Question

A 30 year old male presents with severe bladder irritation, persistent pyuria, microscopic hematuria and absence of bacteria in usual smears and culture. What is the probable diagnosis?

• A. Monilial infection
• B. Lower urinary tract obstruction
• C. Vesical calculus
• D. Genito urinary tuberculosis

Hint:

Think of the classic cause of sterile pyuria.

Answer 1

The Correct Option is D

The clue in this vignette is sterile pyuria, pus cells in the urine with no bacteria growing on a normal culture, along with bladder irritation and blood in the urine.

1. Monilial infection: Candida usually shows up directly on a wet mount or culture using fungal media, and occurs mostly in diabetic or immunosuppressed patients, so it does not fit a no organism seen picture as neatly.
2. Lower urinary tract obstruction: This can cause irritation and stasis, but when infection sets in in this setting it is usually with common bacteria that grow on routine culture, not sterile pyuria.
3. Vesical calculus: A bladder stone explains irritation and blood in urine, but by itself it does not explain sterile pyuria unless tuberculosis is already present.
4. Genito urinary tuberculosis: Mycobacterium tuberculosis reaches the urinary tract from a distant focus, causes chronic inflammation of the bladder and ureter, and gives pus cells and blood cells in urine, but it will not grow on the ordinary bacterial culture media used in a routine urine test. This exactly produces sterile pyuria.

Because the case describes persistent pyuria and hematuria with no organisms on usual smear and culture, genitourinary tuberculosis is the diagnosis that fits best.

Let's summarize:

• Sterile pyuria (pus cells without bacterial growth on standard culture) is a classic clue for genitourinary tuberculosis.
• Special stains and TB cultures, not routine bacterial culture, are needed to confirm this diagnosis.

So the probable diagnosis is genitourinary tuberculosis.