Adult GU Complaint

Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 28-year-old woman presents with a 2-day history of urinary frequency, urgency, and dysuria, stating, “This feels like when I had a urine infection about four years ago.” She denies fever or GI upset and feels otherwise well.  In consideration of the diagnosis of a lower UTI or cystitis, a urinalysis is ordered. Which of the following is the most sensitive and specific finding for a UTI caused by a gram-negative organism?
A. Positive leukocyte esterase.
B. Presence of bacteriuria.
C. Proteinuria.
D. Positive nitrite.
The correct answer here is D. Positive nitrate.
Where do you start? First, determine what kind of a question this is. Given that you're being asked to interpret a lab result in a person with a suspected UTI, this is actually part of information gathering, and as a result, is an assessment question.
Let's take a look, as we do with all of these podcasts, at some background information. And one more time, because it always bears mentioning, what you do is when you're answering board questions, you call on your broad and deep knowledge base and then apply that to the information given to you in the question.
UTIs involve the mucosal tissue of the lower urinary tract, most commonly being cystitis. Most UTIs, particularly when we're talking about women who have the majority of UTIs, these arise from ascending infections from the peri-urethral area, which is naturally colonized with a lot of lower gut flora. And when you think about this, just think about the anatomy of female birth gender assignment, where the urethra and the anus are really quite close to one another.
As a result, the vast majority, likely greater than 85% of UTIs, are caused by gram-negative organisms.
E coli
will be far and away the most common organism that causes UTIs, and it is a lower gut colonizing agent.
E coli
just rules when it comes to UTI regardless of birth gender assignment, age, risk factors for UTIs, or the like.
Women of reproductive age are the most likely demographic for developing UTIs. In addition, a history of UTI is a potent risk factor for future UTI. She said that she had a UTI four years ago and this feels pretty much the same. While her clinical presentation is actually quite classic for UTI, with dysuria, frequency, urgency and the like. Laboratory confirmation, of course, is required. In this question, we're being asked to choose which is the most sensitive and specific finding in the urinalysis for a gram-negative UTI. Sometimes simply called a UA, a urinalysis is a test that can be conducted as point-of-care in the primary, urgent, or ED setting where a dipstick is placed into a urine sample and then a variety of different parameters are shown. And a standard UA, when looking at this variety of clinical measurements that are evaluated, we're actually being asked to choose which is the most sensitive and specific for gram-negative UTI. In other words, looking at the two parameters that describe the accuracy of a test. I have another podcast talking about sensitivity, specificity, true positive, true negative, etc., and if you need more information on that, please access that Q&A podcast.
With that in mind, let's take a look at the question and the proposed responses.
A 28-year-old woman presents with a two-day history of urinary frequency, urgency, and dysuria, stating, “This feels like when I had a urine infection four years ago.” She denies fever, GI upset, and otherwise feels well. In consideration of the diagnosis of lower UTI, also known as cystitis, a urinalysis is ordered. Which of the following is the most sensitive and specific finding for UTI caused by gram-negative organism?
A. Positive leukocyte esterase. This is incorrect. Measuring leukocyte esterase notes the number of WBCs, particularly neutrophils, in the urine. While this is a very common finding in UTIs, in fact virtually a universal finding in UTI, a number of other reasons result in pyuria, defined as the presence of WBCs in the urine. This can include vulvovaginitis where the WBCs are actually vaginal in nature, but were washed out in the urine from the peri-urethral or perineal area. Or non-UTI reasons for bladder inflammation.
B. The presence of bacteriuria. The UTI in question no doubt is caused by a bacterial agent, bacteria from the peri-urethral or perineal surfaces can wash out into the urine and cause bacteriuria. Therefore, this option is incorrect.
C. Proteinuria. During UTI, a small amount of protein sometimes is noted in the urine. Indeed, transient proteinuria is a common response to a variety of clinical scenarios, including vigorous exercise, exposure to temperature extremes like very, very hot, very, very cold, and even episodic fever-inducing illnesses. Persistent proteinuria, of course, is quite worrisome and is often seen in diabetic and or hypertensive nephropathy. In other words, proteinuria is noted in a number of clinical conditions aside from UTI. So, so far the leukocyte esterase, the bacteria, and the proteinuria, yes, all of those can be found in UTI, but they can be found in a variety of other conditions as well.
Well, we're down to just one response: D. Positive nitrite. And that, of course, is the correct answer. A variety of gram-negative organisms, including
E. coli
, the big bug when it comes to urinary tract infections, have nitrate reductase which can convert dietary nitrates to nitrites. Given that the presence of urinary nitrates is only found in gram-negative UTI, this answers the question most accurately, and therefore is the best answer.
Key takeaway: The NP boards will ask you for the best, but not just the possible or correct answer. Take a look at every word that is in the stem of the question. Every word that are in the answers. Apply your deep and broad knowledge base and that will be the key to coming up with not just the right answer, but that best answer.
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