Diagnostic Assessment — Urinary Tract Infection
Example 1 of 1 · fictitious patient (Veteran CK)
Diagnostic Assessment
Urinary Tract Infection
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CK, date of birth 08 July 1991, Australian Army, Driver (Transport), enlisted 14 January 2010, medically discharged 23 May 2022. Operational service: Afghanistan, 03 January 2013 to 25 August 2013 (warlike); Middle East Area of Operations (Iraq), 04 February 2017 to 30 August 2017 (warlike).
Occupational History
Army transport drivers operate heavy and protected vehicles on long road moves and logistic convoys, often for 8 to 14 hours at a time. On operations convoys cannot stop safely outside secured areas, and there are no toilets in vehicles, so drivers, particularly female soldiers, routinely delay voiding for many hours and restrict their fluid intake to avoid needing to stop, despite high temperatures and heavy protective equipment.
Deployed drivers also live in forward operating bases and staging areas with limited water, showers and toilet facilities, work in extreme heat with a high risk of dehydration, and take antimalarial prophylaxis such as doxycycline in malarious areas. Laboratory services for urine culture and specialist urology care are limited or unavailable in forward locations.
History
Veteran CK, an Army transport driver, developed a culture-proven urinary tract infection on 12 June 2013 during warlike service in Afghanistan, after weeks of delayed voiding and fluid restriction on convoys, documented dehydration, lack of washing facilities, long-term doxycycline and the formation of a renal calculus. The infections became recurrent, with incomplete bladder emptying, and worsened to acute pyelonephritis with bacteraemia on 06 October 2017, after her deployment to Iraq and ureteroscopy with catheterisation for an obstructing ureteric stone.
Timeline
- 15 Dec 2012 — Pre-deployment medical examination before Afghanistan. The veteran reported no previous urinary tract infections, renal colic or urinary symptoms. Urinalysis was normal. Doxycycline 100 mg daily was prescribed as malaria prophylaxis, to start on 20 December 2012 and continue for four weeks after return. "no urinary history, urinalysis NAD"
- 08 Jun 2013 — Presentation to the role 2 medical facility in Afghanistan after a 14-hour convoy in 46 degree heat. She reported limiting her fluid intake to about 1.5 litres a day on convoy days, and holding her urine for six to ten hours, three to four days a week since early May, because the convoy could not stop. She had been at a forward staging area without showers for the previous 10 days. Heat exhaustion with dehydration was diagnosed: urine specific gravity 1.035, serum creatinine 118 micromol/L. She received intravenous fluids. "dehydration, SG 1.035, convoy duties"
- 13 Jun 2013 — Presentation with one day of dysuria, frequency, urgency and suprapubic pain. Urine dipstick showed leucocytes, nitrites and blood. Culture at the role 3 laboratory grew Escherichia coli more than 10 to the 8 per litre. She was treated with cefalexin. Ultrasound of the renal tract the same week showed a 4 mm calculus in the lower pole of the left kidney. "E. coli UTI, L renal calculus"
- 14 Aug 2014 — Presentation to the garrison medical officer with her third culture-proven Escherichia coli urinary tract infection in six months, during a three-week field exercise in northern Australia in which she drove a heavy vehicle on long road moves with few toilet stops. She reported again holding her urine for most of each driving day and drinking little to avoid stopping. Each episode had responded to a short course of antibiotics but recurred within weeks. She was referred to a urologist, and the waiting time for review was 15 months. "third UTI in six months"
- 20 Nov 2015 — A urologist reviewed the veteran after four culture-proven urinary tract infections in the previous 12 months, all with Escherichia coli. She reported continuing to delay voiding on long road moves in Australia. Uroflowmetry showed an interrupted flow pattern with a post-void residual of 140 mL. Dysfunctional voiding was diagnosed, and timed voiding, pelvic floor physiotherapy and nightly trimethoprim prophylaxis were commenced. "recurrent UTI, PVR 140 mL"
- 10 Aug 2017 — During warlike service in Iraq the veteran presented with her third urinary tract infection since June. She was again driving on convoys between bases, holding urine for six to eight hours, four days a week. No urine culture was available at the base and each episode was treated empirically with a different antibiotic. Left loin pain was recorded but no imaging was available. "third UTI, no culture available"
- 02 Oct 2017 — After return to Australia CT showed a 7 mm obstructing calculus in the left mid ureter with hydronephrosis. A urologist performed left ureteroscopy, laser lithotripsy and insertion of a ureteric stent. An indwelling urinary catheter remained for 48 hours. She was discharged on 04 October 2017. "ureteroscopy, stent, IDC 48 hours"
- 06 Oct 2017 — Emergency admission with fever of 39.4 degrees, rigors, left loin pain and hypotension. Blood and urine cultures grew an extended-spectrum beta-lactamase producing Escherichia coli. Acute left pyelonephritis with urosepsis was diagnosed. She was treated with intravenous meropenem for five days and the stent was removed on 20 October 2017. Post-void residual was 160 mL. "pyelonephritis, ESBL E. coli bacteraemia"
Symptoms
At onset the veteran had burning on passing urine, frequency, urgency and suprapubic pain, with cloudy, offensive urine. After onset she had repeated episodes with the same symptoms, four in 12 months by 2015, and a sensation of incomplete emptying.
