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Urinary > 9 > Flashcards

9 Flashcards

1
Q

What are the clinical syndromes of lower UTI?

A
  • bacterial cystitis
  • Abacterial cystitis
  • prostatitis
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2
Q

What is bacterial cystitis?

A
  • frequency and dysuria often with pyuria and haematuria
  • cloudy urine
  • nocturia or frequency
  • urgency
  • suprapubic tenderness
  • mild Pyrexia
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3
Q

What is abacterial cystits?

A

-same as bacterial cystitis but without significant bacteriuria

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4
Q

What is prostatits?

A

-fever, dysuria, frequency with perineal and low back pain

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5
Q

What are common clinical syndromes of upper UTI?

A
  • acute pyelonephritis

- chronic interstitial nephritis

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6
Q

What is acute pyelonephritis?

A

-symptoms of cystitis plus fever and loin pain
-tenderness
-rigours
Nausea/vomiting

See session 9 UTI slde 12

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7
Q

What is chronic interstitial nephritis?

A
  • renal impairment following chronic inflammation

- infection is one of many causes

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8
Q

What is a clinical syndrome of asymptomatic UTI?

A

-covert bacteriuria

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9
Q

What is covert bacteriuria?

A

-detected only by culture important in children and pregnancy

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10
Q

What is a common source of Gram-negative septicaemia?

A

UTI

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11
Q

What major defences does the urinary tract have in order to protect it from UTI?

A
  • regular flushing during voiding which removes organisms
  • antibacterial secretions into urine and urethra
  • vesico-urethral valves
  • immunological factors
  • mucosal barriers
  • urine acidity (prevents bacteria from multiplying)
  • one way flow
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12
Q

What host factors promote UTI?

A
  • shorter urethra: more infections in females
  • obstruction: enlarged prostate, pregnancy, stones, tumours
  • neurological: incomplete emptying, residual urine
  • ureteric reflux: ascending infection from bladder especially in children
  • ascending colonization from bacteria from perineum
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13
Q

What bacterial factors promote UTI?

A
  • faecal flora: potential urinary pathogens colonies periurethral area
  • adhesion: fimbriae and adhesions allow attachment to urethral and bladder epithelium
  • K antigens: allow some E.coli to resist host defences by producing polysaccharide capsule
  • Haemolysins: damage membranes and cause renal damage
  • Urease: produced by some bacteria (ex. Proteus)
  • Cystitis: colonization in bladder
  • Pyelonephritis: colonization in kidney

See session 9 UTI slide 6-7, 9

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14
Q

What are some risk factors that will cause UTI?

A
  • obstructive causes: stones, enlarged prostate, retroperitoneal fibrosis
  • neurological conditions affecting bladder emptying: multiple sclerosis, stroke
  • pregnancy: enlarged uterus, hormonal effects on relaxation of musculature, can’t contract bladder as effectively
  • abnormal renal tract: vesico-ureteric reflux in children, indwelling urinary catheter
  • impaired host defence: diabetes mellitus, immunosuppressive
  • patients with kidney disease
  • patients on dialysis or with kidney transplants
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15
Q

Describe the virulence factors of E.coli

A
  • flagellar: movement
  • pili: attachment
  • capsular polysaccharide: colonization
  • haemolysin, toxins: damages host membranes and causes renal damage

See session 9 UTI slide 10

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16
Q

What other causes of urethral inflammation (urethritis) will lead to dysuria?

A
  • STI
  • post sexual intercourse
  • contact with irritants
  • symptoms of menopause, strophic vaginitis or vaginal atrophy
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17
Q

What is uncomplicated UTI?

A
  • infection by a USUAL organism in a patient with a NORMAL URINARY TRACT AND NORMAL URINARY FUNCTION
  • may occur in males and females of any age
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18
Q

What is a complicated UTI?

