3 Cystitis, Pyelonephritis, & Interstitial Cystitis Flashcards
_______ are more specific to pyelonephritis and _______ more specific to glomerulonephritis
WBC casts = pyelonephritis
RBC casts = GN
Urine dipstick is most accurate in predicting a UTI when positive for …
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
What can cause false negative nitrite on urine dipstick?
Non-nitrate reducing organisms
Frequent urination/urine in bladder <4 hours
What can cause false positive leukocyte esterase in urine dipstick?
Vaginal contamination
Trichomonas infection
Among adults 20-50 yo, UTI’s are __________ in women
50x more common
Most commonly as cystitis or pyelonephritis
In men aged 20-50 yo, most UTIs are…
Urethritis or prostatitis
~95% of UTIs occur from …
Ascending bacterial infections
Escherichia coli accounts for 75-95% of cases
Though most UTIs are caused by E.coli, other causative uropathogens can cause them in …
Immunocompromised or hospitalized patients
Staphylococcus saprophyticus Enterococcus species Proteus mirabilis Klebsiella pneumoniae Pseudomonas
What are the risk factors for UTIs
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)
Acute simple cystitis is is an acute UTI presumed to be …
Confined to the bladder in a non-pregnant individual
No s/s that suggest an upper urinary tract or systemic infection (no pyelonephritis)
Acute UTI accompanied by SSx that suggest extension of infection beyond the bladder
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)
Special populations who may have acute simple cystitis but are at risk for a complicated UTI
Pregnant women
Men
Patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities
Classic presentation of acute simple cystitis
Irritative voiding symptoms (Dysuria, Frequency, Urgency)
+/- Hematuria
+/- Suprapubic discomfort
Ask about LMP, sexual activity, Hx of STIs
What ROS questions should you ask in cases of acute simple cystitis?
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
Atypical presentation of acute simple cystitis in the elderly
Urinary incontinence and confusion/change in mental status
What should you do to rule out DDx in acute simple cystitis?
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)
Acute Simple Cystitis DDx
Pyelonephritis Vaginitis, urethritis, prostatitis STI PID Nephrolithiasis Interstitial cystitis/bladder pain syndrome
In addition to (+) leukocyte esterase and nitrites on dipstick, urine microscopy in someone with acute simple cystitis might reveal…
Pyuria (abnormal ≥ 10 leukocytes/µL - amount does not indicate severity of infection)
Bacteriuria
+/- hematuria
When should you perform a urine culture
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
What can you use for SYMPTOMATIC treatment of acute simple cystitis?
OTC Phenazopyridine (Pyridium) 200mg TID prn (urinary analgesic)
What are the precautions for Pyridium?
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
Abx therapy for acute simple cystitis in non-pregnant individuals
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)
When would you avoid Nitrofurantoin & Fosfomycin?
If early pyelonephritis due to low renal concentrations (won’t adequately penetrate the kidney)
How do you treat acute simple cystitis in pregnant women?
Augmentin, Cephalexin, Cefpodoxime, Fosfomycin are all options
Nitrofurantoin/Bactrim - use/avoidance based on trimester (CONSULT OB)
AVOID FLUOROQUINOLONES
How do you treat acute simple cystitis in Men
Same primary therapies (macrobid, bactrim) but for longer duration (7 days)
Also, make sure you r/o underlying prostatitis
How to treat acute simple cystitis in patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities
Primary therapies (macrobid, bactrim) but for longer duration (1-2 weeks)
Low threshold to manage as complicated UTI
Important patient education points for acute simple cystitis
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)
Are follow up urine cultures required for acute simple cystitis
Not needed in simple cases except pregnant women or those whose symptoms don’t resolve on abx
Clinical presentation of acute pyelonephritis
Lower UTI symptoms (frequency, urgency, dysuria) FLANK PAIN Constitutional symptoms GI symptoms (N/V) FEVER CVA tenderness
DDx for acute pyelonephritis
Cholecystitis Pancreatitis Diverticulitis Appendicitis Renal pathology Nephrolithiasis PID Ectopic pregnancy Acute epididymitis Acute prostatitis Lower lobe pneumonia
What diagnostics should you do when suspecting acute pyelonephritis?
UA (all) Urine culture and sensitivity (ALL - unlike acute cystitis) \+/- GC/Chlamydia \+/- Labs (CBC/CMP) \+/- Imaging
What will the UA/culture show in acute pyelonephritis?
(+) LE (+) Nitrites Pyuria (≥10 leukocytes/µl) Bacteriuria \+/- Hematuria WBC casts***** Urine culture positive with ≥10^5 CFU/mL
CBC/CMP not necessary in pyelonephritis unless patient is hospitalized but if you do it, you’ll find…
Leukocytosis with left shift
Look at CMP to assess renal function, hydration, electrolytes
Imaging is not typically indicated in pyelonephritis unless…
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
What is the treatment of choice for outpatient management of mild-moderate acute pyelonephritis?
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
What must the patient education include for mild-moderate outpatient management of acute pyelonephritis?
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
Indications for hospitalization for acute pyelonephritis
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
How do you treat complicated/severe acute pyelonephritis (inpatient management)?
Acceptable IV abx regimens: • Fluoroquinolone • Extended-spectrum cephalosporin • Extended-spectrum penicillin • Carbapenem (Vabomere) • Aminoglycosides (Zemdri)
Supportive care - analgesics/antipyretic, anti-emetic, IVF
What are the possible complications of acute pyelonephritis?
Sepsis with shock
Renal failure
Scarring or chronic pyelonephritis (if coexistence kidney disease)
Renal abscess formation
FOLLOWUP IN 24-48 HOURS
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
Interstitial cystitis
aka Bladder pain syndrome
Aka painful bladder syndrome
What does a typical interstitial cystitis patient look like?
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
What is the pathophysiology of interstitial cystitis?
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
Clinical presentation of interstitial cystitis
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
Physical exam in interstitial cystitis should include…
ABD exam
Bimanual pelvic exam in women
Rectal exam in males
May note variable tenderness, +/- pelvic floor muscle spasm
What are the two big “DONT MISS” DDx for interstitial cystitis?
Urinary and genital tract cancer
Acute cystitis, vaginitis, urethritis, prostatitis
How do you diagnosis interstitial cystitis?
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
If you do a cystoscopy on a patient with suspected interstitial cystitis, what would support your diagnosis?
Altered urothelium - glomerulations and HUNNER LESIONS
What is the first line treatment for interstitial cystitis?
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
Second-line treatment for interstitial cystitis?
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
What are the more advanced treatments for interstitial cystitis?
(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)
Indications for referral in interstitial cystitis
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
