East African Scholars Journal of Medicine and Surgery

Abbreviated Key Title: EAS J Med Surg

ISSN: 2663-1857 (Print) & ISSN: 2663-7332 (Online)
Published By East African Scholars Publisher, Kenya
Volume-3 | Issue-4 | April-2021 | DOI: 10.36349/easjms.2021.v03i04.001

Review Article

Urine Sampling and Culture in the Diagnosis of Urinary Tract Infection:

A Review Article
Iddah M. Ali MSc, PhD1*, Benard O. Wesonga2
1
Department of Medical Microbiology and Parasitology, School of Medicine, Masinde Muliro University of Science and Technology,
P.O. Box 190-50100, Kakamega, Kenya
2
Department of Community Health and Behavoural Sciences, School of Medicine, Masinde Muliro University of Science and
Technology P.O. Box 190-50100, Kakamega, Kenya
Abstract: Among patients with symptoms suggestive of a Urinary tract infection (UTI)
Article History which includes dysuria and frequency, the diagnosis can be confirmed by sending a clean-
Received: 21.01.2021 catch specimen for culture and for urinalysis. One suggested exception recommended by
Accepted: 05.03.2021
most experts is a symptomatic young woman with pyuria detected by urinalysis dipstick who
Published: 06.04.2021
has apparently uncomplicated cystitis. It has been proposed that the findings are sufficiently
Journal homepage: diagnostic that an empiric course and usually three days of antimicrobial therapy can be
https://www.easpublisher.com initiated without performing a urine culture. Children who are toilet trained can provide
clean voided urine samples. Clean voided bag urine samples are acceptable for urinalysis in
Quick Response Code infants and children between two months and two years of age who have unexplained fever
and do not appear ill enough to require immediate antimicrobial therapy. If the sample
suggests infection, then a catheterized urine specimen should be obtained for confirmatory
testing and urine culture. Suprapubic aspiration and transurethral bladder catheterization are
invasive but are the only valid ways to collect urine for culture in febrile young infants under
two months of age and older infants and children with unexplained fever who are younger
than two years of age and ill enough to merit immediate antimicrobial therapy. The use of
portable ultrasound to visualize the bladder increases the success rate for both suprapubic
aspiration and transurethral bladder catheterization. In this review article, we will cover
urine sampling, procedure, culture, and dipstick as a tool of UTI analysis in both adults and
children.
Keywords: Urine Sampling, Diagnosis, Tract Infection.
Copyright © 2021 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.

determined by the local susceptibility patterns of

INTRODUCTION Escherichia coli, the usual causative organism, and a
Urine collected in a normal individual by patient history of antibiotic allergy, especially to
suprapubic aspiration of the bladder is sterile and does sulfonamides. Below are the indications for cultures in
not contain leukocytes. This method represents the gold young women are:
standard in the diagnosis of urinary tract infection (UTI)
 Suspicion of a complicated infection
[1]. It is, however, not performed routinely in clinical
 Atypical symptoms
practice in which urine samples are generally obtained
after natural micturition; in this setting, some degree of  Failure to respond to initial therapy, raising the
artifactual contamination with normal urethral possibility of a resistant organism
organisms must be accepted.  Recurrent symptoms less than one month after
treatment of a previous UTI for which no
Among patients with symptoms suggestive of culture was performed
a UTI, the diagnosis can be confirmed by sending a
clean-catch specimen for culture and for urinalysis. One In children, Urinary tract infections (UTIs) are
suggested exception recommended by most experts is a an important cause of acute and chronic morbidity.
symptomatic young woman with pyuria (detected by Long-term complications include hypertension and
urinalysis or dipstick) who has apparently decreased renal function caused by renal scarring.
uncomplicated cystitis. It has been proposed that this However this may not be suspected by the paeditricians.
constellation of findings is sufficiently diagnostic that The accurate diagnosis of UTI in children is necessary
an empiric course (usually three days) of antimicrobial to ensure appropriate therapy and follow-up for those
therapy can be initiated without performing a urine who need it, and to avoid unnecessary therapy, hospital
culture [2]. The choice of antibiotic is generally admission, and further evaluation in those who do not.

