An 18-year-old female presents to your office with dysuria and urinary frequency. She denies any fever, chills, or flank pain. She has a history of recurrent urinary tract infections, including two episodes over the last six months. She is otherwise healthy. She had no urinary problems in childhood. She has been sexually active with one partner during the last year. She takes oral contraceptives. Urine dipstick is positive for leukocyte esterase and nitrites. Urine cultures are sent. Polymerase chain reaction (PCR) is negative for gonorrhea and chlamydia. Pregnancy test is negative. Which of the following is the best management step for this patient?

Question

An 18-year-old female presents to your office with dysuria and urinary frequency.  She denies any fever, chills, or flank pain.  She has a history of recurrent urinary tract infections, including two episodes over the last six months.  She is otherwise healthy.  She had no urinary problems in childhood.  She has been sexually active with one partner during the last year.  She takes oral contraceptives.  Urine dipstick is positive for leukocyte esterase and nitrites.  Urine cultures are sent.  Polymerase chain reaction (PCR) is negative for gonorrhea and chlamydia.  Pregnancy test is negative.  Which of the following is the best management step for this patient?

Quizplus · Accepted Answer

Explanation: This patient's symptoms of dysuria and frequency with a urine dipstick positive for leukocyte esterase and nitrites are consistent with a urinary tract infection (UTI), now her third in the past six months. Recurrent UTIs are a common problem in otherwise healthy young adult females, however there is no evidence that they lead to other health problems such as hypertension in the absence of underlying anatomic abnormalities. Behavioral interventions such as postcoital voiding and increased intake of cranberry juice may help to decrease the risk of UTIs in some women. Antibiotic prophylaxis can be considered in women who have had more than two UTIs in six months or more than three UTIs in a year. Prophylaxis can be used either continuously for up to several years or solely after intercourse in women whose UTIs occur only after sexual activity. Fluoroquinolones, sulfamethoxazole-trimethoprim, and nitrofurantoin are the most commonly used agents. An additional option is providing female patients with antibiotics in advance, and allowing the patient to self-diagnose and treat her UTIs. (Choice A) Abdominal ultrasound would only be indicated if there was concern for a complicating factor such as obstruction. In patients presenting with ordinary UTIs, further diagnostic evaluation is generally very low-yield. (Choice C) Cystoscopy is very low-yield in the evaluation of young female patients with recurrent UTIs. (Choice D) A non-contrast CT scan should only be performed if there is concern for nephrolithiasis. This possibility should be considered if the patient's urine cultures grow proteus, since this organism is commonly associated with stones. (Choice E) Potassium citrate is used to alkalinize the urine and decrease the risk of stone formation. Educational objective: Antibiotic prophylaxis can be considered in young female patients who have had at least two UTIs in six months or three in a year. Prophylaxis can either be continuous or solely postcoital. Further diagnostic evaluation in these patients is typically unrevealing unless there is clinical evidence to suggest the presence of nephrolithiasis or obstruction.

An 18-Year-Old Female Presents to Your Office with Dysuria and Urinary