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com
Education & Practice Online First, published on November 11, 2016 as 10.1136/archdischild-2015-309083
INTERPRETATIONS

How to use… urine dipsticks

J Cyriac,1 Katy Holden,1 Kjell Tullus2

1
Department of Paediatrics, Mid ABSTRACT each component of urine, both normal
Essex Hospital Services NHS ‘Urine dipstick’, the commonly used point-of- and abnormal. We, clinicians are familiar
Trust, Broomfield Hospital,
Chelmsford, UK care test, is an extremely sensitive investigation. with interpreting leucocyte and nitrite
2
Department of Paediatric Results of this test affected by numerous factors, results in suspected urinary infection, and
Nephrology, Great Ormond if not meticulously linked with detailed history blood and protein for non-infectious
Street Hospital, London, UK
and examination, can lead a well-meaning renal diseases. However, are we familiar
Correspondence to clinician down the wrong clinical pathway. The with the wealth of information the other
Dr J Cyriac, Department of aim of this article is to provide an overview of this parameters can give?
Paediatrics, Mid Essex Hospital every day test, touching on the physiological and Table 1 gives a summary of the physio-
Services NHS Trust, Broomfield
Hospital, Chelmsford, CM1 7ET, technological basis initially, but mainly focusing on logical and technological features of
UK; Job.Cyriac@meht.nhs.uk common questions like when to request the protein, blood, leucocytes and nitrites
dipstick test, the correlation of dipstick results with dipstick parameters and includes some
Accepted 25 October 2016
urine specimen collected by different method and cautions when interpreting results.
complexities of interpretation of dipstick results in Clinical information and interpretation of
everyday clinical scenarios. these important dipstick parameters is
highlighted in detail in the manuscript.
INTRODUCTION In table 2, in addition to the details of
Urinalysis dates back more than physiological and technological para-
3000 years and originally consisted of meters, brief descriptions of common
checking colour, smell and even taste, and uncommon clinical conditions where
and was one of the main investigations information from the rest of dipstick
physicians used to detect disease.1 In results can be applied are highlighted.
1850s, chemists detected sugar in urine
using a paper test and in 1883, English
physiologist George Oliver (1841–1915) INDICATIONS AND LIMITATIONS
marketed ‘Urine Test Papers’. By the Considering the different methods of urine
1950s, urine test sticks were made on an collection in paediatrics and how it affects
industrial scale and marketed commer- the dipstick results, is there a gold standard
cially. Today, millions of urine tests are method of urine collection in children?
performed every day for diagnosing and As paediatricians, we are challenged by a
monitoring a number of conditions. huge variation in our patients, especially
The urine dipstick is an extremely sen- with regard to size and weight. Our
sitive test, which is affected by numerous patient group ranges from premature
factors. The results, if not correlated with babies of 23 weeks’ gestation weighing
detailed history and examination find- <1 kg to 18-year-old young adults who
ings, can lead a well-meaning clinician may be weighing 100 kg or more.
down the wrong clinical pathway. We aim Naturally, the method of choice for urine
to give an overview of every day test, collection varies based on age, toilet train-
touching on the physiological and ing and the obvious anatomical gender
technological basis initially, but mainly differences. The chances of false positives
focusing on common questions like when are considerable in children, especially in
to request the dipstick test, the best the non-toilet trained child. Methods of
method to obtain a reliable sample and urine collection based on age and toilet
how to interpret this simple test in every- training status, their reliability and the
day clinical scenarios. clinical circumstances of when to use
To cite: Cyriac J, Holden K, which method are illustrated in table 3.
Tullus K. Arch Dis Child Educ
Pract Ed Published Online
PHYSIOLOGICAL AND The American Academy of Pediatrics
First: [ please include Day TECHNOLOGICAL BACKGROUND recommends that antibiotics should not
Month Year] doi:10.1136/ There are a number of test pads in the be started based on urinalysis from bag
archdischild-2015-309083 commonly used urine dipstick to analyse urine specimen.5 Samples should ideally

Cyriac J, et al. Arch Dis Child Educ Pract Ed 2016;0:1–7. doi:10.1136/archdischild-2015-309083 1

Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
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Interpretations

