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Urinary Tract Infections > Clinical Presentation and Mangement of UTI > Flashcards

Clinical Presentation and Mangement of UTI Flashcards

1
Q

What is the typical presentation in adult women of acute cystitis or lower tract infection characterised by?

A

Variable combinations of the following:

  • Dysuria (pain on passing urine)
  • Frequency
  • Urgency
  • Suprapubic pain
  • Polyuria
  • Haematuria
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2
Q

What do we mean by frequency?

A

Passing urine more often than usual in small amounts

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3
Q

What do we mean by urgency?

A

Feeling like you need to pass urine

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4
Q

What do we mean by polyuria?

A

Increased volume of urine

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5
Q

When should a women be treated empirically with antibiotics without further investigation?

A

3 or more of:

  • Dysuria
  • Frequency
  • Urgency
  • Suprapubic pain
  • Polyuria
  • Haematuria

Or with particularly severe symptoms

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6
Q

How should a women with mild or only 2 symptoms or fewer be managed?

A

Mid-stream urine (MSU) collected

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7
Q

How do you collect a MSU?

A

Collected in a sterile container after the first 10-20ml of the stream has passed
- (The initial stream is contaminated by urethral contents (urethra is not sterile)

Contamination of the sample by vaginal/ labial organisms is sometimes a problem and washing/ swabbing with sterile saline in advance may help produce a clean specimen which is more likely to represent bladder content.

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8
Q

What does cloudy urine indicate?

A

Evidence suggests that UTI is very unlikely if the urine is not cloudy and another explanation for the symptoms should be sought.

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9
Q

What can dipstick testing detect in the urine that may be associated with a UTI?

A

Nitrite (a metabolic by product of some bacteria)

Protein (not normally detectable in urine, but a sign of inflammation or renal pathology)

Leucocytes (leucocyte esterase is an enzyme found in leucocytes i.e. pus cells - and is a marker of an inflammatory response)

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10
Q

How do you interparate dipstick findings?

A

If nitrite, protein and leucocytes are all negative on dipstick testing it is unlikely symptoms are due to UTI.

If all 3 are positive then empirical therapy is recommended.

A positive leucocyte esterase test alone does not diagnose or exclude infection and urine culture is recommended.

A positive blood or protein result in the absence of nitrite or leucocytes can be due to other causes and should be further investigated, with urine culture part of that process

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11
Q

How are men presenting with UTI symptoms managed?

A

Men with suspected UTI should have an MSU collected and sent to the laboratory

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12
Q

How common is UTI in men?

A

Much less common than women but the incidence increases with age secondary to obstruction caused by prostatic hypertrophy

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13
Q

What does recurrent UTI in men indicate?

A

May be presenting feature of Prostatitis, infection of the prostate and may be acute or chronic

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14
Q

What may cause prostatitis?

A

Difficult to diagnose microbiologically but usually due to coliform organisms in the older patient.

In younger males, sexually transmitted oragnisms such as Chlamydia trachomatis and Neisseria gonorrhoea may be responsible.

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15
Q

What is the commonest renal disease?

A

Bacterial infection of the upper tract

-Most commonly affects women of child bearing age.

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16
Q

What is characteristic of acute pyelonephritis?

A

Loin pain and fever are characteristic

Urinary symptoms such as frequency and dysuria may be less pronounced

Patients may be systemically unwell and in the most severe cases, the causative organism can spread into the bloodstream to cause bacteraemia

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17
Q

What are the systemic symptoms of sepsis?

A

Rigors (uncontrolled shivering/ shaking)

Nausea and vomiting

Unwell enough to be admitted to hospital

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18
Q

How do you manage suspected pyelonephritis?

A

Urine culture

Commenced on antibiotics immediately
- The choice of antibiotic being reviewed once culture results are known

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19
Q

When should blood cultures be done in pyelonephritis?

A

If patient is systemically unwell

20
Q

How does antibiotic treatment of acute pyelonephritis differ to cystitis?

A

Generally more aggressive than for simple cystitis and should be extended to at least 7 days.

21
Q

What do recurrent episodes of pyelonephritis indicate?

A

The need for further investigation of the urinary tract for the presence of calculi or other abnormalities

22
Q

How common is bacteruria in patients with indwelling catheters?

What does this mean clinically?

A

Very common
-occuring at a rate of 5% per day, and the rate is cumulative

As such, people with long-term catheters inevitably have bacteriuria.
(NOT synonymous with UTI and hence no indication for routine culture of catheter urine nor for treatment in the absence of symptoms or signs suggestive of UTI)

23
Q

If a patient becomes symptomatic (plus signs) of UTI with a long term catheter what is the management?

A

Culture and antibiotic

Catheter should be changes immediately prior to any treatment

24
Q

There is no indication for screening cultures in the asymptomatic population.

What is the exception to this rule?

A

Pregnancy

Patients undergoing urological surgery

Surgery involving the implantation of artificial prosthesis

25
Q

Why is it common practice to screen pregnant women at booking by urine MSU culture and treating those with significant bacteriuria?

