B5.076 Big Case: Dysura/UTI Flashcards
typical symptoms of cystitis
dysuria urgency frequency burning or pressure sensation fever or chills if severe (more common in pyelonephritis)
atypical symptoms of cystitis
lethargy
anorexia
new incontinence
psychiatric changes- mania, anorexia, delirium
who more commonly presents with atypical symptoms and why?
more common in the elderly
alterations in immune function may prevent some of the other “typical” symptoms
broad categories for differential diagnosis of dysuria
infectious
non-infectious
infectious causes of dysuria
cystitis (acute or chronic)
non cystitis infections (like STIs)
examples of noninfectious causes of dysuria
interstitial cystitis/bladder pain syndrome/chronic prostatitis chemical cystitis radiation cystitis BPH atrophic vaginitis bladder cancer
what is acute bacterial cystitis
bacterial infection of the lower urinary tract (bladder/urethra)
commonly called a UTI
symptoms of acute bacterial cystitis
inflammation in bladder and urethra causes dysuria, frequency, hematuria, urgency, incontinence
where do bacteria for UTIs originate?
GI tract
common: E.coli (85%), klebsiella, enterobacter, enterococcus
why are females more at risk for bacterial cystitis
shorter urethra
proximity of urethra to anus
bacterial cystitis related sexual activity in female gender
increased infections with increased sexual activity (honeymoon cystitis)
sexual activity leads to increased deposition of bacteria into urethra and bladder
void after sex or consider pericoital antibiotic prophylaxis
additional risk factors for bacterial cystitis outside of female gender
urinary retention/ incomplete bladder emptying
bladder stones or foreign bodies
urine “yo-yo”
what are bladder diverticula and how do they increase risk for cystitis
out pouching of bladder wall due to lack of muscle
when bladder contracts to expel urine, urine fills diverticula rather than exiting urethra due to path of lower resistance
what is vesicoureteral reflux (VUR)
congenital condition where urine can reflex from bladder into the kidney
muscles don’t close off ureters during voiding
what is acute bacterial pyelonephritis
bacterial infection of the kidney
infection of the upper urinary tract, usually a complication of a lower urinary tract infection
2 mechanisms for acute bacterial pyelonephritis
- ascending infection (most common, starts in bladder and migrates up ureters)
- hematogenous spread (uncommon, bacteria in bloodstream filter and deposit in kidneys)
symptoms of pyelonephritis
local: flank pain (SEVERE)
systemic: fever, chills, malaise, lethargy, nausea, vomiting
complication of pyelonephritis
bacteria can get into the bloodstream due to infecting the “filter”
more readily causes bacteremia compared to cystitis
can lead to sepsis
what are some manifestations of STIs that may mimic UTIs
urethritis from G&C in males
cervicitis in females
related to recent sexual contact
what is interstitial cystitis/bladder pain syndrome
an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms
more than six weeks duration
absence of infection or other identifiable causes
causes associated with interstitial cystitis/bladder pain syndrome
increased stress pelvic floor trigger points menopause/atrophic vaginitis idiopathic psychosomatic changes in bladder sensation changes in bladder glycosaminoglycans
causes of chemical cystitis
caffeine (bladder irritant)
spicy foods
acidic foods (change bladder pH)
describe radiation cystitis
dysuria with negative culture in a patient with previous radiation
often had colon, prostate, or cervical neoplasms
what is BPH
benign prostatic hypertorphy
what is atrophic vaginitis
common condition in post-menopausal women
due to decreased estrogen concentration in vaginal tissues
physical exam findings in atrophic vaginitis
thin, pale, tan tissues (most common)
friable, inflamed, red tissues
associated with dysuria and dyspareunia (pain with sexual activity)
how can atrophic vaginitis lead to UTIs?
change in normal vaginal flora
loss of lactobacillus (natural host/defense mechanism)
vaginal fluid becomes more alkaline
treatment of atrophic vaginitis
topical estrogen
re-acidifies vaginal fluid to enhance growth of lactobacillus
avoid if history of breast or uterine cancer (hormonally driven)
symptoms of bladder cancer
can cause frequency, dysuria, urgency, hematuria
leading cause in US is smoking
ALWAYS evaluate blood in urine for potential serious causes
what is asymptomatic bacteriuria
bacteria present in urine, but no clinical symptoms
20% of post-menopausal women
episodic
does NOT require antibiotic treatment
what does a urinalysis check for
dip stick test with reagents that evaluate for common indicators of UTI
RBCs
WBCs
bacteria
does a urinalysis diagnose a UTI?
NOOOOO
need positive urine culture + symptoms
other noninfectious causes of cystitis can have positive urinalysis and symptoms
overview of urine culture
key to diagnosis of UTI
helps guide antibiotic treatment if there is a UTI
takes 48-72 hours to get result
what can you do if you suspect a UTI before culture results come back?
start empiric antibiotics
good coverage for suspected bacteria (GI pathogens)
good penetration to infected area (large amount excreted in urine for cystitis…can act topically)
think about local antibiogram and chance for resistance
levofloxacin for UTIs
good gram - coverage
85% excreted in urine unchanged
inhibits DNA gyrase and topoisomerase
pyridium
topical analgesic in the urinary system
unknown mechanism of action
turns urine orange
can give symptomatic relief, but has NO antimicrobial activity