Table 1 Commonly used urine parameters

Dipstick test pad Physiological and technological background Cautions

Protein ▸ Protein test pad is based on the principle of ‘protein error of ▸ The protein pad does not detect other proteins such as
indicators’ in which tetrabromphenol blue is yellow at the pH gamma-globulins or Bence Jones proteins
of 3 in absence of proteinuria ▸ The protein pad is affected by the pH and the concentration
▸ Change in colour correlates with the concentration of albumin, of the urine sample
the main urinary protein the test is sensitive for ▸ Hence, false positives can be caused by alkaline or
▸ Dipstick protein pad gives a semiquantitative result concentrated urine and conversely, false negatives can be
▸ For accurate quantification of proteinuria, request timed urine due to acidic or dilute urine and when the primary protein is
collection or protein/creatine ratio not albumin2
Blood ▸ Blood test pad detects tetramethylbenzidine caused by ▸ Very sensitive test, hence negative result virtually eliminates
peroxidase-like reaction of haemoglobin haematuria
▸ Spotted positivity indicates intact red blood cells ▸ Falsely positive in presence of ascorbic acid (vitamin C) in
▸ Uniform positivity indicates free haemoglobin the urine, elevated specific gravity, pH <5.1, proteinuria and
treatment with captopril2
Leucocytes ▸ Leucocyte test pad detects leucocyte esterase enzyme released ▸ False-positive results commonly occur with contamination of
from lysed leucocytes in the urine urine by vaginal secretions, flushing of the prepuce etc
Nitrites ▸ Most uropathogenic bacteria elaborate the nitrate reductase ▸ Sensitive test detecting even 10–15 organisms per mL of
enzyme that reduces nitrates normally present in the urine to urine
nitrites, which is detected by the nitrite test pad ▸ A positive nitrite test only means presence of bacteriuria,
which often can be asymptomatic

be dipstick tested without any delay, but can be stored infections (UTIs) associated with inflammation of the
in a refrigerator or preserved in boric acid-containing urinary tract should have significant pyuria. Lower
containers. amounts of leucocytes, reflected as the absence of
In summary, method of choice of urine collection leucocyte esterase, are seen in children with ASB.
depends on the clinical context, age and gender of the False-positive test results are often found in older girls
patient and especially if infection is being considered during any febrile infection and postexercise.2
or not? Urinalysis in asymptomatic children of both genders
is generally identical when obtained by gold standard
method like suprapubic aspiration. However, in prac-
Should every child attending a paediatric consultation
tice there are differences in dipstick parameters,
require a urine analysis?
microscopy and colony counts due to varying urine
The American Academy of Paediatrics no longer
collection methods for different age group children,
recommends routine urinalysis on children as it gives
gender difference and physiological factors like
a low diagnostic yield.5 One study of 2000 asymptom-
prepuce flushing in infancy and vaginal flushing.
atic patients found abnormal urine dipsticks in 9% of
In conclusion, in this specific scenario of fever and
patients, but when repeated only 1.5% showed a per-
no focus, the presence of leucocytes on dipstick does
sistent abnormality.8 Recent reviews also reveal no evi-
raise the possibility of a urine infection. The diagnosis
dence that detection and treatment of children with
should only be finalised with the isolation of signifi-
asymptomatic bacteriuria (ASB) prevents subsequent
cant bacterial growth on culture.
pyelonephritis or scarring.9
In conclusion, currently there is no justification for
performing urinalysis as a screening test and it should
Does an isolated positive nitrite test, which indicates
only be performed if clinically indicated and if results
bacteriuria, in an asymptomatic child represent a urine
alter the clinical management.
infection?
More than 85% of pathogenic bacteria causing UTI in
In well-appearing febrile children under 3 years, in whom children have the enzymes to convert endogenous
no other focus of infection can be found, does the nitrates in the urine to nitrites, which are detected by
presence of solitary leucocytes on a urine dipstick indicate urine dipstick. Some bacteria such as Klebsiella and
a urine infection that needs treatment? Enterococcus are non-nitrate reducing. The bacterial
The leucocyte esterase test detects esterase, which is conversion from nitrate to nitrite takes 1–4 hours, and
an enzyme released by leucocytes. Normal children therefore the test is not reliable in children, particu-
have <10 leucocyte count/mL in midstream urine larly infants, who empty their bladders frequently.
(MSU), although neonates can have up to 50 leuco- False-negative nitrite tests can also occur in ‘low-
cyte count/mL.3 All symptomatic urinary tract count’ UTI (<103 colony forming unit of bacteria per

2 Cyriac J, et al. Arch Dis Child Educ Pract Ed 2016;0:1–7. doi:10.1136/archdischild-2015-309083

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Interpretations

Table 2 Less-commonly used urine parameters

Dipstick test
pad
Normal ranges Physiological and technological background/cautions Affected in and affected by

