Exam 2: Cystitis / Prostate disease DSA

Question 1

examples of urinary tract infection (UTI) clinical entities

Answer 1

• encompasses a variety of clinical entities:
  
  • cystitis (symptomatic disease of the bladder)
  • pyelonephritis (symptomatic disease of the kidney)
  • prostatitis (symptomatic disease of the prostate)
  • asymptomatic bacteriuria (ABU).
• Uncomplicated UTI
  
  • refers to acute disease in nonpregnant outpatient women without anatomic abnormalities or instrumentation of the urinary tract
• Complicated UTI
  
  • refers to all other types of UTI

Question 2

urinary tract infection (UTI) Epidemiology

Answer 2

• UTI occurs far more commonly in females than in males
• Obstruction from prostatic hypertrophy causes men >50 years old to have an incidence of UTI comparable to that among women of the same age
• 50–80% of women have at least one UTI during their lifetime, and
  20–30% of women have recurrent episodes.
• Risk factors for acute cystitis include recent use of a diaphragm with
  spermicide, frequent sexual intercourse, a history of UTI, diabetes
  mellitus, and incontinence; many of these factors also increase the risk of pyelonephritis.

Question 3

urinary tract infection (UTI) Microbiology

Answer 3

• In the United States
• Cystitis isolate
  
  • Escherichia coli accounts for 75–90%
  • Staphylococcus saprophyticus for 5–15%
  • Klebsiella species, Proteus species, Enterococcus species, Citrobacter species, and other organisms for 5–10%
• Uncomplicated pyelonephritis
  
  • is similar, with E. coli predominating.
• Complicated UTI
  
  • Gram-positive bacteria (e.g., enterococci and Staphylococcus aureus) and yeasts are also important pathogens

Question 4

urinary tract infection (UTI) Pathogenesis

Answer 4

• In the majority of UTIs
  
  • bacteria establish infection by ascending from the urethra to the bladder.
  • Continuing ascent up the ureter to the kidney is the pathway for most renal parenchymal infections.
• The pathogenesis of candiduria is distinct
  
  • in that the hematogenous route is common.
  • The presence of Candida in the urine of a noninstrumented immunocompetent pt implies either genital contamination or potentially widespread visceral dissemination.

Question 5

Clinical Manifestations of UTIs:

Asymptomatic bacteriuria

(ABU)

Answer 5

• diagnosed when a screening urine culture performed for a reason unrelated to the genitourinary tract is incidentally found to contain bacteria
• but the pt has no local or systemic symptoms referable to the urinary tract

Question 6

Clinical Manifestations of UTIs:

Cystitis

(symptomatic disease of the bladder)

Answer 6

• Cystitis presents with:
  
  • dysuria
  • urinary frequency and urgency
  • nocturia
  • hesitancy
  • suprapubic discomfort
  • gross hematuria
• Signs that the upper urinary tract is involved:
  
  • Unilateral back or flank pain
  • fever

Question 7

Clinical Manifestations of UTIs:

Pyelonephritis; Papillary necrosis

(symptomatic disease of the kidney)

Answer 7

• Pyelonephritis presents with:
  
  • fever
  • lower-back or costovertebral-angle pain
  • nausea
  • vomiting
  • Bacteremia develops in 20–30% of cases.
• Papillary necrosis
  
  • can occur in pts with obstruction, diabetes, sickle cell disease, or analgesic nephropathy.

Question 8

Clinical Manifestations of UTIs:

Pyelonephritis; Emphysematous pyelonephritis

(symptomatic disease of the kidney)

Answer 8

• Pyelonephritis presents with:
  
  • fever
  • lower-back or costovertebral-angle pain
  • nausea
  • vomiting
  • Bacteremia develops in 20–30% of cases.
• Emphysematous pyelonephritis
  
  • is particularly severe
  • is associated with the production of gas in renal and perinephric tissues
  • occurs almost exclusively in diabetic pts.

Question 9

Clinical Manifestations of UTIs:

Pyelonephritis; Xanthogranulomatous pyelonephritis

(symptomatic disease of the kidney)

Answer 9

• Pyelonephritis presents with:
  
  • fever
  • lower-back or costovertebral-angle pain
  • nausea
  • vomiting
  • Bacteremia develops in 20–30% of cases.
• Xanthogranulomatous pyelonephritis
  
  • occurs when chronic urinary obstruction
    
    • often by staghorn calculi
  • together with chronic infection, leads to suppurative destruction of renal tissue

Question 10

Clinical Manifestations of UTIs:

Prostatitis

(symptomatic disease of the prostate)

Answer 10

• can be either infectious or noninfectious
• noninfectious cases are far more common.
• Acute bacterial prostatitis presents with:
  
  • dysuria
  • urinary frequency
  • fever
  • chills
  • symptoms of bladder outlet obstruction
  • pain in the prostatic, pelvic, or perineal area.

