Urogenital Practice Standard Summary

The Urogenital (UTI) Practice Standard supports the diagnosis and treatment of urogenital conditions. These conditions include UTI, Pyelonephritis, Vaginitis, and Trichomonas.

Background 

The UTI Practice Standard will launch if all of the following criteria are met:

• Patient is AFAB (Assigned Female At Birth) and between the ages of 18 and 64

• Based on the patient’s Chief Complaint, the diagnoses predicted by machine learning relate to Pyelonephritis, Vaginitis, UTI, or Trichomoniasis

Clinical Content

Medical Interview Summary

The Urogenital/UTI Practice Standard asks about red flags, such as kidney pain, pelvic pain, and fever. These questions intend to identify patients who may be experiencing a severe infection or other condition that would warrant a referral to urgent care or the emergency department. In those cases, the provider will be prompted to consider referring the patient to urgent care or the emergency department.

If red flag symptoms are not identified, the interview will proceed by eliciting relevant urogenital symptoms and pieces of patient history. At the end of the patient answering all of the pertinent questions, a diagnosis will be presented for the provider’s consideration, along with relevant medication(s), and documentation to support the provider’s medical decision making. In addition, referrals and lab suggestions will be displayed. Based on the diagnosis selected by the provider, care plans will be entered in for the patient’s education. The provider can choose to use the suggestions provided, or change them based on their clinical decision making. 

Virtual Care Management Pearls

• UTI/Pyelonephritis

  • The Practice Standard will suggest that the provider consider ordering an UA, UCx AND/or medications when it is NOT an uncomplicated UTI (any of the following):

    • Only 1 uti symptom

    • Onset >30 days

    • Co-existing vaginitis/vaginal discharge

    • Pregnancy

    • >1 uti in last 3months OR >2 uti in 1 year (this visit = +1)

    • International travel in last 3 months

    • Systemic antibiotics in last 3 months

    • Inpatient stay in last 3 months

  • Pyelonephritis symptoms include the following:

    • Kidney pain

    • Fever

    • Chills

    • Nausea

    • Vomiting  

• Vaginitis

  • Vaginal candidiasis often presents with pruritus, vulvar erythema, thick white curd like discharge

  • Bacterial vaginosis often presents with a fishy odor, off-white/thin/homogeneous discharge

  • Trichomonas often presents with a frothy discharge 

Medication Guidelines

• UTI 

  • Nitrofurantoin (macrobid) - presented for consideration as 1st line (due to cost and less resistance) for UTI

    • 100mg PO BID for 5 days

    • The practice standard will only suggest this medication for a UTI

  • Other options include trimethoprim/sulfamethoxazole (bactrim DS), 160/800mg PO BID 3 days and Fosfomycin 3g PO once but these will not be suggested as part of the practice standard. 

• Pyelonephritis- presented for consideration if patient doesn’t appear sick and mild (0-3) or moderate (4-6) pain out of 10 based on NRS scale

  • Ciprofloxacin - presented for consideration as 1st line 

    • 500mg PO BID for 7 days

    • The practice standard will only suggest this medication for pyelonephritis

• Vaginal Candidiasis

  • Fluconazole 

    • 150mg PO once, may repeat in 72 hours

    • The practice standard will only suggest this medication for vaginal candidiasis

• Bacterial Vaginosis

  • Metronidazole

    • 0.75% vaginal gel 5 grams inserted nightly x 5 days

    • The practice standard will only suggest this medication for bacterial vaginosis

• Trichomonas

  • Metronidazole

    • 500mg PO BID for 7 days

Follow-up Recommendations Identified for Discussed with the Patient

• Possible Sepsis or SIRS symptoms

  • Refer to ED

• UTI 

  • If no improvement in 48h, return for visit or seek in-person care 

  • No need to stay home from work/school

  • If >3 UTIs/year or urine culture is negative consider in-person referral 

  • Onset >30 days consider in-person referral 

  • Co-existing vaginitis/vaginal discharge consider in-person referral 

• Pyelonephritis

  • May need an in-person visit if moderate or severe symptoms

  • May need to stay home from work/school for 48-72h

• Vaginal Candidiasis

  • If >1 previous vaginal infections in previous 6 months or >2 previous vaginal infections in previous 1 year consider in-person testing or specialty referral

• Bacterial Vaginosis

  • If >1 previous vaginal infections in previous 6 months or >2 previous vaginal infections in previous 1 year consider in-person testing or specialty referral

ICD-10 Codes Provided

Associated Available TextExpanders (if needed)

Please see your institution's Text Snippet document on available options.

Chat and Documentation Suggestions

In addition to presenting diagnostic and treatment suggestions for consideration by the provider, the Urogenital Practice Standard presents chat and documentation suggestions to the provider for consideration based on previous machine learning. The suggestions are tied to the selection of a diagnosis suggested for consideration by the provider. For example, if the Practice Standard suggests Urinary tract infection (N39.0) as the ICD-10 diagnosis AND the provider selects Urinary tract infection (N39.0) as the ICD-10 diagnosis, the chat and documentation suggestions will relate primarily to UTI management.

Citations

1. Centers for Disease Control and Prevention. (2021, July 22). STI Treatment Guidelines. Centers for Disease Control and Prevention. Retrieved September 12, 2022, from https://www.cdc.gov/std/treatment-guidelines/default.htm

2. Centers for Disease Control and Prevention. (2022, August 9). Sepsis Technical Resources & Guidelines. Centers for Disease Control and Prevention. Retrieved September 12, 2022, from https://www.cdc.gov/sepsis/clinicaltools/index.html

3. Hooten, T. M., & Gupta, K. (2021, March 15). Acute simple cystitis in women. UpToDate. Retrieved September 12, 2022, from https://www.uptodate.com/contents/acute-simple-cystitis-in-women

4. Lee, H. S., & Le, J. (2018). Urinary Tract Infections. In Pharmacotherapy self-assessment program (PSAP) (pp. 7–28). essay, ACCP.

5. McNulty, C., Jones, L., Cooper, E., & Joseph, A. (2020, May). Diagnosis of urinary tract infections. Public Health England. Retrieved September 12, 2022, from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/927195/UTI_diagnostic_flowchart_NICE-October_2020-FINAL.pdf

6. Paladine, H. L., & Desai, U. A. (2018, March 1). Vaginitis: Diagnosis and treatment. American Family Physician. Retrieved September 12, 2022, from https://www.aafp.org/pubs/afp/issues/2018/0301/p321.html

7. Sobel, J. D., & Kaye, D. (2015). Urinary tract infections. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. https://doi.org/10.1016/b978-1-4557-4801-3.00074-6