Glucose ▸ Based on the glucose oxidase reaction and does not ▸ Glycosuria occurs when the filtered load of glucose exceeds the
cross-react with other sugars ability of the proximal tubule to reabsorb it, eg, diabetes mellitus,
▸ Plasma glucose tubular absorption threshold is Cushing’s syndrome, etc
9–10 mmol/L ▸ The threshold for tubular reabsorption can be altered in isolated
tubular dysfunction like renal glycosuria or generalised ones like
Fanconi syndrome, cystinosis or Wilson’s disease, where blood
glucose is normal
Ketones ▸ Ketones are products of fat metabolism not normally ▸ Positive in diabetes mellitus, pregnancy, ketogenic diet
found in urine ▸ In hypoglycaemia, presence of ketones suggests ketotic
▸ Among the ketones, only acetoacetic acid and acetone hypoglycaemia, if absent, points to fatty acid metabolic
that react with nitroprusside are detected by dipsticks abnormalities like medium chain acyl CoA dehydrogenase
deficiency
▸ Ketonuria is a physiological response to starvation; many small
children get morning ketonuria with normal ‘starvation’ overnight
▸ Ketonuria also occurs with cold exposure and extended periods of
exercise
pH ▸ Generally, patients on a typical western diet tend to have ▸ Mundane clinical conditions like diarrhoea and vomiting that result
range 4.5–8 slightly lower acidic urinary pH in dehydration are the common causes of acidic urine
▸ For accurate measurement of pH, urine sample should be ▸ Interestingly in conditions like pyloric stenosis with metabolic
sealed to prevent CO2 evaporation alkalosis, urine is paradoxically acidic due to the preferential
▸ Delaying the test >30 min at room temperature makes excretion of hydrogen ions to conserve potassium in the blood
urine alkaline due to the breakdown of urea ▸ Urine pH can help to determine the cause of metabolic acidosis
(pH>5 indicates renal tubular acidosis rather than an inborn error
of metabolism) and distinguish different types of renal tubular
acidosis3
▸ Alkaline urine in patient with urinary tract infection suggests urea
splitting organism like Proteus, which can cause magnesium–
ammonium phosphate crystals, which form staghorn calculi3
▸ Alkaline urine can also form calcium carbonate and calcium
phosphate stones
▸ Acidic urine is associated with uric acid stones
▸ Urine pH is actively monitored in therapeutic alkalisation for
conditions like salicylate poisoning and tumour lysis syndrome
SG ▸ SG test is based on the change of pH dye due to binding ▸ Increased with glycosuria, proteinuria, syndrome of inappropriate
Normal range H+ ions, which in turn linearly corresponds to urine antidiuretic hormone secretion4
1.003–1.030 osmolality ▸ Decreased with diuretics, diabetes insipidus, adrenal insufficiency,
▸ Hence physiologically SG test reflects hydration status aldosteronism and impaired tubular function
and concentrating ability of the kidney ▸ Low SG in a dehydrated patient indicates impaired concentrating
▸ <1.010 indicates relative hydration ability, which points towards a renal tubular dysfunction
▸ >1.020 indicates relative dehydration
▸ SG is high in urine with significant proteinuria
▸ As SG test is closely related to H+ ion concentration it
can be falsely elevated at urine pH <6 and falsely
lowered by urine pH >7
▸ Poor correlation with pathological urine to estimate urine
osmolality4
Bilirubin ▸ Bilirubin is not normally detected in the urine ▸ Prehepatic cause like haemolysis causes rise of urobilinogen in the
▸ Even a trace of bilirubin in the urine requires further urine
investigations ▸ Hepatocellular disease like hepatitis results in presence of bilirubin
▸ Bilirubin is destroyed by light and air, hence should be and urobilinogen in urine
tested promptly or stored properly

Urobilinogen ▸ Urobilinogen is the product of bacterial action of direct ▸ Presence of bilirubin and absence of urobilinogen points towards
bilirubin in the gut an obstructive cause.
▸ Urobilinogen can be present in normal urine in small ▸ Administration of antibiotics may result in decreased level of
amounts urobilinogen due to sterilisation of bowel

SG, specific gravity.

