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Clin Med II Unit III > 3 Cystitis, Pyelonephritis, & Interstitial Cystitis > Flashcards

3 Cystitis, Pyelonephritis, & Interstitial Cystitis Flashcards

1
Q

_______ are more specific to pyelonephritis and _______ more specific to glomerulonephritis

A

WBC casts = pyelonephritis

RBC casts = GN

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2
Q

Urine dipstick is most accurate in predicting a UTI when positive for …

A

Leukocyte esterase and/or nitrite in SYMPTOMATIC patients

BUT negative results do not reliably r/o UTI if symptomatic and positive results don’t necessarily support UTI in ASYMPTOMATIC patients

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3
Q

What can cause false negative nitrite on urine dipstick?

A

Non-nitrate reducing organisms

Frequent urination/urine in bladder <4 hours

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4
Q

What can cause false positive leukocyte esterase in urine dipstick?

A

Vaginal contamination

Trichomonas infection

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5
Q

Among adults 20-50 yo, UTI’s are __________ in women

A

50x more common

Most commonly as cystitis or pyelonephritis

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6
Q

In men aged 20-50 yo, most UTIs are…

A

Urethritis or prostatitis

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7
Q

~95% of UTIs occur from …

A

Ascending bacterial infections

Escherichia coli accounts for 75-95% of cases

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8
Q

Though most UTIs are caused by E.coli, other causative uropathogens can cause them in …

A

Immunocompromised or hospitalized patients

Staphylococcus saprophyticus
Enterococcus species
Proteus mirabilis
Klebsiella pneumoniae
Pseudomonas
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9
Q

What are the risk factors for UTIs

A

Reduced urine flow (obstruction, inadequate fluid intake, neurogenic bladder)

Promotion of colonization (sexual activity, spermicide use, recent abx)

Fascilitated ascent (catheterization, urinary or fecal incontinence)

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10
Q

Acute simple cystitis is is an acute UTI presumed to be …

A

Confined to the bladder in a non-pregnant individual

No s/s that suggest an upper urinary tract or systemic infection (no pyelonephritis)

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11
Q

Acute UTI accompanied by SSx that suggest extension of infection beyond the bladder

A

Acute complicated UTI (ie pyelonephritis)

SSx include:
Fever (>99.9)
Chills, rigor, significant fatigue/malaise
Flank pain
CVA tenderness
Pelvic or perineal pain in men (if prostatitis)

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12
Q

Special populations who may have acute simple cystitis but are at risk for a complicated UTI

A

Pregnant women
Men
Patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities

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13
Q

Classic presentation of acute simple cystitis

A

Irritative voiding symptoms (Dysuria, Frequency, Urgency)

+/- Hematuria

+/- Suprapubic discomfort

Ask about LMP, sexual activity, Hx of STIs

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14
Q

What ROS questions should you ask in cases of acute simple cystitis?

A

Fever, N/V, flank pain (should be no for simple cystitis)

Obstructive urinary symptoms (hesitancy, dribbling) esp in men

Penile discharge, vaginal pruritis or discharge, pelvic or perineal pain

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15
Q

Atypical presentation of acute simple cystitis in the elderly

A

Urinary incontinence and confusion/change in mental status

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16
Q

What should you do to rule out DDx in acute simple cystitis?

A

General assessment/vitals (should be stable)

Check for abdominal/suprapubic tenderness/CVAT (to rule out pyelonephritis)

Pelvic exam in women (looking for vaginal discharge, cervical motion tenderness)

Genital and rectal exam in men (looking for penile discharge/ulceration, testicular/scrotal pain, prostatic tenderness or enlargement)

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17
Q

Acute Simple Cystitis DDx

A 
Pyelonephritis 
Vaginitis, urethritis, prostatitis
STI
PID
Nephrolithiasis
Interstitial cystitis/bladder pain syndrome
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18
Q

In addition to (+) leukocyte esterase and nitrites on dipstick, urine microscopy in someone with acute simple cystitis might reveal…

A

Pyuria (abnormal ≥ 10 leukocytes/µL - amount does not indicate severity of infection)

Bacteriuria

+/- hematuria

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19
Q

When should you perform a urine culture

A 
Atypical presentation/diagnostic uncertainty
Suspect complicated UTI
Symptoms that do not resolve or recur
Suspect antimicrobial resistance
Special populations (men, elderly, etc)

≥10^3 colony-forming units of a uropathogen is diagnostic

> 10^2 CFU/mL in women with typical symptoms of cystitis

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20
Q

What can you use for SYMPTOMATIC treatment of acute simple cystitis?

