Clinical Approach to Hematuria, Dysuria, and Nocturia (Selby) Flashcards
What are 4 Gram (-) bacteria and 3 Gram (+) bacteria that can lead to Urinary Tract Infections?
Which one is the most common cause of both Uncomplicated and Complicated UTIs?
Gram (-): E. coli, Klebsiella, Proteus, Pseudomonas
Gram (+): Enterococcus, Staphylococcus saprophyticus, Group B streptococcus (diplococci)
most common pathogens is E. COLI
What is the classical presentation of Cystitis vs Pyelonephritis?
What is a common presentation that is classically seen in OLDER adults?
Cystitis: dysuria (pain/burning), urinary frequency, urinary urgency
- suprapubic abdominal pain
Pyelonephritis: fever/chills, flank pain, CVA tenderness, fatigue, N/V
altered mental status is commonly seen in older adult patients
What are 3 tests used to diagnose UTIs and what amount of colony-forming units do TRUE UTIs have?
What two findings are important to check for on Urine Dipstick tests?
- Urine Dipstick - leukocyte esterase, nitrites, blood, color
- Urinalysis with urine microscopy
- Urine cultures with sensitivity
- True UTIs have > 1000 CFUs
- make sure to check for LEUKOCYTE ESTERASE and NITRITES on urine dipstick (75% sensitivity and 82% specificity)
What imaging is done to help diagnose Urinary Tract Infections and when is it commonly used?
- use abdomen/pelvis CT WITHOUT IV contrast
- typically reserved for patients with acute complicated UTIs and/or possible pyelonephritis
- calculi, obstruction, perinephric abscesses
What are three drugs used to treated Uncomplicated Cystitis?
UC: nitrofurantoin, trimethoprim-sulfamethoxazole DS, fosfomycin
- 2nd line: fluoroquinolones/B-lactams
What is the difference between:
- Acute Bacterial Prostatitis
- Chronic Bacterial Prostatitis
- Chronic Pelvic Pain Syndrome
- Asymptomatic Prostatitis
- acute infection of the prostate gland
- chronic infection of the prostate gland (> 3 months)
- chronic pelvic pain with no detectable infection of the prostate gland
- infection present in prostate gland but patient is asymptomatic
What are 4 Gram (-) and 2 Gram (+) bacteria that are common causes of Prostatitis?
Which bacteria is the most common cause of Prostatitis?
Gram (-): E. Coli, Klebsiella, Proteus, Pseudomonas
Gram (+) cocci: Enterococcus, normal skin flora
most common cause is E. COLI
What is the difference in the clinical presentation of Acute Bacterial Prostatitis vs Chronic Bacterial Prostatitis?
ABP: patients appear ACUTELY ILL
- fever, chills, malaise, N/V, sepsis
- obstructive symptoms and suprapubic pain
CBP: patients present with subtle signs/symptoms compared to acute prostatitis
- Sx of recurrent UTIs, obstructive symptoms
- suprapubic pain and pain with ejaculation
- blood in semen
What is the diagnosis of Acute and Chronic Prostatitis?
AP: usually based on HISTORY and EXAM
- digital rectal exam (tenderness, edema, large)
- urinalysis and urine culture
CP: PROSTATIC MASSAGE is diagnostic
- digital rectal exam (often normal findings)
- urinalysis and urine culture (usually not diagnostic)
consider testing for gonorrhea and chlamydia in high-risk patient
What are the two agents used to treat both Acute and Chronic Prostatitis?
How long should they be given for?
Tx: fluoroquinolones and trimethoprim-sulfamethoxazole
- duration of Abx should be 4-6 weeks
What is the difference in pathogenesis between Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS)?
BPH: inc. total # of stromal and glandular epithelial cells within the prostate
LUTS: bladder outlet obstruction from BPH and/or detrusor muscle overactivity 2ndary to BOO
each pathophysiology is not completely understood
What two major symptoms help differentiate BPH from LUTS and which one is usually more bothersome for male patients?
- BPH can be asymptomatic, so when symptoms ARE present pts. present with lower urinary tract symptoms (LUTS)
1. Storage Symptoms: frequency, urgency, nocturia, incontinence
2. Voiding Symptoms: slow stream, straining, intermittency, splitting of voiding stream
STORAGE symptoms are MORE bothersome to most men and usually motivate them to seek medical advice
How is BPH typically diagnosed?