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The manner in which urine is collected and processed still grow on culture medium. However,
before it is cultured can affect the validity of the culture urinary leukocytes may be altered by
result. Children who are toilet trained can provide clean refrigeration, possibly affecting interpretation
voided urine samples. Samples of urine from children of the urinalysis.
who are not toilet trained can be obtained by "clean
voided" bag samples, suprapubic bladder aspiration A positive urine culture
(SPA), or transurethral bladder catheterization (TUBC). The standard definition of a positive urine
SPA and TUBC are invasive but are the only valid ways culture is ≥105 CFU/mL together with pyuria (eg,
to collect urine for culture in febrile young infants leukocyte count ≥105 WBC/mL). Normal values in a
under two months of age and older infants and children noninfected midstream, clean-catch sample are <105
with unexplained fever who are younger than two years colony-forming units (CFU, primarily due to
of age and ill enough to merit immediate antimicrobial contaminating Escherichia coli) and <10,000 leukocytes
therapy [1]. per mL of urine [3-7]. Contamination in the absence of
UTI is typically suggested by high CFU counts without
Urine sampling significant leukocyturia in a patient with no urinary
The likelihood of detecting a urethral tract tract symptoms such dysuria, frequency or fever.
infection (UTI) by urine culture is highest if urine is
collected on arising. This sample is likely to be most However, this definition does not apply to all
concentrated and bacteria in the bladder will have had patients. If fecal contamination has been ruled out, a
time to multiply overnight. However, getting an ideal lower colony count (>102/mL) may be indicative of
sample is not practical since most cultures are obtained UTI. This was best demonstrated in studies in women
at the time the patient is seeing the clinician. In this who had dysuria and frequency but a midstream culture
setting, the combination of a more dilute urine and contained less 10 5 CFU/mL [1, 8, 9]. This condition
partial bacterial washout due to multiple voids may had been called the acute urethral syndrome [1]. In one
lower the colony count below the accepted definition study, for example, 42 such women (most of whom had
for a UTI. ≥102 CFU/mL on culture of a midstream specimen) who
also had pyuria underwent suprapubic bladder
The following steps should be performed to minimize aspiration. Thirty seven had a positive aspirate culture:
the degree of bacterial contamination. 24 E. coli, 3 Staphylococcus saprophyticus, and 10
 Local disinfection of the meatus and adjacent Chlamydia [1]. All of these women responded to
mucosa should be performed with a non- appropriate antimicrobial therapy. In comparison, a
foaming antiseptic solution; this region should positive culture was very uncommon in women with
then be dried with a sterile swab to avoid similar symptoms but no pyuria.
mixture of the antiseptic with urine.
 Contact of the urinary stream with the mucosa Similar findings have been reported by others.
should be minimized by spreading the labia in In a gynecology clinic at a student health center, for
females and by pulling back the foreskin in example, 33 percent of women with urinary tract
uncircumcised males. symptoms had ≥105 CFU/mL while another 46 percent
 The first voided specimen should be discarded had CFU counts between 102 and 104 /mL [10]. When
since the initial urine flushes urethral asymptomatic patients were included, there was a
contaminants. It is the second, midstream stepwise relation between the colony count and the
sample that should be sent to the laboratory. likelihood of symptoms.
 Evaluation of the last few drops of urine is
indicated after prostatic massage in men with On the basis of these findings, it has been
suspected prostatitis. Firm prostatic massage suggested that a CFU count ≥102 /mL be considered
per rectum, from lateral to midline on each positive on a midstream urine specimen in women with
side, causes the contents of the prostatic ducts acute symptoms and pyuria. It has been estimated that
to be expressed; vertical strokes in the midline 88 percent of such women have a UTI [8]. If symptoms
will then project the secretions into the urethra persist and the standard bacterial culture is negative, a
and permit counting of leukocytes. pelvic examination should be performed with culture of
 The urine sample should be sent immediately a cervical swab for Chlamydia.
to the bacteriology laboratory since bacteria
will continue to proliferate in the warm It is not well understood why some infected
medium of freshly voided urine, leading to women have low colony counts. Two possibilities are
increased bacterial counts. If such immediate that low counts reflect an earlier stage of infection and
referral is not possible, the container should be that low counts reflect the efficacy of bladder washout
transported in iced water and then stored in a during urination to eliminate the organisms.
refrigerator at 4ºC. Cooling stops bacterial
growth, but the following day the bacteria can