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Interpretations

Table 3 Urine collection methods

Methods of urine collection in children

Toilet trained/
Method non-toilet trained Reliability Invasiveness Comments

Cotton balls in nappy Non-toilet trained High contamination Non-invasive ▸ Good for its negative predictive value
risk ▸ Can be used if child felt to be at low risk
▸ If dipstick is positive further urine sample should be
obtained by a more reliable method based on the clinical
urgency
Nappy pad Non-toilet trained High contamination Non-invasive ▸ As above
risk
Urine bag Non-toilet trained High contamination Non-invasive ▸ As above
risk6
Clean catch (with no Both Low contamination Non-invasive ▸ Method of choice for non-toilet trained children
prior cleaning) risk ▸ Similar contamination rates to catheter6
▸ Recommended by National Institute for Health and Care
Excellence7
Midstream urine Toilet trained Low contamination Non-invasive ▸ Best method for toilet trained children6
Children adult method risk ▸ Gold standard method for toilet trained children who can
void at request

Catheter collection Both Minimal Invasive ▸ Similar contamination rates to clean catch6
contamination risk
Suprapubic aspiration Both No contamination Invasive ▸ Lowest contamination rates6
risk ▸ High positive predictive value6

mL of urine), dilute urine specimens or acid urine.2

Box 1 Physical and behavioural risk factors for
Nitrites do therefore have quite a low sensitivity in
urinary tract infection (UTI)
detecting a UTI in children (often about 50%) but a
very high specificity (approaching 100%).2
ASB is defined as the presence of significant bacter- Physical
ial growth in urine without any overt symptoms. The ▸ Uncircumcised males: uncircumcised males
concern is that these bacterial growths represent sub- <3 months have a much higher prevalence of UTI
clinical infection, which if left untreated could result than circumcised males of the same age.13
in renal scarring. Prevalence of ASB varies with age, ▸ Male: physiological phimosis in males results in bal-
sex, race and socioeconomic status. In infants under looning of the prepuce, stasis of residual urine in the
3 months, ASB prevalence is estimated to be 1.8% for prepuce, irritation and inflammation of the urethral
girls and 0.5% for boys. After infancy, the incidence meatus.
in males falls to virtually 0% and in preschool girls ▸ Female: shorter urethra, poor hygiene, lack of pro-
0.8%, rising to 1.8% over the age of 6 years.10 tective hair and atrophy of labia majora due to lack
For low-risk adult patients, ASB is not thought to of oestrogen in prepubertal females, labial adhesions.
be harmful. Although patients are more susceptible to Behavioural
symptomatic UTIs, treatment does not decrease the ▸ Voiding postponement: voiding interval needs to be
frequency of symptomatic infection or improve other <3 hours in school-age children or incomplete pelvic
outcomes such as renal scarring.11 In fact, treatment floor relaxation occurs and therefore incomplete
has led to the selection of resistant organisms and the bladder emptying.
risk of side effects like Clostridium difficile infection.12 ▸ Constipation: the over distended rectum affects
There are some risk factors behavioural patterns bladder sensitivity and contractility.
specific to the paediatric population, which include ▸ Poor fluid intake.
atrophy of labia majora, lack of protective hair (easy
colonisation of pathogenic bacteria due to impairment In this clinical scenario, the presence of isolated posi-
of barrier defence) and some behaviour patterns tive nitrites only represents bacteriuria and per the
voiding postponement, constipation (urinary stasis), National Institute for Health and Care Excellence
which can contribute to proliferation of bacteriuria (NICE) guidelines, asymptomatic bacteria should not
leading to UTI. These are illustrated in box 1. be treated.7

