Cystitis, Pyelo, Interstitial Cystitis Flashcards
Urine dipstick is most accurate in predicting UTI when positive for _________ and/or _________ in ______patients
Leukocyte esterase
Nitrite
Symptomatic
Does a negative dipstick rule out UTI in symptomatic pts
No
Does a positive dipstick support a UTI in asymptomatic pts
No
What can cause false negative nitrite on a dipstick
Non-nitrate reducing organisms
Frequent urination/urine in bladder <4hrs
What can cause a false positive leukocyte esterase on dipstick
Vaginal contamination
Trichomonas
Upper urinary tract infections are called
Pyelonephritis
Lower UTIs are called
Cystitis
Or prostatitis or urethritis but thats not what this lecture is about
In men aged 20-50 yo, most UTIs are _________
Urethritis or prostatitis
UTI’s are 50x more common in
Women
95% of UTIs occur from _____________
Ascending bacterial infection
The rest are hematogenous
What bacteria most commonly causes UTI
E. coli
Let’s see a list of other pathogens that cause UTIs in immunocompromised ppl
Let’s not because its prob not on test
What are the 3 broad categories of UTI risk factors
- Reduced urine flow- obstruction, dehydrated, neurogenic bladder
- Promote colonization- sex, spermicide use, recent abx use
- Facilitate ascent- catheterization, urinary/fecal incontincenc
What is the definition of Acute Simple Cystitis
UTI confined to the bladder
Non pregnant
No sx that suggest upper UTI/systemic infection
What is the definition of acute complicated UTI
S/s that suggest extension of infection beyond the bladder:
Fever, chills, rigor, fatigue/malaise, flank pain, CVA tenderness, pelvic/perineal pain in men
Who are “special populations” when they get UTIs
Pregnant women
Men
Pts with comordiities, immunocompromised, urologic abnormalities
What are irritative voiding sx
Dysuria
Urinary frequency
Urgency
What population may have an atypical presentation of UTI
Elderly
Can acute simple cystitis include hematuria or suprapubic discomfort
Yes, may or may not be present.
Irritative voiding sx ALWAYS present though
What will you find when you do your exam on someone with acute simple cystitis
NORMAL EXAM
Mightttt find suprapubic tenderness but thats it
What do you need to do with your patients urine sample if they have acute simple cystitis
Dipstick: +leukocyte esterase and nitrites
Microscopy: Pyuria and Bacteriura
+/- pregnancy test
Do you need to a urine culture for acute simple cystitis
No
Might do it to check for drug resistance bugs
When do you NEED to do a urine culture for acute simple cystitis
Atypical presentation/diagnostic uncertainty
Suspect complicated UTI
Sx do not resolve
Suspect antimicrobial resistance (recently took abx)
Special populations- men, pregnant, immunocompromised
What values on your urine culture will represent positive cultures
10^3 CFUs
But….. 10^2 CFUs is considered positive if the patient has typical UTI symptoms
How do you treat the sx of acute simple cystitis
OTC Phenazopyridine (Pyridium) 200mg TID prn
NO MORE THAN 2 DAYS
TURNS PEE ORANGE
(Dont know if dosages are important )
What is the antibiotic treatment for Acute Simple Cystitis for a NON-pregnant person
Nitrofurantoin (Macrobid) 100mg BID x 5 days
Bactrim 160/800 BID x 3 days
Fosfomycin (monaural) 3gm PO single dose
When should you not use bactrim for acute simple cystitis
20% of the local E. coli are resistant
Can you use nitrofurantoin (macrobid) or Fosfomycin (Monurol) for early pyelonephritis
No, they do not penetrate the kidney enough
What are some alternative abx for acute simple cystitis in a non pregnant person if you’re concerned about allergies or cost or whatever (probably not on test)
Beta lactams- augmentin, cefdinir
Fluoroquinolones- Ciprofloxacin, Levaquin etc
What are your antibiotic options for acute simple cystitis in a PREGNANT woman
Augmentin, cephalexin, cefpodoxime, fosfomycin
Nitrofurantoin/Bactrim- ask their OB if its ok
**AVOID FLUOROQUINOLONES **!!
How do you treat acute simple cystitis in MEN
Primary therapies for a longer duration (7 days)
**must rule out prostatitis - dribbling, enlarged prostate, etc
How do you treat acute simple cystitis in patients who are immunicompromised or have underlying urologic abnormalities
Primary therapies for longer (1-2 weeks)
-low threshold to manage as complicated UTI
What are the things you need to educate your pt about for acute simple cystitis
Drink more water
Void when you need to
Wash your snatch
Pee after sex?
