• Urine dipstick and urine culture before antibiotics, if possible
• Post-void residual bladder scan to see whether urine is being retained
• Kidney function and medication review when indicated
• Examination for pelvic organ prolapse, vaginal atrophy, stone, or obstruction

1. Take a midstream urine sample for urinalysis and culture before antibiotics.
2. Check post-void residual with a bladder scan. If significant retention is present, treatment includes catheter drainage and fixing the cause, not antibiotics alone.
3. Select an antibiotic and adjust it when culture results return.

• If she is stable, has only bladder symptoms, and can take oral medication, the prescriber may choose an oral agent based on culture susceptibility, such as a suitable oral cephalosporin, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or another locally appropriate option.
• Avoid assuming nitrofurantoin or single-dose fosfomycin is adequate when there is retention, fever, back/flank pain, systemic illness, or concern for kidney involvement. These are not appropriate for pyelonephritis.
• Ciprofloxacin should not be the automatic choice, especially in older adults, due to resistance and important adverse effects. Guidelines reserve it for specific situations when alternatives are unsuitable and local resistance is low.
• If fever, chills, vomiting, confusion, low blood pressure, flank pain, or inability to pass urine occurs, she needs urgent assessment and may need IV antibiotics. The EAU infection guideline recommends IV therapy chosen using local resistance and prior cultures for systemic UTI, then tailoring to susceptibility.

Why I am concerned

• Dysuria, suggesting lower UTI
• Urine passing drop by drop, suggesting poor bladder emptying or overflow from retention
• Bilateral flank pain, which raises concern for upper-tract involvement, bilateral obstruction, or hydronephrosis
• Diabetes, which increases the chance of UTI, autonomic neuropathy causing underactive bladder, and kidney complications

Working diagnosis

1. Complicated UTI with lower urinary tract symptoms
2. Incomplete bladder emptying/urinary retention with overflow dribbling
3. Rule out:
   • Obstructed infected urinary tract or hydronephrosis
   • Acute pyelonephritis
   • Ureteric stones
   • Diabetic cystopathy/neurogenic bladder
   • Pelvic organ prolapse, urethral stricture, bladder lesion, or medication-related retention

What I expect you to do today

• Full vital signs, including temperature, pulse, blood pressure, oxygen saturation
• Check hydration, mental state, lower abdominal/suprapubic distension and tenderness
• Check for costovertebral-angle tenderness
• Pelvic examination if appropriate, looking for prolapse, vaginal atrophy, mass, discharge
• Review all medications, recent antibiotics, prior cultures, renal disease, allergies

• Midstream urine: urinalysis, microscopy, culture and susceptibility
• CBC, creatinine/eGFR, urea, electrolytes including potassium, glucose, CRP
• Blood cultures if fever or any systemic unwellness
• Bladder scan immediately after voiding for post-void residual
• Renal and bladder ultrasound urgently if residual is high, creatinine is elevated, pain persists, or obstruction/hydronephrosis is suspected. CT may be needed if stone is suspected.

Management logic

• If she has a large post-void residual or cannot void effectively: prompt bladder decompression, usually catheterization, while investigating the underlying cause. Retention management in women requires catheterization plus correction of treatable causes.
• Start antibiotics after urine is obtained, but do not delay antibiotics if she appears systemically ill or obstructed infection is suspected.
• Antibiotic choice must be based on renal function, allergy, prior cultures, local antibiogram, and whether this is cystitis versus pyelonephritis/systemic UTI. If she is unwell, has renal impairment, or has obstruction, she may need admission and IV antibiotics, then step-down according to culture. The EAU guideline recommends culture-directed treatment and IV regimens for systemic UTI.
• Do not use nitrofurantoin as sole treatment if pyelonephritis, obstruction, reduced renal function, or systemic infection is suspected.

Medication safety point