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There are also several other settings in which a  When organisms other than E. coli and Proteus
colony count of ≤105 /mL often represents true infection are present. Included in this group are
rather than contamination: Pseudomonas, Klebsiella-Enterobacter-
 In patients already being treated with Serratia, and Moraxella species, particularly in
antimicrobials. symptomatic patients with an indwelling
 In men in whom contamination is a much bladder catheter.
lesser problem.

Fig-1a: A negative urine culture

Fig-1b: A positive urine culture

Pyuria These observations indicate that the customary

Pyuria is defined as>20,000 leukocytes/mL (by determination of leukocyte counts per high-power field
hemocytometry) in women with low count bacteriuria is not sufficiently accurate and that the use of white cell
[10]. Others have defined pyuria as the presence of at counting is preferred in the diagnosis of UTI. A
least 8000 leukocytes per mL of uncentrifuged urine, significant number of leukocytes (>10/microL or
which corresponds to 2 to 5 leukocytes per high power 10,000/mL) should be present in truly infected patients.
field in centrifuged sediment [1]. The presence of bacteria in the absence of pyuria,
especially when various strains are found, is usually due
Given the very high association between to contamination during sampling.
infection and pyuria, a careful examination of the urine
sediment is indicated in all patients with suspected UTI. Sterile pyuria
However, assessment of pyuria is subject to some Whereas true infection without pyuria is
technical pitfalls [9]. Two important variables are unusual, pyuria can occur in the absence of apparent
contamination with vaginal secretions in women and bacterial infection, particularly in patients who have
the volume of supernatant in which the centrifuged already taken antimicrobials (often due to self-
pellet is resuspended, which will affect the leukocyte medication). Other causes of sterile pyuria include:
count.

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 Contamination of the urine sample by Dipsticks

sterilizing solution Dipsticks may be used as a screening tool for
 Contamination of the urine sample with diagnosis of UTI; they detect the presence of leukocyte
vaginal leukocytes esterase and nitrite in the urine. The dipstick nitrite test
 Chronic interstitial nephritis depends on the conversion of nitrate (from dietary
 Nephrolithiasis metabolites) to nitrite by bacteria in the urine; normally
 Uroepithelial tumor no detectable nitrite is present. When bacteriuria is
 Painful bladder syndrome/interstitial cystitis significant, the test is positive about 80 percent of cases
in which the urine has incubated for at least four hours
In the case of uroepithelial tumors, both in the bladder [13]. Leukocyte esterase corresponds to
malignant cells and leukocytes are shed [11]. The tumor pyuria and nitrite reflects the presence of
can cause inflammation those results in the appearance Enterobacteriaceae, which convert urinary nitrate to
or exacerbation of sterile pyuria. Malignant cells are nitrite [14, 15]. In one study, dipstick was comparable
difficult to distinguish from leukocytes on routine to urinalysis for UTI screening; both had high false
urinalysis. When the more common causes of sterile positive and false negative rates [16]. A negative
pyuria have been eliminated, patients with dysuria and dipstick in a patient with symptoms of UTI may
frequency should be tested for atypical organisms such represent false negative results, and a urine culture
as Chlamydia, Ureaplasma urealyticum, or tuberculosis should be performed [17].
[1, 12].