What molecule is typically elevated in pts. with BPH?
Dx: typically based upon HISTORY and EXAM
- digital rectal exam: enlarged, non-tender
- urinalysis: no alternative diagnosis
- BMP: check normal creatinine
PSA (prostate specific antigen) is often elevated in BPH, but is also seen to be elevated in PROSTATITIS and PROSTATE CANCER
What are the 4 most common drugs used to treat BPH and how do they work?
- alpha blockers (improvement in 1-2 weeks)
- block sympathetic contraction of prostate
- 5a-reductase inhibitors (improvement 6-12 months)
- dec. testosterone –> DHT (shrinks prostate)
- anticholinergic agents (predominately INPATIENT)
- inhibits muscarinic receptors, dec. bladder contract
- phosphodiesterase-5 inhibitors (INPATIENTS)
- inc. cAMP and cGMP = smooth muscle relaxation
can combine these drugs as well as monotherapy
What are 2 potential surgical treatments that can be performed on BPH patients?
- transurethral resection of prostate (TURP)
- remove layers of the prostate
- simple prostatectomy
What is the risk factor of developing a second kidney stone at:
- 1 year
- 5 years
- 10 years
What are the 3 most common types of kidney stone and what material do these 3 stones share?
- 15%
- 35-40%
- 50%
Stones: Calcium Oxalate (58.8%), mixed Calcium Oxalate/Calcium Phosphate (11.4%), and Calcium Phosphate (8.9%)
- CALCIUM stones account for almost 80% of stones
What are 5 reasons that can contribute to the the pathogenesis of Calcium Nephrolithiasis?
- dietary factors (low fluid intake, high calcium, etc)
- genetic predisposition (family history)
- acquired metabolic defects 2nd to disease
- high urine SUPERSATURATION
- dec. urinary stone inhibitors (CITRATE)
What is the clinical presentation of Nephrolithiasis?
What are common complications of Nephrolithiasis?
- kidney stones can be asymptomatic and are often detected incidentally on imaging
- Sx usually from URINARY OBSTRUCTION
- intermittent, severe flank pain (groin radiation)
- hematuria and N/V
- gravel passage/visible stone passage
Comp: hydronephrosis, AKI/CKD, recurrent UTIs
What is the main way that Nephrolithiasis is diagnosed?
Which kidney stones are radiopaque (3) and radiolucent (2)?
Dx: NON-contrast CT Abdomen and Pelvis
- “Renal Stone Protocol CT”
- Kidney Ureter Bladder X-Ray
- radiopaque: calcium oxalate/phosphate, struvite
- radiolucent: uric acid and cystine
Renal and Bladder U/S is bad at detecting stones but GOOD at detecting hydronephrosis
What types of stones are these crystal patterns indicative of:
- Hexagonal crystals
- Rhombic plates or Rosette-shaped crystals
- “Coffin-lid” crystals
- Dumbbell-shaped crystals
- Envelope-shaped crystals
- CYSTINE crystals
- URIC ACID crystals
- STRUVITE (magnesium-ammonium-phosphate)
- calcium oxalate MONOHYDRATE crystals
- calcium oxalate DIHYDRATE crystals
How is Nephrolithiasis managed?
How can kidney stones be treated using medical therapy vs surgical therapy?
- smaller and more distally located stones are MORE likely to be passed SPONTANEOUSLY
Medical: fluids (oral/IV), pain control (NSAIDs), expulsive therapy (dilates ureters)
Surgical: Extracorporeal Shock Wave Lithotripsy, Ureteroscopy with basket stone extraction, nephrolithotomy (percutaneous or open)
What is the difference between these conditions:
- Uncomplicated UTI
- Complicated UTI
- Recurrent UTI
- Asymptomatic bacteriuria
- Catheter-associated UTI
- acute cystitis or pyelonephritis in a non-pregnant outpatient without any anatomical abnormalities or urinary instrumentation
- all other urinary infections are considered complicated
- 2+ infections in 6 months OR 3+ infections in 1 year
- bacteriuria present on urine culture but NO clinical UTI symptoms present in patient
- UTI associated with placement of urinary catheter or within 48 hrs of removal