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Interpretations

There are a number of localised perineal conditions

that can give positive urine dipstick results and can Box 3 Common causes of chronic haematuria
mimic UTI (box 2). Therefore, thorough history includ-
ing use of bubble baths and reports of vaginal discharge Causes of microscopic/macroscopic haematuria
should be taken. An external examination including the ▸ Calculi
perineum is essential to rule out these conditions. ▸ IgA nephropathy
▸ Alport’s disease
▸ Sickle cell disease
What does isolated proteinuria on a urine dipstick ▸ Schistosomiasis
indicate? What are your management considerations? ▸ Haemorrhagic cystitis
The importance of proteinuria is very different in dif- ▸ Renal tumours
ferent clinical scenarios. Proteinuria in the acutely
unwell child should be correlated to the overall clin-
ical presentation including oedema, macroscopic or
microscopic haematuria, raised blood pressure and
impaired kidney function.
There are many benign causes for proteinuria. They Table 4 Causes and investigations of fixed proteinuria in
include children
▸ fever Renal causes of
▸ exercise proteinuria Investigations
▸ contamination with vaginal secretions ▸ Nephrotic syndrome ▸ Quantification of proteinuria
▸ orthostatic proteinuria ▸ Acute ▸ Serum albumin/serum creatine
None of these signifies an important clinical condi- glomerulonephritis ▸ Complements: C3 and C4
tion but need further evaluation to ensure the transi- ▸ Henoch-Schonlein ▸ Streptococcal antibodies
nephritis ▸ Antinuclear antibodies
ent nature of the abnormality and ensure long-term ▸ IgA nephropathy ▸ Antibodies against double-stranded DNA
follow-up of children with chronic kidney disease. ▸ Lupus nephritis ▸ ANCA antibodies
In conclusion, transient proteinuria is generally con- ▸ ANCA positive nephritis
sidered to be due to benign or non-renal causes. It is
important to repeat the test or consider a formal In a child known to have chronic kidney disease,
quantification of the proteinuria using timed urine degree of proteinuria is related to the long-term progno-
collection or protein/creatine ratio to confirm the sis with increasing amounts of proteinuria indicating
transient nature of the proteinuria. faster progression to end-stage renal failure. These chil-
dren need regular renal follow-up and are typically
treated with an ACE inhibitor or an angiotensin II recep-
Should your approach to proteinuria change if the child is
tor blocker to reduce their proteinuria and slow down
known to have chronic kidney disease?
their progression to end-stage kidney disease.
Children with impaired glomerular filtration generally
have fixed proteinuria of varying degree. Significant In a child with isolated haematuria on urine dipstick, could
fixed proteinuria, which is mostly albuminuria as this indicate renal disease?
highlighted in table 1, is due to glomerular impair- The urine strip detects blood by the peroxidase-like
ment will need appropriate renal work up. Some of action of both haemoglobin and myoglobin. Hence,
the common renal conditions causing proteinuria and the blood reagent on urine dipstick can be positive in
their investigations before considering renal biopsy are the presence of red blood cells, free haemoglobin and
given in table 4. This is partly due to hyperfiltration myoglobin in the urine.
of remaining glomeruli in a damaged kidney. Clinical considerations include the presence of
dysuria, fever and flank or abdominal pain, and clin-
ical findings of microscopic or macroscopic haema-
Box 2 Mimics of urinary tract infection (UTI) turia, hypertension, oedema, rash and proteinuria.
Further evaluation of haematuria should commence
with confirming the presence of red blood cells by
Irritants such as chemicals including bubble baths
direct microscopy. The long-term management
▸ Self-exploration
depends on whether haematuria is microscopic or
▸ Pinworms
macroscopic, persistent or intermittent associated with
▸ Nappy rash
proteinuria, which in turn needs to be differentiated
▸ Sexually transmitted infections/abuse
from the benign causes. Box 3 gives an outline of the
▸ Vulvovaginitis—can progress to UTI14
causes of haematuria.
▸ Foreign bodies such as toilet paper3
A child with symptoms and signs of an acute renal
▸ Balanitis
disease should be investigated further