Fig-2a: Procedure for urine dipstick test

Results are in qualitative and semi- the strip need to be compare with colour chart as below
quantitative. The test strip that has been dip into the in figure 2b.
urine will change in color. Than the colour produce in

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Iddah, M. Ali & Benard O. Wesonga, East African Scholars J Med Surg; Vol-3, Iss-4 (Apr, 2021): 59-69

Fig-2b: (Chart 1 – Colour chart provided by the manufacturer: Source Siemens Multistix 10 SG)

In a review of six studies including women cloudiness, dysuria and nocturia) were also taken into
aged 17 to 70 with suspected UTI in primary care account. The negative predictive value was 67 percent
settings; positive dipstick findings (nitrite or leukocyte for none of the features, and the positive value was 82
esterase and blood) had sensitivity and specificity of 75 percent for three features. The authors concluded that
and 66 percent, respectively [18]. A meta-analysis dipstick results can modestly improve, but poorly rule
including 70 publications noted concluded that urine out infection [21]. Among 2252 women with overactive
dipstick test alone is useful when both nitrite and bladder, dipstick test was not sufficient to identify
leukocyte esterase tests are negative (sensitivity 68 to patients with UTI (sensitivity and specificity 44 and 86
88 percent) [19]. A systematic review including 30 percent, respectively) [22, 23]. Thus, a positive test is a
studies noted that a positive leukocyte esterase or nitrite reliable index of significant bacteriuria, though a
test had the highest sensitivity and the lowest negative negative test does not exclude bacteriuria. Reasons for a
likelihood ratio [20]. Subsequent studies reveal fewer negative nitrite test in the presence of bacteriuria
positive results of the dipstick test. A total of 434 adult include insufficient bladder incubation time for
females with suspected lower UTI in a primary care conversion of nitrate to nitrite, low urinary excretion of
setting were assessed. Presence of blood was a criterion nitrate, inability of some organisms to convert nitrate to
added to the nitrite and leukocyte esterase tests. Sixty- nitrite such as E. faecalis and decreased urine pH due to
six patients had confirmed UTI. Clinical criteria (urine cranberry juice or other dietary supplements.

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Fig-2c (Chart 1 – Colour chart provided by the manufacturer: Source Siemens Multistix 10 SG)
Parameter Normal Influence factor such diet and environment that interfere Clinical significance
reference results
range (Limit of detection)
Description for False Positive and False Negative:
Results from the strip shown positive or negative (nil) but
not caused by the organ problem.
Blood Negative False Positive: Taking any food that can colour the urine or 1. Hematuria
having menstrual. Urine exposed to hypochlorite as chlorox. (nephritis,trauma)
False Negative: Taking Vitamin C (ascorbic acid) 2. Myoglobinuria
Bilirubin Negative False Positive: Taking medicine such as chlorpromazine or 1. Liver diseases as
phenazopyridine. hepatitis
False Negative: Taking Vitamin C (ascorbic acid). Urine 2. Jaundice
exposed to sunlight or lamp.
Urobilinogen 3.2 – 16 False Positive: Urine contaminated with p-aminobenzoic 1. Liver diseases as
umol/L acid. cirrhosis
False Negative: Urine exposed to sunlight or lamp. 2. Hemolytic anemia
Ketone Negative False Positive: Taking low carbohydrate such as wheat or 1. Ketonuria
rice, vomit or diarrhoea’. Urine exposed to moisture too long. 2. Diabetic
Taking medicine such as MESNA and captopril. Ketoacidosis
3. Prolonged fasting
Protein Negative dan False Positive: Extreme exercise, dehydrated, taking high 1. Fever
Trace protein or emotional stress. Urine exposed to hypochlorite as 2. Proteinuria
(<0.15g/L) chlorox or blood. 3. Kidney disease
4. Nephrotic syndrome
Nitrite Negative False Positive: Urine exposed to room temperature more Urinary Tract Infection
than 2 hours.
False Negative: Taking Vitamin C (ascorbic acid). Collect
urine so early (less bacteria incubation period in bladder).
Glucose Negative False Positive: Taking Vitamin C (ascorbic acid). 1. Glucosuria
False Negative: Low glucose renal threshold and high 2. Diabetis mellitus
ketone. 3. Renal glycosuria
pH pH5 hingga More alkaline: Diets with a high content of vegetables and 1. Kidney stone
pH7.5 citrus fruit.Vomit or starvation. Urine exposed to room 2. Metabolic acidosis
temperature for more than 2 hours. 3. Renal tubular
acidosis
Specific 1.002 hingga False Positive: Dehydrated diarrhoea or taking antibiotic or Diabetis insipidus
Gravity 1.030 diuretic medicines (substance that removes water from the
body by promoting urine formation and the loss of salt
(sodium). Urine exposed to room temperature for more than
2 hours.
Leukocyte Negative False Positive: Urine exposed to Formalin or hypochlorite as 1. Urinary Tract
esterase chlorox. Taking Vitamin C (ascorbic acid). High specific Infection
gravity. 2. Pyuria
False Negative: Glucose level more than 3g/dL. Taking 3. Kidney stone
antibiotic such as cephalexin, cephalotin and tetracycline. 4. Acute inflammation
Renal calculus