After the 2017 worsening she had fever, rigors, loin pain and urosepsis requiring admission. She now has two to three infections a year despite prophylaxis, persisting urgency and frequency, and anxiety about long journeys, and she plans her day around access to toilets.
Imaging
- 14 Jun 2013 — Ultrasound renal tract: "4 mm echogenic calculus in the lower pole of the left kidney. No hydronephrosis. Bladder wall normal."
- 20 Nov 2015 — Ultrasound renal tract with post-void residual: "Two left renal calculi, 4 and 5 mm. No hydronephrosis. Post-void residual 140 mL."
- 02 Oct 2017 — CT kidneys, ureters and bladder: "7 mm calculus in the left mid ureter with moderate left hydronephrosis and perinephric stranding. 3 mm right renal calculus."
Onset Date
The most likely date of onset of this condition is 12 Jun 2013.
At that date the veteran was serving on warlike service in Afghanistan as a transport driver on logistic convoys. She had been restricting her fluid intake and holding her urine for six to ten hours on convoy days, had been treated for dehydration four days earlier, had spent 10 days at a staging area without showers, and had taken doxycycline daily since 20 December 2012. On 12 June 2013 she developed dysuria, frequency and suprapubic pain.
This date is appropriate because her pre-deployment examination of 15 December 2012 recorded no urinary history and normal urinalysis, and the role 2 assessment of 08 June 2013 recorded no urinary symptoms. She presented on 13 June 2013, one day after the symptoms began, with a positive culture. It falls within uninterrupted full-time warlike service.
For the delayed voiding factor, the 4 weeks before onset run from 15 May 2013 to 12 Jun 2013, during which she held urine for six to ten hours three to four days a week on convoys. For the dehydration factor, the 7 days before onset run from 05 Jun 2013 to 12 Jun 2013, and dehydration was documented on 08 Jun 2013. For the hygiene factor, the 4 weeks before onset run from 15 May 2013, and she was without showers from 29 May to 08 Jun 2013. For the antibiotic factor, the 4 weeks before onset run from 15 May 2013 to 12 Jun 2013, and she had taken doxycycline daily since 20 Dec 2012. The renal calculus was present at onset, shown on ultrasound on 14 Jun 2013.
For the worsening factors, the infections became recurrent from 2014 and were assessed by a urologist on 20 Nov 2015. The worsening to acute pyelonephritis with bacteraemia is documented on 06 Oct 2017. The 7 days before the worsening run from 29 Sep 2017 to 06 Oct 2017, during which she had ureteroscopy, a ureteric stent and an indwelling catheter from 02 to 04 Oct 2017. The 3 months before the worsening run from 06 Jul 2017 to 06 Oct 2017, and from July to the end of August 2017 she delayed voiding on convoys in Iraq. Incomplete bladder emptying and an obstructing ureteric calculus were present at the worsening. From February to August 2017 she could not obtain appropriate clinical management in Iraq.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Urinary Tract Infection (ICD-10-AM N39.0), recurrent, with progression to acute left pyelonephritis (N10). No Statement of Principles has been determined for this condition.
