At the outset, it may be said that in case there is any predisposing/ obstructive factor (like urinary stones, benign enlargement of prostate, congenital abnormalities of urinary tract, etc.), it must be investigated and treated according to the lines already described.
The various tests required for the diagnosis/treatment of UTI are as under:
1. Examination of urine
It is one of the most important tests, and it should not be taken casually. It indicates whether the patient is suffering from UTI or not especially, when symptoms of cystitis/pyelonephritis are not marked, or happen to be completely absent.
The urine specimen for test in laboratory should be very carefully collected, keeping the following steps strictly in view:
(i) The specimen should be from midstream. The patient must pass some urine outside, before passing the urine in a sterilized container.
(ii) Before giving the sample of urine, wash the whole area properly so that there is no contamination of E. coli, especially in women.
(iii) The specimen should be given in laboratory as urine sample often gets spoiled, on the way to the laboratory.
(iv) Second morning sample is always preferred. In the first morning sample, some changes are likely to occur due to overnight standing of urine, in the urinary bladder.
2. Urine for culture and sensitivity
If the examination of urine shows the presence of pus cells, the urine should be given in the laboratory for culture and sensitivity. It may be noted that 0 5 pus cells and 0 1 RBC (a little more in females, and markedly if a woman is in mensis) per high power field may be normally present in urine, especially when there is no associated/ contributing factor to UTI. The report of culture and sensitivity is usually available after 48 72 hours, and it guides the physician regarding the administration of antibiotics in a particular case. The treatment of UTI may not be possible without this test, and the entire course of treatment depends upon the report of this test. Therefore, it should be carried out by an experienced laboratory technician and the urine must be collected under strict aseptic conditions.
Besides the examination of pus cells, as well as of the culture and sensitivity of the urine, a complete detailed routine examination of the urine must be carried out so that any other abnormality, if present, can also be considered while treating the case. Many a time one finds in the urine analysis report, traces of albumin, although there is no apparent cause of passing albumin in urine in the concerned case. Traces of albumin in urine could be due to the contamination of the urine sample by vaginal secretion/ seme~f the previous night s intercourse. Hence the importance of proper washing of the whole area, especially in women, before giving the sample, is again emphasised. And, if still, in spite of all such precautions, traces of albumin in the urine persist, the albumin should be measured in 24 hour urine, and normally it should be less than 3.0 g per day. However, presence of albumin in urine is an important finding for kidney damage, not only due to pyelonephritis, but also due to other diseases of the kidneys. It tells us that the patient is passing into the chronic stage, although he/she may remain asymptomatic. Hence a periodical examination of urine is an important factor to assess the extent of kidney damage.
3. Blood urea and serum creatinine tests
Normal levels of blood urea range from 15 35 mg/ dl with an average of 25 mg/ dl. Normal serum creatinine leve1s range from 0.8 to 1.4 mg/ dl, the average being 1.00 mg/ dl. Both these tests should be carried out in order to be on the safe side, although blood urea is a simple test and serum creatinine a little more difficult to carry out serum creatinine is more sensitive than blood urea. If the levels of serum creatinine are 1.5 mg/ dl, although the kidneys may be fairly damaged, it is still considered early. When levels of serum creatinine are raised to the extent of 3.5 to 5.5 mg/ dl, the kidneys may still be said to be moderately damaged and one should not lose time in initiating the necessary tests arid treatment. But if levels of serum creatinine rise above 8 mg/ dl, it means that the kidneys are severely affected, leading to renal failure, requiring urgent dialysis.
4. 24 hour creatinine clearance
It is much more reliable than the serum creatinine test. But it is somewhat cumbersome as in this test, a 24 hour collection of urine is required. It may be carried out to diagnose very early cases, wherever facilities exist.
5. Ultrasonographic examination
It must be carried out in each and every case of UTI. It is a non invasive test and usually gives valuable information regarding occult causes of UTI. For example, there may be an asymptomatic stone lying in the urinary tract, or there may be some congenital abnormality of the kidneys causing obstruction in the urinary tract, or there may be an early enlargement of the prostate, in the case of males.
6. Plain X ray abdomen, intravenous pyelography
These may be required depending upon the case.
7. Renal/kidney biopsy
It may be indicated to know about the exact nature of pathology causing renal damage.
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