In children culture, 63 percent of clean voided bag specimens were

Clean voided bag samples contaminated compared with 9 percent of catheter
The practice of obtaining urine specimens by specimens (63 percent versus 9 percent [25]. An
the "clean voided" bag appeals to medical staff and adverse outcome (delayed diagnosis and treatment,
parents because it is noninvasive. However, it should unnecessary recall, unnecessary treatment, unnecessary
not be used to obtain urine samples for culture [24]. hospital admission, and/or unnecessary radiologic
Appropriate collection of clean voided bag urine investigation) occurred in 132 of the 3440 children who
samples requires proper cleansing, rinsing, and drying had a false positive urine culture.
of the perineum before application of the bag,
immediate removal of the bag after urine is voided, and According to the guidelines of American
prompt processing of the urine. Cultures of urine Academy of Pediatrics Subcommittee on UTI, clean
specimens obtained by clean voided bag have an voided bag urine samples are acceptable for urinalysis
unacceptably high rate of false positive results in infants and children between two months and two
compared with catheterized specimens [25-28]. As an years of age who have unexplained fever and do not
example, in an observational study of 7584 children appear ill enough to require immediate antimicrobial
younger than two years) undergoing urine collection for therapy. An infant or young child should never receive

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antibiotics on the basis of a urinalysis from a clean of contamination (0 versus 73 percent for mixed growth
voided bag urine specimen. Thus, another urine sample from both bag and clean voided samples; and 0 versus 6
for urinalysis and culture should be collected by percent and 13 percent for intermediate growth from
invasive means if the urinalysis from the bag sample clean voided and bag samples, respectively).
suggests a UTI by any of the following:
 Positive leukocyte esterase or nitrite test The following steps are performed [35, 36]
 Greater than 5 white blood cells per high-  The child is restrained in the supine and frog
power field (spun urine) leg position. This position permits adequate
 Presence of bacteria on Gram stained urine stabilization of the pelvis.
(unspun urine)  The site for needle insertion, in the midline,
approximately one to two centimeters above
Monitoring the clinical course of the infant or the pubic symphysis, is widely prepared with
child without antibiotic therapy is a reasonable course povidone-iodine solution.
of action if the urinalysis is not suggestive of UTI.  The planned puncture site may be locally
However, a negative urinalysis does not exclude a UTI. anesthetized with lidocaine. Many
practitioners do not perform this step because
Clean voided samples they believe it is more painful than the
Children who are toilet trained can provide procedure itself.
clean voided midstream urine samples. Cleansing the  The urethral opening should be occluded just
perineum with soap prior to urine collection may before needle insertion because the procedure
decrease the rate of contamination [29]. will stimulate urination in many children. This
is accomplished by squeezing the penile
We suggest using the following technique to collect urethra in boys or applying urethral pressure to
urine samples: the meatus in girls [35].
 For girls, the labia should be spread and the  A 1.5 inch, 22-gauge needle attached to a 3 or
perineum cleansed two to three times with 5 mL syringe is inserted one to two
nonfoaming antiseptic solution or mild soap. centimeters above the pubic symphysis. The
For boys, the meatus should be cleansed in a needle should be angled 10 to 20 degrees
similar fashion. The foreskin should be cephalad and advanced under negative
retracted before cleansing for those who are pressure until urine returns. The needle should
uncircumcised. be partially withdrawn and redirected at an
 Contact of the urinary stream with the mucosa angle more perpendicular to the frontal plane if
can be minimized by pulling back the foreskin the initial attempt is unsuccessful.
in boys who are uncircumcised and by
spreading the labia in girls during urination. Urine is not likely to be obtained after the third
 The child should urinate into a toilet or urinal. attempt and thus, one can either perform transurethral
Midway through urination, a specimen should bladder catheterization or wait 15 to 30 minutes for the
be collected in a sterile container. bladder to become more distended [36].

