B5.076 Big Case: Dysura/UTI

Question 1

typical symptoms of cystitis

Answer 1

dysuria
urgency
frequency
burning or pressure sensation
fever or chills if severe (more common in pyelonephritis)

Question 2

atypical symptoms of cystitis

Answer 2

lethargy
anorexia
new incontinence
psychiatric changes- mania, anorexia, delirium

Question 3

who more commonly presents with atypical symptoms and why?

Answer 3

more common in the elderly

alterations in immune function may prevent some of the other “typical” symptoms

Question 4

broad categories for differential diagnosis of dysuria

Answer 4

infectious

non-infectious

Question 5

infectious causes of dysuria

Answer 5

cystitis (acute or chronic)

non cystitis infections (like STIs)

Question 6

examples of noninfectious causes of dysuria

Answer 6

interstitial cystitis/bladder pain syndrome/chronic prostatitis
chemical cystitis
radiation cystitis
BPH
atrophic vaginitis
bladder cancer

Question 7

what is acute bacterial cystitis

Answer 7

bacterial infection of the lower urinary tract (bladder/urethra)
commonly called a UTI

Question 8

symptoms of acute bacterial cystitis

Answer 8

inflammation in bladder and urethra causes dysuria, frequency, hematuria, urgency, incontinence

Question 9

where do bacteria for UTIs originate?

Answer 9

GI tract

common: E.coli (85%), klebsiella, enterobacter, enterococcus

Question 10

why are females more at risk for bacterial cystitis

Answer 10

shorter urethra

proximity of urethra to anus

Question 11

bacterial cystitis related sexual activity in female gender

Answer 11

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

Question 12

additional risk factors for bacterial cystitis outside of female gender

Answer 12

urinary retention/ incomplete bladder emptying
bladder stones or foreign bodies
urine “yo-yo”

Question 13

what are bladder diverticula and how do they increase risk for cystitis

Answer 13

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

Question 14

what is vesicoureteral reflux (VUR)

Answer 14

congenital condition where urine can reflex from bladder into the kidney
muscles don’t close off ureters during voiding

Question 15

what is acute bacterial pyelonephritis

Answer 15

bacterial infection of the kidney

infection of the upper urinary tract, usually a complication of a lower urinary tract infection

Question 16

2 mechanisms for acute bacterial pyelonephritis

Answer 16

1. ascending infection (most common, starts in bladder and migrates up ureters)
2. hematogenous spread (uncommon, bacteria in bloodstream filter and deposit in kidneys)

Question 17

symptoms of pyelonephritis

Answer 17

local: flank pain (SEVERE)
systemic: fever, chills, malaise, lethargy, nausea, vomiting

Question 18

complication of pyelonephritis

Answer 18

bacteria can get into the bloodstream due to infecting the “filter”
more readily causes bacteremia compared to cystitis
can lead to sepsis

Question 19

what are some manifestations of STIs that may mimic UTIs

Answer 19

urethritis from G&C in males
cervicitis in females
related to recent sexual contact

Question 20

what is interstitial cystitis/bladder pain syndrome

Answer 20

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

Question 21

causes associated with interstitial cystitis/bladder pain syndrome

Answer 21

increased stress
pelvic floor trigger points
menopause/atrophic vaginitis
idiopathic
psychosomatic
changes in bladder sensation
changes in bladder glycosaminoglycans

Question 22

causes of chemical cystitis

Answer 22

caffeine (bladder irritant)
spicy foods
acidic foods (change bladder pH)

Question 23

describe radiation cystitis

Answer 23

dysuria with negative culture in a patient with previous radiation
often had colon, prostate, or cervical neoplasms

Question 24

what is BPH

Answer 24

benign prostatic hypertorphy

Question 25

what is atrophic vaginitis

Answer 25

common condition in post-menopausal women

due to decreased estrogen concentration in vaginal tissues

Question 26

physical exam findings in atrophic vaginitis

Answer 26

thin, pale, tan tissues (most common)
friable, inflamed, red tissues
associated with dysuria and dyspareunia (pain with sexual activity)

Question 27

how can atrophic vaginitis lead to UTIs?

Answer 27

change in normal vaginal flora
loss of lactobacillus (natural host/defense mechanism)
vaginal fluid becomes more alkaline

Question 28

treatment of atrophic vaginitis

Answer 28

topical estrogen
re-acidifies vaginal fluid to enhance growth of lactobacillus
avoid if history of breast or uterine cancer (hormonally driven)

Question 29

symptoms of bladder cancer

Answer 29

can cause frequency, dysuria, urgency, hematuria
leading cause in US is smoking
ALWAYS evaluate blood in urine for potential serious causes

Question 30

what is asymptomatic bacteriuria

Answer 30

bacteria present in urine, but no clinical symptoms
20% of post-menopausal women
episodic
does NOT require antibiotic treatment

Question 31

what does a urinalysis check for

Answer 31

dip stick test with reagents that evaluate for common indicators of UTI
RBCs
WBCs
bacteria

Question 32

does a urinalysis diagnose a UTI?

Answer 32

NOOOOO
need positive urine culture + symptoms
other noninfectious causes of cystitis can have positive urinalysis and symptoms

Question 33

overview of urine culture

Answer 33

key to diagnosis of UTI
helps guide antibiotic treatment if there is a UTI
takes 48-72 hours to get result

Question 34

what can you do if you suspect a UTI before culture results come back?

Answer 34

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

Question 35

levofloxacin for UTIs

Answer 35

good gram - coverage
85% excreted in urine unchanged
inhibits DNA gyrase and topoisomerase

Question 36

pyridium

Answer 36

topical analgesic in the urinary system
unknown mechanism of action
turns urine orange
can give symptomatic relief, but has NO antimicrobial activity