A
  • 1 or more factors that predispose to persistent infection, recurrent infection or treatment failure
  • abnormal urinary tract
  • virulent organism (i.e. staph aureus)
  • impaired host defence (immunosuppression, poorly controlled diabetes mellitus)
  • impaired renal function
19
Q

What is the difference between complicated and uncomplicated UTI?

A
  • infections in kids and men and some cases of pyelonephritis may meet the definition of uNCOMPLICATE
  • BUT in practice most cases in children, men and pregnant women, are investigated and managed as “complicated”

See session 9 UTI slide 15

20
Q

In what instances would you use a urine culture to investigate for UTI?

A

-in complicated UTI (i.e. pregnancy, treatment failure, recurrent infections, suspected pyelonephritis, complications, male, children)

21
Q

How would you collect the specimen for urine culture?

A
  • Mid-stream urine (MSU): cleansing not required, ideally holding labia apart in women so it doesn’t infect urine
  • clean catch in children (get kids to pee in pot)
  • collection bag (20% false positives due to contamination of perineum)
  • catheter sample
  • supra-pubic aspiration (gold standard, poke needle into bladder through the skin)
  • culture urine within 4 hours of collection, refrigerate or use boric acid preservative
22
Q

What is a urine dipstick and when would you use it?

A
  • Urine dipstick: leukocyte esterase, nitrites (since Coliforms break down nitrics to nitrites), blood, pH, protein
  • useful in females <65years with suspected uncomplicated UTI as an aid to diagnosis
  • useful in ruling out infection in children >3 months old
  • not useful in: patients >65 year old (asymptomatic infection common) and catheterised patients

See session 9 UTI slide 18-20, 22-23

23
Q

How would you visually inspect a UTI?

A

In boric acid bottle

  • if clear no UTI
  • if cloudy then probably a UTI, due to numerous WBCs

See session 9 UTI slide 21

24
Q

How would you analyze the urine cultures?

A
  • screen it with microscopy
  • detects white cells, red cells, epithelial cells and bacteria

See session 9 UTI slides 24-28

25
Q

Who would get imaging of urinary tract done for UTI?

A
  • considered in all children with UTI
  • valuable in septic patients to identify renal involvement (i.e. pyelonephritis)
  • Males: posterior urethral valves
  • Females and kids: vesicles-ureteric reflux
26
Q

What is sterile pyuria?

A 
-WBC in urine but no UTI
Can be caused by:
-prior antibiotics
-urethritis (chlamydia/gonococci)
-vaginal infection/inflammation
-TB (need prolonged incubation)
-appendicitis
-fastidious organisms (organisms that are very slow-growing but they are rare)
27
Q

What is asymptomatic bacteriuria?

A
  • significant levels of bacteria in urine with no UTI symptoms
  • high prevalence in elderly, indwelling catheters
  • screened for and treated only in pregnancy (untreated leads to higher risk of premature labour and pyelonephritis)
  • that’s why no urine dip sticks for old people since they have asymptomatic bacteria
28
Q

How can we treat UTI?

A
  • increase fluid intake
  • regular analgesia (i.e. paracetamol/ibuprofen)
  • no good evidence that cranberry products work
  • address underlying disorders
  • 3 day courses for uncomplicated UTI
  • 5-7 day course for complicated lower UTI (i.e. pregnant, male, underlying disorders)
  • CSU: only treat if systemically unwell
29
Q

How do you treat simple cystitis?

A
  • uncomplicated infections can be treated with nitrofurantonin, trimethoprim, pivmecillinam or fosfomycin
  • 3 days course as effective as 5 or 7 days
  • limiting prescription to 3 days reduces the selection pressure for resistance

See session 9 UTI slide 34

30
Q

How do you treat complicated lower UTI?

A
  • ex. Male, pregnant women, catheter associated UTI
  • nitrofurantonin, trimethoprim, pivmecillinam, fosfomycin or cefelexin (for pregnant women) may be used (review susceptibility report)
  • 5 to 7 day course
31
Q

How would you treat pyelonephritis (upper UTI)/septicaemia?