Suprapubic bladder aspiration (spa) Portable ultrasound

Suprapubic bladder aspiration is a safe and Portable ultrasound (US) is becoming
effective method for obtaining urine specimens in increasingly available in the emergency department and
infants and young children (usually not performed in helps to improve the success rate of obtaining urine
children who are older than two years). The distended with SPA. In a randomized study of 66 patients, the
bladder, which extends above the level of the pubic success rate with US was 79 percent (versus 52 percent
symphysis into the lower abdomen, is easy to access without US) [37].
percutaneously. Success is more likely if the bladder
can be visualized by portable ultrasonography, Complications
percussed, or palpated and the child has not emptied the Minor complications, such as microscopic
bladder in the 60 minutes before the procedure [30, 31]. hematuria, are common. Major complications, such as
Percussion or palpation of the bladder may stimulate gross hematuria [38, 39] and anterior abdominal wall
urination in some children. This method represents the abscess, are rare [40]. Intestinal perforation can occur if
gold standard in the diagnosis of UTI [32-34]. In one a loop of bowel overlies the bladder, but the small
study, clean voided bag, clean voided, and SPA urine puncture rarely leads to peritonitis [41]. Intestinal (or
samples were obtained on the same day from thirty other viscus) perforation can be avoided if the
hospitalized children between the ages of one day and procedure is not performed in children who have
three years [34]. Compared with the other collection abdominal distension, organomegaly, volume depletion,
methods, SPA yielded no cultures with mixed growth or or congenital anomalies of the gastrointestinal or
colony count less than 10,000 per mL/urine, suggestive genitourinary tract [41].

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Transurethral bladder catheterization (tubc) external bladder sphincter. This can generally
The catheterization of the urethra is another be overcome by maintaining traction on the
safe and effective method for obtaining urine samples penis, while applying gentle pressure with the
for culture in most infants and children who are not catheter. The catheter should never be forced
toilet trained. Specimen contamination may occur in up
to 15 percent of children under two years of age and is Girls
more common in uncircumcised boys, infants under six  The urethra may be difficult to visualize in
months of age, and children in whom the urethra is not girls. An assistant often is needed to retract the
well visualized or who require several attempts to pass labia majora. In addition, redundant tissue
the catheter [42]. An explanation of the anatomy and around the introitus can sometimes obscure the
the indications for the procedure should be given to urethral meatus. Swabbing the area from front
parents and caregivers before transurethral bladder to back may push this tissue out of the way and
catheterization is performed to avoid unnecessary permit the povidine-iodine solution to pool in
parental anxiety about the manipulation of their child's the meatus, making it easier to identify.
genitals. In addition, whether the child has latex allergy  The catheter is inserted into the urethral
must be determined because the condition is common in meatus until urine returns. Catheters that are
children with spina bifida and other conditions that inadvertently placed in the vagina may be left
require frequent bladder catheterization. in place to serve as a landmark for subsequent
attempts.
The following steps are performed  The first few drops of urine obtained should be
 The child is restrained in the supine and frog discarded to prevent contamination of the urine
leg position. This position permits adequate with urethral organisms or cells. A prospective
stabilization of the pelvis and complete study comparing early and later urine samples
visualization of the external genitalia. obtained by TUBC in 86 children
 The anterior urethra is cleansed thoroughly demonstrated that inclusion of the early stream
with povidone-iodine solution. urine increases false positive results on
 A sterile lubricant jelly is applied to the end of urinalysis for white blood cell counts and
an appropriately sized catheter (5 French for bacteria detection [45].
children younger than six months; 8 French for
those between six months and adolescence, Portable ultrasound
and 10 French for adolescents). Portable ultrasound (US) is increasingly
available in the emergency department and helps to
The efficacy of using topical lidocaine to improve the success rate of obtaining urine with TUBC.
reduce pain during urethral catheterization in children is In a prospective study, the success rate for obtaining
uncertain. In one randomized trial, children who were urine on the first attempt with US was 96 percent
catheterized using a lubricant containing lidocaine (versus 72 percent without US) [46].
experienced less pain during the procedure [43]. In a
similar report in infants, however, there was no Complications
difference in pain scores with and without topical Complications of bladder catheterization are
lidocaine [44]. If a topical anesthetic is used, it should minimal and include urethral trauma and microscopic
be applied two to three minutes before the procedure is hematuria. In addition, catheterization can cause
performed. iatrogenic infection. However, this risk was assessed by
the AAP subcommittee on UTI and found to be
Boys extremely low, and no change was made in the
 The foreskin of the glans is retracted gently to recommendation to perform the procedure.
permit complete visualization of the urethral
meatus if the boy is uncircumcised. The Comparison of suprapubic bladder aspiration and
foreskin must be repositioned after the transurethral bladder catheterization
procedure to prevent paraphimosis. Few studies have compared suprapubic bladder
 The urethra is straightened by using the aspiration and urethral catheterization in infants and
nondominant hand to hold the penis children:
perpendicular to the lower abdomen. Gentle  One hundred infants younger than six months
traction is applied. of age who were being evaluated for febrile
 The catheter is inserted with the dominant illness, suspected UTI, or sepsis were
hand until urine returns. randomly assigned to undergo SPA or TUBC.
 As the catheter is being advanced, it can be TUBC was more successful (100 versus 46
palpated along the posterior aspect of the percent) but took more time (mean time of 81
penis. Resistance may be encountered near the versus 17 seconds) than did SPA [31]. In
base of the penis due to contraction of the

