My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Although historically sterile pyuria (SP) has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient (1-3).    

Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  Sexually transmitted diseases such as gonorrhea and Chlamydia trachomatis should also be considered in at risk patients. Hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia, appendicitis, diverticulitis) may also have SP (1-3). High prevalence of SP (>70%) has been reported among patients with appendicitis or diverticulitis (2). 

Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  Kawasaki’s disease, autoimmune diseases (eg, SLE) and analgesic nephropathy. 

I would start with repeating the u/a as 50% of sterile pyuria may be transient (3). If repeat u/a still shows pyuria, a prostate exam in our elderly male is indicated to exclude prostatitis. 

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References:

  1. Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54. https://www.nejm.org/doi/pdf/10.1056/NEJMra1410052
  2.  Goonewardene S, Persad R. Sterile pyuria: a forgotten entity. Ther Adv urol 2015; 7:295-298.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549703/ 
  3. Hooker JB, Mold JW, Kumar S. Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract. J Am Board Fam Med 2014;2&:97-103. https://www.jabfm.org/content/27/1/97.long#T1 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

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