A

OTC Phenazopyridine (Pyridium) 200mg TID prn (urinary analgesic)

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21
Q

What are the precautions for Pyridium?

A

LIMITED TO TWO-DAY COURSE to make sure you’re not just masking Sx

Turns body secretions red/orange - don’t wear contacts as it will stain them

Caution if CR<50 or declined kidney function

22
Q

Abx therapy for acute simple cystitis in non-pregnant individuals

A

Primary:
• Nitrofurantoin (Macrobid) 100 mg PO BID x 5 days
• Bactrim 160/800 mg PO BID x 3 days (avoid if ≥20% local Ecoli are resistant)
• Fosfomycin (Monurol) 3 GBM PO single dose

Alternatives (if allergy, drug runs, resistance)
• Beta-lactate (Augmenting, Cefdinir)
• Fluoroquinolones (Cipro, Levaquin)

23
Q

When would you avoid Nitrofurantoin & Fosfomycin?

A

If early pyelonephritis due to low renal concentrations (won’t adequately penetrate the kidney)

24
Q

How do you treat acute simple cystitis in pregnant women?

A

Augmentin, Cephalexin, Cefpodoxime, Fosfomycin are all options

Nitrofurantoin/Bactrim - use/avoidance based on trimester (CONSULT OB)

AVOID FLUOROQUINOLONES

25
Q

How do you treat acute simple cystitis in Men

A

Same primary therapies (macrobid, bactrim) but for longer duration (7 days)

Also, make sure you r/o underlying prostatitis

26
Q

How to treat acute simple cystitis in patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities

A

Primary therapies (macrobid, bactrim) but for longer duration (1-2 weeks)

Low threshold to manage as complicated UTI

27
Q

Important patient education points for acute simple cystitis

A 
Increase fluid intake
Void when you feel the urgency
Proper hygiene
Postcoital voiding
COMPLETE course of abx - should expect relief in 48 hours
ER precautions (signs of pyelonephritis)
28
Q

Are follow up urine cultures required for acute simple cystitis

A

Not needed in simple cases except pregnant women or those whose symptoms don’t resolve on abx

29
Q

Clinical presentation of acute pyelonephritis

A 
Lower UTI symptoms (frequency, urgency, dysuria)
FLANK PAIN
Constitutional symptoms
GI symptoms (N/V)
FEVER
CVA tenderness
30
Q

DDx for acute pyelonephritis

A 
Cholecystitis
Pancreatitis
Diverticulitis
Appendicitis
Renal pathology
Nephrolithiasis
PID
Ectopic pregnancy
Acute epididymitis
Acute prostatitis
Lower lobe pneumonia
31
Q

What diagnostics should you do when suspecting acute pyelonephritis?

A 
UA (all)
Urine culture and sensitivity (ALL - unlike acute cystitis)
\+/- GC/Chlamydia
\+/- Labs (CBC/CMP)
\+/- Imaging
32
Q

What will the UA/culture show in acute pyelonephritis?

A 
(+) LE
(+) Nitrites
Pyuria (≥10 leukocytes/µl)
Bacteriuria
\+/- Hematuria
WBC casts*****
Urine culture positive with ≥10^5 CFU/mL
33
Q

CBC/CMP not necessary in pyelonephritis unless patient is hospitalized but if you do it, you’ll find…

A

Leukocytosis with left shift

Look at CMP to assess renal function, hydration, electrolytes

34
Q

Imaging is not typically indicated in pyelonephritis unless…

A

Severely ill
Persistent symptoms despite 48-72 hours of abx
Suspicion for obstruction
Recurrent symptoms within a few weeks of treatment

CT A/P (w/ and w/o contrast) image of choice - caution if risk of contrast neuropathy

Renal U/S and MRI also used

35
Q

What is the treatment of choice for outpatient management of mild-moderate acute pyelonephritis?

A

Fluoroquinolones
• Ciprofloxacin 500 mg PO BID x 5-7 days
• Ciprofloxacin extended release 1000 mg PO qd x 5-7 days
• Levofloxacin 750 mg PO qd x 5-7 days

If local FLQ resistance, initial IV or IM dose of Ceftriaxone (Rocephin) 1g, followed by above regimen

If uropathogen known to be susceptible to Bactrim, then 160/800 mg PO BID x 7-10 days

36
Q

What must the patient education include for mild-moderate outpatient management of acute pyelonephritis?

A

Analgesic/antipyretic
Phenazopyridine x 2 days for dysuria
ER precautions

MUST FOLLOWUP IN 24-48 HOURS!!!!

