Sterile Pyuria

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Sterile pyuria is the presence of elevated numbers of white cells (>10 white cells/mm3) in urine which appears sterile using standard culture techniques:

  • Sterile pyuria is not an uncommon laboratory finding.[1]
  • Sterile pyuria is often found in female patients with symptoms of urinary tract infection (UTI). However, these results may be misleading for various reasons:
    • Standard laboratory culture conditions may not be optimal for growth of atypical organisms.
    • Laboratory may not report significant growth either because it was not a single organism or recognised urinary pathogen.
    • Fewer than 100,000 colony-forming units (cfu) per mL reported - eg it may be that urine was diluted by high fluid intake or an organism may be slow-growing. Studies have shown that approximately half of women presenting with symptoms and counts of 100 -10,000 cfu/mL have genuine bladder infections.
  • The presence of pyuria increases the significance of a low bacterial count in the urine.
  • Cell count per high power field is inaccurate and use of a counting chamber or similar gives more accurate results.

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  • Urinalysis: initial test to identify likely infection but a urine sample needs to be sent to the laboratory. See separate article Urine Dipstick Analysis. Positive nitrite test +/- positive leukocyte esterase test. Haematuria and proteinuria occur in urinary tract infection (UTI) but are also present in other conditions.
  • Urine microscopy, culture and sensitivities; ask the laboratory to culture under conditions allowing identification of fastidious or slow-growing organisms.
  • Consider the possibility of sexually transmitted disease; take a sexual history and consider sending swabs for chlamydia and N. gonorrhoeae.
  • Polymerase chain reaction (PCR) testing of sterile pyuria has been recommended for the detection of Chlamydia trachomatis, mycoplasma and ureaplasma infections.[3]
  • Always consider tuberculosis; culture for AFBs (3 early morning urine samples).
  • With urine obtained direct from the bladder, any organism grown is significant and should be treated with a prolonged course of appropriate antibiotics.
  • Cystoscopy may be required to exclude non-infective causes.
  • Management of any identified underlying cause.

Further reading & references

  1. Dieter RS; Sterile pyuria: a differential diagnosis. Compr Ther. 2000 Fall;26(3):150-2.
  2. Tayal SC, Pattman RS; Sterile pyuria: consider chlamydial infection. Br J Clin Pract. 1996 Apr-May;50(3):166-7.
  3. Nassar FA, Abu-Elamreen FH, Shubair ME, et al; Detection of Chlamydia trachomatis and Mycoplasma hominis, genitalium and Adv Med Sci. 2008;53(1):80-6.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Document ID:
1054 (v22)
Last Checked:
18/02/2011
Next Review:
17/02/2016