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Interpretations
▸ for a glomerulonephritis (see under proteinuria) TOPICS FOR FURTHER RESEARCH
▸ for haemorrhagic cystitis with urine microscopy and Further studies are required to have a better under-
culture standing of sensitivity and specificity urinary leuco-
▸ for a calculi or malformation with ultrasound of the cytes and/or nitrite test to include or exclude the
urinary tract (and plain abdominal X-ray in case of suspi- diagnosis of UTI in different age groups. There is con-
cion of renal calculi) siderable research using molecular biology techniques
In conclusion, children with persistent microscopic to identify and quantify bacterial colonies to reduce
haematuria, in the absence of proteinuria, with the time taken by the gold standard method of urine
normal serum creatine and normal renal ultrasound culture.16 In future, bedside confirmation of urinary
and without history of any renal disease in the family infection and identification of the causative organisms
do not generally need invasive investigations such as
renal biopsy. However, these children should be moni-
tored yearly considering the increased risk of end- Test your knowledge
stage renal failure in this group.15
1. A negative nitrite result can be due to
A. Urinary frequency
Clinical bottom line B. Elevated specific gravity
C. Oxidising drugs
▸ Clinicians should request a urine dipstick analysis D. Vitamin C
only if clinically indicated. As per the recent NICE E. Glycosuria
guidelines, urinalysis is advised in children with clin- 2. Causes of transient proteinuria and false-positive pro-
ical signs of UTI and/or unexplained fever over 38°C teinuria include
for 24 hours.7 Medical and nursing staff should be A. Fever
educated to stop testing urine samples on every child B. Concentrated urine
who passes through the paediatric doors. C. Alkaline urine
▸ Considering the high specificity and negative predict- D. Phenazopyridine
ive value of the urine dipstick, UTI can be effectively E. Exercise
ruled out, in at least all children outside infancy, if 3. Causes of sterile pyuria include
the dipstick is completely negative for leucocytes and A. Chlamydia
nitrites regardless of the urine collection method. B. Fever
▸ UTI as a diagnosis should only be considered when C. Tuberculosis
there is a combination of positive clinical history, abnor- D. Kawasaki disease
mal urine dipstick results (ideally which are reprodu- E. Appendicitis
cible) accumulated by a reliable collection method and F. Urethritis
lack of signs or symptoms of alternative diagnoses. UTI G. Bladder tumours
should only be confirmed by a positive culture of uro- H. Foreign bodies
pathogenic bacterial growth with adequate colony I. Exercise
count for the method of collection of urine sample. J. Corticosteroids
▸ In older children with no symptoms or with non-
specific symptoms who have positive urine dipstick 4. Alkaline urine is associated with the following renal
results, a provisional diagnosis of ASB should be calculi
strongly suspected and the sample should be sent to A. Calcium carbonate
the lab without embarking on empiric antibiotic B. Calcium phosphate
treatment. Further enquiry about dysfunctional C. Xanthine
voiding habits, bowel movement pattern, drinking D. Cysteine
habits and a thorough clinical examination including E. Calcium oxalate
the perineal area is highly likely to give further valu- F. Uric acid
able clinical information towards the final diagnosis G. Magnesium phosphate
and long-term prevention. 5. Spot the odd one/ones out—which of these foods
▸ Apart from diagnosing and ruling out urinary infec- will not affect urine colour
tion, the other parameters provide valuable informa- A. Beetroot
tion about number of non-infectious, but significant B. Carrot
renal and metabolic diseases. Giving attention to less C. Rhubarb
heeded parameters may give valuable pointers to D. Blackberries
changes in the homeostasis of bodily functions and E. Spinach
occasionally clues to rare, but significant clinical F. Cherries
disease processes. The answers are after the references.

6 Cyriac J, et al. Arch Dis Child Educ Pract Ed 2016;0:1–7. doi:10.1136/archdischild-2015-309083

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Interpretations

might be possible if the new methodology as 8 Kaplan RE, Springate JE, Feld LG. Screening dipstick analysis:
described by Lehman et al can be incorporated into a time to change. Pediatrics 1997;100:919–21.
the current urine dipstick parameters.17 From a wider 9 Cormican M, Murphy A, Vellinga A. Interpreting
asymptomatic bacteriuria. BMJ 2011;343:d4780.
context, urine dipstick tests for colon cancer, coeliac
10 Nicolle LE. Asymptomatic bacteriuria when to screen and
disease, prostate cancer, ulcerative colitis, pneumonia
when to treat. Infect Dis Clin North Am 2003:17:367–94.
and organ transplant rejection are being developed.1 11 Hansson S, Jodal U, Norén L, et al. Untreated bacteriuria in
Acknowledgements The authors thank Dr Dean Lethaby, asymptomatic girls with renal scarring. Paediatrics
Mr Ciaran Cyriac and Miss Lisbeth Cyriac for proof reading 1989;84:964–8.
and correcting the manuscript. 12 Pallet A, Hand K. Complicated urinary tract infections:
Contributors KH: Formulated the first draft of the article and practical solutions for the treatment of multiresistant
did further revisions. KT: Specialist advice and revision of the Gram-negative bacteria. J Antimicrob Chemother 2010;65
article. JC: The conception, design, revision and the overall (Suppl 3):iii25–33.
responsibility of the article.
13 Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary
Competing interests None. tract infection in childhood; a meta-analysis. Pediatric Infect
Provenance and peer review Commissioned; externally peer Dis J 2008;27:302–8.
reviewed. 14 Emans S. Vulvovaginitis in the child and adolescent. Paediatr
Rev 1986;8:12–9.
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How to use… urine dipsticks

J Cyriac, Katy Holden and Kjell Tullus

Arch Dis Child Educ Pract Ed published online November 11, 2016

Updated information and services can be found at:

http://ep.bmj.com/content/early/2016/11/11/archdischild-2015-309083

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