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addition, TUBC was 100 percent successful present. When bacteriuria is significant, the test is
after failed SPA. positive about 80 percent of cases in which the urine
 Thirty-three neonates who required sterile has incubated for at least four hours in the bladder.
collection of urine were randomly assigned to Leukocyte esterase corresponds to pyuria and nitrite
urine collection by SPA or TUBC [46]. TUBC reflects the presence of Enterobacteriaceae, which
was more successful (81 versus 65 percent), convert urinary nitrate to nitrite.
but the volume of urine obtained was
insufficient for analysis more often (69 versus
41 percent).
RECOMMENDATION
Among patients with symptoms suggestive of
 Urine samples from 42 children, aged three
a UTI (dysuria and frequency), the diagnosis can be
months to 10 years, were obtained by SPA and
confirmed by sending a clean-catch specimen for
TUBC after elective surgery. TUBC samples
culture and for urinalysis. One suggested exception
were divided into first and second portions
recommended by most experts is a symptomatic young
[33]. Sterile cultures were obtained more often
woman with pyuria (detected by urinalysis or dipstick)
from SPA than from second TUBC sample,
who has apparently uncomplicated cystitis. It has been
and more often from second than from first
recommended that a CFU count ≥102 /mL be considered
TUBC sample (95 versus 80 versus 60
positive on a midstream urine specimen in women with
percent). When cultures with nonpathogenic
acute symptoms and pyuria whereas true infection
organisms or colony counts less than 10.000
without pyuria is unusual, pyuria can occur in the
per mL/urine were assumed to be
absence of apparent bacterial infection, particularly in
contaminated, the agreement between SPA and
patients who have already taken antimicrobials most
TUBC for "sterility" was 98 percent for the
often due to self-medication. It is important to note that
second portion and 93 percent for the first.
in Uroepithelial tumor when the more common causes
of sterile pyuria have been eliminated, patients with
Processing of urine samples
dysuria and frequency should be tested for atypical
The urine sample should be sent immediately
organisms, such as Chlamydia, Ureaplasma
to the bacteriology laboratory because bacteria will
urealyticum, or tuberculosis.
continue to proliferate in the warm medium of freshly
voided urine, leading to increased bacterial counts. If
such immediate dispatch is not possible, the container REFERENCES
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Complication of suprapubic bladder

Cite This Article: Iddah, M. Ali & Benard O. Wesonga (2021). Urine Sampling and Culture in the Diagnosis of Urinary
Tract Infection: A Review Article. East African Scholars J Med Surg, 3(4), 59-69.

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