Follow up urine cultures not needed except in pregnant women or those who’s symptoms don’t resolve

37
Q

Indications for hospitalization for acute pyelonephritis

A

Critically ill/hemodynamically instability
Persistently high fever (>103)
Persistent pain/marked debility
Suspected or documented urinary tract obstruction
Metabolic derangement (renal dysfunction)
Unable to take liquids by mouth
Concerns about compliance with followup instructions

38
Q

How do you treat complicated/severe acute pyelonephritis (inpatient management)?

A 
Acceptable IV abx regimens:
• Fluoroquinolone
• Extended-spectrum cephalosporin
• Extended-spectrum penicillin
• Carbapenem (Vabomere)
• Aminoglycosides (Zemdri)

Supportive care - analgesics/antipyretic, anti-emetic, IVF

39
Q

What are the possible complications of acute pyelonephritis?

A

Sepsis with shock
Renal failure
Scarring or chronic pyelonephritis (if coexistence kidney disease)
Renal abscess formation

FOLLOWUP IN 24-48 HOURS

40
Q

An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower UT symptoms of more than six weeks duration in the absence of infection or other identifiable causes

A

Interstitial cystitis

aka Bladder pain syndrome

Aka painful bladder syndrome

41
Q

What does a typical interstitial cystitis patient look like?

A

Woman in fourth decade or later, often with coexisting chronic pain condition (ie Fibromyalgia, IBS)

It’s a clinical diagnosis of exclusion - patients experience symptoms for an avg of 5-7 years before receiving a correct dx

42
Q

What is the pathophysiology of interstitial cystitis?

A

Altered urothelium

Likely a multifactorial involving varying components of:
• Disruption of the glycosaminoglycan (GAG) layer
• Bladder urothelial injury
• Secretion of proinflammatory substances, mast cell activation, fibrosis
• Neural hypersensitivity
• Neuropathic pain and voiding dysfunction

43
Q

Clinical presentation of interstitial cystitis

A

Suprapubic/bladder pain (pressure, discomfort), often worse with bladder filling, relieved with voiding

+/- urinary urgency, frequency, nocturia

+/- pain in pelvis, perineum, urethra, lower ABD, lower back

+/-dyspareunia, vaginal burning

Men: pelvic pain with concomitant sexual dysfunction

44
Q

Physical exam in interstitial cystitis should include…

A

ABD exam
Bimanual pelvic exam in women
Rectal exam in males

May note variable tenderness, +/- pelvic floor muscle spasm

45
Q

What are the two big “DONT MISS” DDx for interstitial cystitis?

A

Urinary and genital tract cancer

Acute cystitis, vaginitis, urethritis, prostatitis

46
Q

How do you diagnosis interstitial cystitis?

A

UA with microscopy and urine culture - unremarkable/negative (done to r/o infection and hematuria)

If (+) hematuria —> urine cytology and cystoscopy to r/o cancer, esp if smoker

Urine cytology if (+) smoking history

STI testing in patients at risk

+/- postvoid residual urine volume - r/o bladder outlet obstruction or neuro disorder

+/- cystoscopy —> if in doubt

47
Q

If you do a cystoscopy on a patient with suspected interstitial cystitis, what would support your diagnosis?

A

Altered urothelium - glomerulations and HUNNER LESIONS

48
Q

What is the first line treatment for interstitial cystitis?

A

Self-care and behavioral modifications

Diet - consider avoiding citrus fruits, acidic/spicy foods, caffeine, EtOH, carbonated beverages

Bladder retraining

Low-impact exercise

Psychotherapy or IC support groups

Urinary analgesics (pyridium) short term 2 day use for flares

49
Q

Second-line treatment for interstitial cystitis?

A

Oral meds:
• Tricyclic antidepressant (Amitriptyline)
• Pentosan Polysulfate (Elmiron) - may take 3-6 months to respond
• Antihistamines (Hydroxyzine) restores GAG layer to reduce inflammation

Intravesical meds:
• Lidocaine

Pelvic Physical Therapy

50
Q

What are the more advanced treatments for interstitial cystitis?

A

(All by urology, not by us)

Cystoscopy with short-duration, low pressure bladder hydrodistension
Intravesical instillation of glycosaminoglycans
Intravesical Dimethyl sulfoxide (DMSO)
Intradetrusor botulinum toxin
Sacral neuromodulation
Cyclosporine
Surgery (urinary diversion)

51
Q

Indications for referral in interstitial cystitis

A

Hematuria
Complex symptoms
Incomplete bladder emptying
A neurologic disorder that affects bladder function
Prior pelvic radiation
Prior pelvic surgery
Have not responded to initial tx with oral meds

Clin Med II Unit III (6 decks)

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