Finish abx- expect relief within 48hrs
go to ER if sx of pyelonephritis
Do you need to do follow up urine cultures for acute simple cystitis ?
only pregnant women
What are some sx that suggest pyelonephritis instead of cuystsits
Flank pain
Constitutional sx (fever,chills, maialise)
GI sx (N/V abdominal pain)
CVA tenderness
What do you need to do with the urine sample if you suspect pyelonephritis
Dipstick: leukocyte esterase, nitrites
Microscopy: Pyuria (>10 leukocytes/mL), bacteriuria, WBC casts***
Culture: positive if >10^5 CFU
Do you need to do a CBC or BMP for pyelonephritis
No, but if you did:
CBC: leukocytosis w left shift
BMP: assess renal function, hydration, electrolytes (due to nausea/vomiting)
Do you need to do imaging for pyelonephritis?
No. Only if you suspect an obstruction.
You’d do a CT with and without contrast
What is the antibiotic treatment for mild-moderate pyelonephritis?
Cipro 500mg BID x 5-7 days
Cipro-ER 1000mg once/day x 5-7 days
Levofloxacin- 750mg once/day x 5-7 days
If local resistance to Fluoroquinolones, provide an initial IV/IM dose of ceftriaxone 1g in addition to Fluoroquinolones
If you treat your pt for mild-mod pyelonephritis as an outpatient, when do they NEED to follow up?
Do you need to get follow up cultures?
24-48hrs!!!
F/u cultures only if pregnant
When do you need to hospitalize your pt for pyelonephritis
Suspected obstruction***
Critically ill/hemodynamically unstable
Persistently high fever >103 F
Marked pain
Metabolic derangements
Unable to take liquids PO
Concerns about compliance with f/u
What kind of IV antibiotics can you give during inpatient treatment for complicated/severe pyelonephritis?
Fluoroquinolones
Broad spectrum cephalosporin
Broad spectrum PCN
Carbapenem
Aminoglycoside
What complications are you looking for at the 24-48 hr follow up
Sepsis
Renal failure
Scarring/chronic pyelo
Renal abscess formation
What are the other 2 names for interstitial cystitis
Bladder pain syndrome
Painful bladder syndrome
What is the definition of IC
Unpleasant sensation perceived to be related to the bladder, associated with UTIO sx of more than 6 weeks duration in the absence of infection or other identifiable causes
Who usually gets IC?
Women
4th decade or older
Other chronic pain: fibromyalgia, IBS
Interstitial Cystitis is: Chronic debilitating condition characterized by bladder pain
No question just read it becasue she put it in red and I didn’t know how to make a card
How can IC impact your life
Psychosocial functioning
Quality of life
Sexual dysfucntion
Sleep dysfunction
Depression
What is the pathophysiology of IC?
ALTERED UROTHELIUM🐝
Caused by some combination of these things that probably wont be on the test:
Disruption of GAG layer
Bladder urothelilal injury
Secretion of proinflammatory substances, mast cell activation, fibrosis
Neural hypersensitivity
Neuropathic pain and voiding dysfunction
What are the presenting symptoms of IC
Suprapubic/bladder pain that is often WORSE with bladder filling and RELIEVED with voiding***
+/- urgency, frequency, nocturia
+/- pain in other areas, vaginal burning
How long must sx last for a diagnosis of IC
6 weeks *******
Yes yes we all know that IC is a ~diagnosis of exclusion~ but what are the most important things to rule out
Cancer
Infection
What will you see on cystoscopy if the patient has IC?
ALTERED UROTHELIUM
What is the 1st line tx for IC
Self care
Diet mods- avoid citrus, acid, spicy, caffeine, etoh, soda
Bladder retraining (⬆️voiding intervals)
exercise
psychotherapy/support gourps
Pyridium (short term 2 day use for flares)
What is the 2nd line to for IC?
Tricyclics antidepressant (Amitriptyline)
Pentosan Polysulfate (Elmiron) - FDA approved for IC. Takes 3-6 months to work
Antihistamines (Hydroxyzine)
Lidocaine in the bladder
Pelvic physical therapy
What is the 3rd line tx for IC
Cystoscopy with short duration bladder hydro distention (under anesthesia)
Intravesical instillation of GAGs
Intravesical Dimethyl sulfoxide
What are the 4-6th line tx of IC
4th: Botox, sacral neuromodulation
5th: cyclosporine
6th: surgery
Do you NEED to do cystoscopy to diagnose IC?
No, but it will support you dx when you see that ALTERED UROTHELIUM