A urinary tract infection is a bacterial infection of the bladder (cystitis) or the kidney (pyelonephritis), most often caused by Escherichia coli ascending from the perineum through the urethra. Infection is promoted by anything that allows bacteria to colonise the periurethral area or remain in the bladder: delayed and infrequent voiding, low urine flow from dehydration, poor perineal hygiene, disruption of the protective vaginal flora by antibiotics, urinary stones, incomplete bladder emptying and urinary catheters and stents. Recurrent infection is defined as at least three episodes in 12 months or two in six months, and infection can ascend to the kidney and the bloodstream.
In this veteran the first infection began on 12 June 2013 during warlike service in Afghanistan, became recurrent from 2014, and worsened to pyelonephritis with bacteraemia on 06 October 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 June 2013.
When did the veteran first present to a health / medical provider for this condition?
13 June 2013.
When was the condition confirmed / formally diagnosed?
13 June 2013.
When did the veteran first present to you (or your practice) for this condition?
02 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on 13 June 2013 by typical symptoms of dysuria, frequency, urgency and suprapubic pain, with leucocytes and nitrites on dipstick and a culture growing Escherichia coli more than 10 to the 8 per litre. Recurrent infections followed from 2014, and four further culture-proven Escherichia coli infections in the 12 months before 20 November 2015 meet the definition of recurrent urinary tract infection, and a urologist confirmed the diagnosis with dysfunctional voiding and a raised post-void residual of 140 mL.
On 06 October 2017 fever, rigors, loin pain and hypotension with an extended-spectrum beta-lactamase producing Escherichia coli in blood and urine confirmed acute pyelonephritis with urosepsis, a worsening of the condition. Sexually transmitted infection, interstitial cystitis and structural abnormality of the urinary tract were excluded on testing, cystoscopy and imaging.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 12 June 2013, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. No Statement of Principles has been determined for urinary tract infection, so the claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits of a Statement of Principles. The reasonable hypothesis standard applies to the veteran's warlike service in Afghanistan in 2013, where the condition began, and in Iraq in 2017, before it worsened. The balance of probabilities standard applies to peacetime service.
Each cause must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: delaying voiding for at least 4 hours at a time on at least 3 days per week for at least the 4 weeks before the clinical onset of urinary tract infection; — MET
- From early May 2013, during warlike service in Afghanistan, the veteran drove on logistic convoys that could not stop safely outside secured areas, and she held her urine for six to ten hours at a time on three to four days a week, as recorded by the role 2 medical officer on 08 June 2013. This continued throughout the 4 weeks before onset, from 15 May 2013 to 12 June 2013. Infrequent voiding allows bacteria that enter the bladder to multiply rather than being flushed out.
Cause 2: having clinically documented dehydration within the 7 days before the clinical onset of urinary tract infection; — MET
- On 08 June 2013, four days before onset, the veteran was treated at the role 2 facility for heat exhaustion with dehydration after a 14-hour convoy in 46 degree heat, with a urine specific gravity of 1.035 and a serum creatinine of 118 micromol/L. She had been restricting her fluid intake to about 1.5 litres a day on convoy days to avoid needing to stop. Low urine flow reduces bladder washout.
Cause 3: being without access to adequate washing and toilet hygiene facilities for at least 7 days within the 4 weeks before the clinical onset of urinary tract infection; — MET
- From 29 May 2013 to 08 June 2013, during warlike service in Afghanistan, the veteran was at a forward staging area with no showers and only pit latrines, and could not wash properly for 10 days while wearing the same uniform in extreme heat. This fell within the 4 weeks before onset. Poor perineal hygiene increases periurethral colonisation with bowel bacteria.
Cause 4: taking a broad-spectrum antibiotic for at least the 4 weeks before the clinical onset of urinary tract infection; — MET
- The veteran took doxycycline 100 mg daily as malaria prophylaxis from 20 December 2012, prescribed by Defence for her deployment to Afghanistan, and continued it throughout the 4 weeks before onset, from 15 May 2013 to 12 June 2013. Long-term antibiotics deplete the protective lactobacilli of the vaginal flora and allow colonisation with Escherichia coli.
Cause 5: having urolithiasis at the time of the clinical onset of urinary tract infection; — MET
- Ultrasound on 14 June 2013 showed a 4 mm calculus in the lower pole of the left kidney, which was present at the onset on 12 June 2013. The stone formed during months of dehydration and fluid restriction in the heat on warlike service in Afghanistan. Urinary stones harbour bacteria and impair clearance of infection.
