Q: Pyuria
A 55-year-old woman has had urine showing pus cells but no growth on two occasions. What further tests are needed and what pathology is suspected? Also a similar problem was experienced with a young woman of 20. In both, a chlamydia test was negative.
The management of these two patients depends on symptoms and the absence of haematuria.
Sterile pyuria in women who are asymptomatic and have no blood in the urine probably does not need investigation, unless pus is actually visible.
If symptoms are present, then again haematuria and the presence or absence of risk factors for urethral tumours will influence the investigations carried out. One would be more scrupulous about investigating the 55-year-old smoker than a 20-year-old non-smoker from the point of view of detecting bladder tumours. Equally a 20-year-old who had recently been holidaying in bilharzia areas might demand attention.
In general, urine microscopy is the first investigation, followed by imaging of the bladder and upper tracts as appropriate. While CT urography will give the highest yield, KUB ultrasound with plain X-ray is more used in the UK. In non-smokers without haematuria, the diagnosis yield at cystoscopy is limited but it will clearly exclude urothelial lesions.
Overall, a few pus cells in the urine are generally not of concern in either sex as long as there are no complications.
- Mr Gordon Muir is consultant urologist at King's College Hospital, London.
Q: Menorrhagia
A 45-year-old female patient had menorrhagia with flooding and clots - her transvaginal ultrasound was normal. She has been taking norethisterone 5mg twice daily on days 5-22 to control her periods.
She stopped treatment after four months, but her symptoms returned, so she started taking it again. She has been on this treatment for 18 months and does not want to stop. She has tried the Mirena coil, but this did not help. Are there any problems with continuing the norethisterone?
You mention a transvaginal ultrasound, so I assume that the patient has been investigated for possible causes and nothing (for example, fibroids) has been found.
It might just be worth considering a clotting screen in case she has a clotting disorder.
You also mention that the patient has tried the Mirena coil, but do not say for how long; she should have given it at least six months, to allow for the bleeding that occurs early in its use.
Interestingly, norethisterone is not considered particularly effective in treating menorrhagia, being greatly surpassed by tranexamic acid. Nevertheless, it clearly works for this patient and I see no problem with continuing it, if she is happy.
However, if she does not smoke and has no other risk factors for cardiovascular disease and no other contraindications, this patient might want to consider trying the combined oral contraceptive Pill, which would offer her contraception, bleeding control and ease of use.
- Dr Anne Szarewski is clinical consultant and honorary senior lecturer, Cancer Research UK, Wolfson Institute of Preventive Medicine, London
- Further reading: Protheroe J. Modern management of menorrhagia. J Fam Plann Reprod Health Care 2004; 30: 118-22.