A
  • Pyelonephritis 7-10 days course
  • use agent with systemic activity (NOT nitrofurantonin, fosfomycin)
  • possibly IV initially unless good PO absorption and patient well enough/tolerating orally: Co-amoxiclave, ciprofloxacin (effective as a 7 day course), gentamicin NB IV only; nephrotoxic
32
Q

Who would you give prophylaxis to in regards to a UTI?

A
  • these are long term low-does antibiotics
  • give them to pt’s who have had >3 episodes in one year
  • despite behavioural and personal hygiene measures
  • no treatable underlying condition
  • choice of antibiotics according to recent culture and susceptibility results (i.e. trimethoprim or nitrofurantonin as a single nightly dose)
  • ensure all breakthrough infections documented
33
Q

What is a urinary tract caliculi?

A
  • stone formed from calcium
  • made up of calcium oxalate and calcium phosphate
  • calcium is 80% of the stones
  • uric acid makes up about 9%
  • struvite (magnesium ammonium phosphate hexahydrate, from infection by bacteria that have urease) makes up 10%
  • 1% makes up the rest: cystine, drug stones, ammonium acid irate
34
Q

How often do urinated tract caliculi occur?

A
  • incidence of acute renal colic is 1-2cases/1000/year
  • important cause of morbidity
  • high recurrence rate 60-80%
  • most small stones pass spontaneously within 1–2 months
  • stones>6mm likely to require intervention
35
Q

What is the aetiology of urinary tract caliculi?

A
  • metabolic: secondary hypercalcuria (causes salt to crystallize in the urine)
  • urinary infection: proteus, pseudomonas, klebsiella
  • diet: high in table salt, obesity, ketogenic diet
  • medication: furosemide, diuretics
  • genetic: primary hyperoxaluria, cystinuria (mainly in kids)
36
Q

How do you diagnose urinary tract caliculi?

A
  • hydronephrosis (dilation of kidney if it’s blocked)
  • loin to groin pain, haematuria
  • CT KUB diagnostic accuracy >95%
  • identify stone size and position associated obstruction/complication
  • identify alternative diagnosis (ex. Ruptured AAA, appendicitis)

See session 9-stones slide 4

37
Q

How would a large renal calculus appear on a US?

A

-US wave cannot penetrated beyond the stone so there is a shadow below it

See session 9-stones slide 5

38
Q

What is the likelihood of passage of ureteric stones?

A
  • kidney stones <5mm in diameter have a chance of being passed
  • 5-7mm have 50% chance
  • > 7mm needs urological intervention

See session 9-stones slide 7

39
Q

How are kidney stones categorized?

A

Staghorn: filling numerous major or minor calices
Non-staghorn: calyceal or pelvic in location
Ureteral: proximal, middle or distal

40
Q

How do we treat urinary caliculi stones?

A
  • depends on stone size, location and composition
  • extracorporeal shock-wave lithotripsy- ESWL
  • Percutaneous nephrolithotomy- PCNL (more invasive, make a hole through skin into kidneys to remove stone), see session 9-stones slide 11-14
  • Ureteroscopy: camera into ureter, apply laser treatment to remove stone, invasive
  • open surgery/nephrectomy
  • urinary tract sepsis related to stones is highly morbid
41
Q

How does ESWL work and what are the indications?

A
  • non invasive treatment to fragment urinary calculi
  • utilizes shock waves from a lithotripter
  • stone localized with fluoroscopy or US (gets shattered by shockwaves)
  • fragments pass out over several weeks

Indications

  • suitable: <2cm can be localized with imaging
  • unsuitable: large renal calculus >2cm, in lower pole calyx, radiolucent, resistant to ESWL, body habitus, weight

See session 9-stones slide 9-10

42
Q

What is paediatric cystinuria?

A
  • children it is different
  • recurrent infections, failure to thrive
  • cystinuria is a hereditary condition
43
Q

What is DMSA split function?

A

-looking at function of each kidney separately

See session 9-stones slide 16-19

Urinary (11 decks)

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