexafungerp (Brexafemme®) - two 300 mg doses (two 150 mg tablets) given 12 hours apart ($$$$)

Treatment for recurrent infections

Prolonged therapy
  • Prolonged topical therapy - 7 to 14 days of therapy
  • Fluconazole 100 - 200 mg every third day for a total of 3 doses ($)
Maintenance therapy
  • Fluconazole 100 - 200 mg once weekly for 6 months ($)
  • Ibrexafungerp (Brexafemme®) - two 300 mg doses (two 150 mg tablets) given 12 hours apart for one day every month for six months ($$$$)
  • Oteseconazole (Vivjoa®)
    • Vivjoa-only regimen
      • On Day 1: 600 mg as a single dose
      • On Day 2: 450 mg as a single dose
      • Beginning on Day 14: 150 mg once weekly for 11 weeks ($$$$)
      • Take with food. Do not chew, crush, dissolve, or open the capsules.
    • Fluconazole/Vivjoa regimen
      • On Day 1, Day 4, and Day 7: fluconazole 150 mg
      • On Days 14 through 20: Vivjoa 150 mg once daily for 7 days
      • Beginning on Day 28: Vivjoa 150 mg once weekly for 11 weeks ($$$$)
      • Take with food. Do not chew, crush, dissolve, or open the capsules.

EVALUATING MICROHEMATURIA


  • Reference [17]
AUA 2025 Diagnostic Algorithm for Microhematuria
STEP 1 - Confirm microhematuria with a proper specimen

  • Microhematuria definition: greater than or equal to 3 red blood cells per high-power field (RBC/HPF) on microscopic evaluation of a single, properly collected urine specimen. Patients receiving antiplatelet agents or anticoagulants should be evaluated in the same manner as patients who are not on these agents.

  • Proper specimen collection
    • A random midstream clean-catch sample should be collected. Samples should not be collected immediately after prolonged recumbency (e.g., first void in the morning), vigorous physical activity, or intercourse. Females should not collect samples during menses.
    • Preparation:
      • Male: Men should gently clean the urethral meatus with a sterilization towelette. In uncircumcised men, it is important to retract the foreskin to avoid contamination.
      • Female: Women should spread the labia adequately to allow for cleansing of the urethral meatus with a sterilization towelette and to avoid introital contamination.
    • The first 10 ml of voided urine should be discarded into the toilet in order to collect the midstream void.
    • If a significant number of squamous cells are present, contamination is possible, and a repeat specimen collection or catheterization should be considered

  • ➤ After confirming microhematuria on a properly collected sample, proceed to STEP 2
STEP 2 - Evaluate for the following gynecologic or non-malignant urologic etiologies

  • UTI
  • Kidney stones
  • Menses or other vaginal bleeding
  • Vaginal atrophy
  • Pelvic organ prolapse
  • Benign prostatic hyperplasia (BPH)
  • Exposure to trauma or recent urological procedures/catheterization

  • ➤ If no gynecologic or non-malignant urologic etiology is identified, proceed to STEP 3. If an etiology is present, address the issue as indicated and consider repeating urinalysis in the future.
STEP 3 - Categorize the patient by their risk for genitourinary malignancy

  • Low-risk (all of the following are present)

  • Intermediate-risk (any of the following are present)
    • Women age ≥60; Men age 40-59
    • 10-30 pack-years smoking
    • 11-25 RBC/HPF on one UA
    • One or more additional risk factors for urothelial cancer
    • Previously low/negligible-risk, no prior evaluation and 3-25 RBC/HPF on repeat UA

  • High-risk (any of the following are present)
    • Women should not be categorized as high-risk based on age alone; Men ≥60
    • >30 pack-years smoking
    • >25 RBC/HPF on one UA
    • History of gross hematuria
    • One or more additional risk factors for urothelial cancer

  • ➤ After assigning a risk category, proceed to STEP 4
STEP 4 - Diagnostic evaluation

  • Low-risk
    • Repeat UA within 6 months
      • Negative result: Use shared decision-making on whether to repeat UA in the future
      • Positive result: Use shared decision-making on whether to perform additional evaluation. If the patient develops gross hematuria, a significant increase in the degree of microhematuria, or new urologic symptoms, further evaluation is indicated.

  • Intermediate-risk
    • Perform cystoscopy and renal ultrasound. Cross-sectional imaging with urography or retrograde pyelograms may be performed if hematuria persists after negative renal ultrasound.

  • High-risk
    • Perform cystoscopy and multiphasic CT urography, including imaging of the urothelium. If CT urography is contraindicated, perform MR urogram or non-contrast imaging plus retrograde pyelograms.


PRICE ($) INFO

  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $150
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability

BIBLIOGRAPHY