A

There is good evidence that aymptomatic bacteriuria in pregnancy is associated with an incraesed risk of pyelonephritis and premature delivery

26
Q

What is the textbook cause of sterile pyuria?

A

Renal TB

  • Rare in the UK but should not be missed
  • Collect 3 early morning urines for a ZN stain and TB culture
27
Q

What infections should be considered in any sexually active man or woman with urinary symptoms?

A

Genito-urinary infections such as Chlamydia trachomatis

28
Q

Why should recurrent sterile pyuria always be investigated?

A

Can be a sign of non-infective pathology in the bladder or kidneys, including renal tract stone disease, interstitial cystitis, urological malignancy, chronic prostatitis, etc.

29
Q

What is the simplest explanation of sterile pyuria?

A

Undeclared presence of antibiotic in the urine sample, which prevents bacteria from growing

30
Q

How does the presentation of UTI in children differ to adults?

A

Important diagnosis to make

Can present in a much more non-specific way than in adults.

UTI should be considered as a diagnosis in any sick child and every yound child with unexplained fever

31
Q

What is the association between UTI and renal damage in later life?

A

No evidence that asymptomatic bacteriuria in adults is associated with renal damage in later life.

Probably an association between UTI and renal damage in children.
The combination of vesico-ureteric reflux and infection is thought to be responsible for renal scarring in the first 5 years of life, although the relative contribution of these two factors is uncertain.

32
Q

Most cases of chronic pyelonephritis in adult life probably result from what?

A

Damage done due to vesico-ureteric reflux and infection during early childhood.

Therefore of great importance to follow up and treat UTI in young children.

33
Q

How may patients with chronic pyelonephritis present?

A

With vague abdominal discomfort

Hypertension may also be present but renal fuction is seriously impaired only in a minority of patients.

Urine may be sterile but contain significant numbers of pus cells.

34
Q

What are the histopathological changes in chronic pyelonephritis?

A

Chronic interstitial nephritis

35
Q

What is IVP?

A

Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate your kidneys, ureters and bladder and help diagnose blood in the urine or pain in your side or lower back. An IVP may provide enough information to allow your doctor to treat you with medication and avoid surgery.

36
Q

What are the radiological changes on IVP seen in chronic pyelonephritis?

A

Clubbing of calyces with scarring or cortical parenchyma.

If ureters appear dilated a micrurating cystogram to detect vesico-ureteric reflux should be performed.

37
Q

What are the predisposing anatomical UTI factors in females?

A

Short urethra and its proximity to the rectum.

This allows transperineal introital colonisation with bacteria from the large bowel

38
Q

What female events predispose to UTI?

A

Trauma to female urethra during coitus and childbirth

In pregnancy stasis of urine allows bacteria to flourish.
This is due to a combination of the effect of progesterone dilating the ureters and physical pressure from the foetus

39
Q

What anatomical abnormalities predispose to UTI?

A

Congenital pelvi ureteric junction obstruction

Vesico-ureteric reflux

Duplex kidneys

Horseshoe kidney

Urethral valves

Prostatic enlargement

Chronic urinary retention

40
Q

What urinary conditions predispose to UTI?

A

Renal cysts

Pre-existing renal parenchemal damage (e.g. from recurrent pyelonephritis)

Stones in the urinary tract, including kidneys, ureter or bladder

41
Q

Immunosuppression including what predisposes to UTI?

A

Diabetes mellitis

Prolongued steroid therapy

Transplant rejection medications

42
Q

What medical interventions predispose to UTI?

A

Instumentation of urinary tract, including presence of a cystoscopy

Presence of a foreign body in the urinary tract, including urethral catheter or ureteric stent

43
Q

What are uncomplicated UTIs?

A

UTIs which occur in healthy, sexually active young women, in which there is a clear correlation between episodes of UTI with having sexual intercourse.

44
Q

What are the organisms in uncomplicated UTI?

A

Either E. Coli or skin commensals such as Staph. Saprophyticus

45
Q

What are complicated UTIs?

A

Occur in all other situations that do not qualify for uncomplicated UTI.

Including any UTI in

  • Children,
  • Men,
  • Patients with abnormal renal tract (e.g. pelvi-ureteric junction obstruction, vesico-ureteric reflux, renal tract stone etc)
  • Immunosuppression
  • Foreign body within renal tract (e.g. urethral catheter, ureteric stent)
  • Bladder tumour
  • Chronic urinary retention
  • Abnormal bladder outflow tract (e.g. benign prostatic enlargement, urethral stricture, meatal stenosis, phimosis etc)
46
Q

How do you manage complicated UTIs?

A

Require investigation, whcih should include :

  • An assessment of the upper renal tract (e.g. ultrasound scan or CT scan),
  • Bladder (cystoscopy and post void bladder scan)
  • Urinary flow studies

(until a cause is found).

Urinary Tract Infections (3 decks)

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