Worsening factors
Worsening 1: having an indwelling urinary catheter or ureteric stent within the 7 days before the clinical worsening of urinary tract infection; — MET
- On 02 October 2017 the veteran had left ureteroscopy, laser lithotripsy and insertion of a ureteric stent, with an indwelling urinary catheter until 04 October 2017. This was within the 7 days before the worsening to acute pyelonephritis with bacteraemia on 06 October 2017. The surgery was for a ureteric calculus that formed on warlike service, and was performed and funded by Defence while she was serving.
Worsening 2: having incomplete bladder emptying with a post-void residual volume of at least 100 millilitres at the time of the clinical worsening of urinary tract infection; — MET
- Dysfunctional voiding with a post-void residual of 140 mL was diagnosed by a urologist on 20 November 2015, the result of years of habitually holding urine on convoys and road moves. The residual was 160 mL on 06 October 2017, at the worsening. Residual urine allows bacteria to persist and multiply.
Worsening 3: delaying voiding for at least 4 hours at a time on at least 3 days per week for at least 4 weeks within the 3 months before the clinical worsening of urinary tract infection; — MET
- During warlike service in Iraq the veteran drove on convoys between bases four days a week and held her urine for six to eight hours at a time, as recorded on 10 August 2017. Within the 3 months before the worsening, from 06 July 2017 to 06 October 2017, this continued for more than seven weeks, until she left Iraq on 30 August 2017.
Worsening 4: having urolithiasis at the time of the clinical worsening of urinary tract infection; — MET
- CT on 02 October 2017 showed a 7 mm obstructing calculus in the left mid ureter with hydronephrosis, and a right renal calculus. Stone fragments remained after lithotripsy and the stent remained in place at the worsening on 06 October 2017. Obstruction behind a ureteric stone is a major cause of pyelonephritis and urosepsis.
Worsening 5: inability to obtain appropriate clinical management for urinary tract infection. — MET
- During warlike service in Iraq from February to August 2017 there was no urine culture at the base, so three infections were treated empirically with different antibiotics without sensitivity testing, and no imaging was available when she developed left loin pain on 10 August 2017. The obstructing stone and the antibiotic-resistant organism were identified only after her return, shortly before the bacteraemia. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The recurrent urinary tract infections have led to urosepsis, repeated antibiotic courses with colonisation by an antibiotic-resistant organism, and anxiety about travel and access to toilets. Repeated infection and obstruction carry a risk of renal scarring, and her estimated glomerular filtration rate should be monitored. These are sequelae of the condition and should be considered in any related claim.
Unintended Consequence
Met. The worsening to acute pyelonephritis with bacteraemia on 06 October 2017 followed ureteroscopy, ureteric stenting and urinary catheterisation on 02 October 2017, treatment provided and paid for by Defence while the veteran was serving, and is an unintended consequence of that treatment. The disruption of her vaginal flora by Defence-prescribed doxycycline is also an unintended consequence of treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. During warlike service in Iraq from February to August 2017 the veteran's recurrent urinary tract infections could not be appropriately managed. Urine culture was unavailable, each infection was treated empirically without sensitivity testing, her prescribed timed voiding program could not be followed on convoys, and there was no imaging when she developed loin pain from an obstructing stone. She was colonised with a resistant organism and developed pyelonephritis with bacteraemia soon after her return. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent investigation and prescribed management amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 15 Dec 2012, Pre-deployment medical examination, Medical Officer, Garrison health centre
- 08 Jun 2013, Role 2 medical facility record, Medical Officer, Afghanistan
- 13 Jun 2013, Role 2 medical facility record and urine culture, Medical Officer, Afghanistan
- 14 Jun 2013, Ultrasound renal tract, Role 3 hospital, Afghanistan
- 14 Aug 2014, Outpatient health record and urine culture, Medical Officer, Garrison health centre
- 20 Nov 2015, Urology consultation and ultrasound, Urologist
- 10 Aug 2017, Base medical record, Medical Officer, Iraq
- 02 Oct 2017, CT kidneys, ureters and bladder, Radiologist
- 02 Oct 2017, Operation report, Urologist
- 06 Oct 2017, Hospital admission and discharge summary, General physician