Question 11

Clinical Manifestations of UTIs:

Complicated UTI

Answer 11

• presents as symptomatic disease in:
  
  • a man or woman with an anatomic predisposition to infection
  • with a foreign body in the urinary tract
  • or with factors predisposing to a delayed response to therapy

Question 12

urinary tract infection (UTI) Diagnosis

Answer 12

• The clinical history
  
  • has a high predictive value in diagnosing uncomplicated cystitis
• in a pt presenting with both dysuria & urinary frequency
  
  • in the absence of vaginal discharge
  • the likelihood of UTI is 96%.
• A urine dipstick test
  
  • positive for nitrite or leukocyte esterase
  • can confirm the diagnosis of uncomplicated cystitis in pts with a high pretest probability of disease.
• The detection of bacteria in a urine culture
  
  • is the diagnostic gold standard for UTI.

Question 13

Treatment of UTIs:

Uncomplicated cystitis** in **women

Answer 13

• Trimethoprim-sulfamethoxazole (TMP-SMX)
  
  • has been recommended as first-line treatment for acute cystitis,
  • but should be avoided in regions with resistance rates >20%.
• Nitrofurantoin is another first-line agent with low rates of resistance.
• Fluoroquinolones
  
  • should be used only when other antibiotics are not suitable because of increasing resistance or their role in prompting
    nosocomial outbreaks of Clostridium difficile infection.
• Except for pivmecillinam
  
  • β-lactam agents are associated with lower rates of pathogen eradication and higher rates of relapse.

Question 14

Treatment of UTIs:

Pyelonephritis

Answer 14

• Given high rates of TMP-SMX-resistant E. coli
  
  • fluoroquinolones (e.g., ciprofloxacin) are first-line agents for the treatment of acute uncomplicated pyelonephritis.
• Oral TMP-SMX
  
  • is effective against susceptible uropathogens.

Question 15

Treatment of UTIs:

UTI in pregnant women

Answer 15

• Considered relatively safe in early pregnancy
  
  • Nitrofurantoin
  • ampicillin
  • and the cephalosporins

Question 16

Treatment of UTIs:

UTI in men

Answer 16

• In men with apparently uncomplicated UTI
  
  • 7- to 14-day course of a fluoroquinolone or TMP-SMX is recommended.
• If acute bacterial prostatitis is suspected
  
  • antibiotics should be initiated after urine and blood are obtained for cultures.
  • Therapy can be tailored to urine culture results and should be continued for 2–4 weeks
• for chronic bacterial prostatitis.
  
  • a 4- to 6-week course is often necessary

Question 17

Treatment of UTIs:

Asymptomatic bacteriuria

(ABU)

Answer 17

• ABU should be treated only in:
  
  • pregnant women
  • in pts undergoing urologic surgery
  • and perhaps in neutropenic pts
  • and renal transplant recipients
• antibiotic choice is guided by culture results.

Question 18

Treatment of UTIs:

Catheter-associated UTI

Answer 18

• Urine culture results are essential to guide therapy.
• Replacing the catheter during treatment is generally necessary.
  
  • Candiduria, a common complication of indwelling catheterization,
• *resolves in ~1/3 of cases with catheter removal**.
• Fluconazole for 14 days is recommended for pts who have:
  
  • symptomatic cystitis
  • or pyelonephritis
  • and for those who are at high risk for disseminated disease.

Question 19

Treatment of UTIs:

Prevention of Recurrent UTI

Answer 19

• Women experiencing symptomatic UTIs ≥2 times a year are candidates for prophylaxis
  
  • either continuous or postcoital, or pt-initiated therapy.
• Continuous prophylaxis and postcoital prophylaxis usually entail low doses of:
  
  • TMP-SMX
  • a fluoroquinolone
  • or nitrofurantoin
• Pt-initiated therapy involves supplying the pt with materials for urine culture and for selfmedication with a course of antibiotics at the first symptoms of infection.

Question 20

Interstitial cystitis

(painful bladder syndrome)

Answer 20

• chronic condition
• The cardinal symptoms
  
  • pain (often at ≥2 sites)
  • urinary urgency and frequency
  • and nocturia occur in no consistent order.
• Unlike pelvic pain arising from other sources
  
  • pain caused by interstitial cystitis is exacerbated by bladder filling and relieved by bladder emptying.
• 85% of pts void >10 times per day
  
  • some do so as often as 60 times per day.
• Many pts with interstitial cystitis have comorbid functional somatic
  syndromes (e.g., fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, vulvodynia, migraine).
• The goal of therapy is the relief of symptoms, which often requires a multifaceted approach
  
  • e.g., education, dietary changes, medications such as nonsteroidal anti-inflammatory drugs or amitriptyline, pelvic-floor physical therapy, and treatment of associated functional somatic syndromes).

Question 21

Prostate Hyperplasia key info

Answer 21

• Hyperplasia usually begins by age 45 years
• Occurs in the area of the prostate gland surrounding the urethra
  
  • and produces urinary outflow obstruction.
• Symptoms develop on average by age 65 in whites and 60 in blacks.
  
  • Symptoms develop late because hypertrophy of the bladder detrusor compensates for ureteral compression.
• On digital rectal exam (DRE) a hyperplastic prostate is
  
  • smooth, firm, and rubbery in consistency
  • the median groove may be lost.
• Prostatespecific antigen (PSA) levels may be elevated but are ≤10 ng/mL unless cancer is also present.
  
  • Cancer may also be present at lower levels of PSA.

Question 22

Prostate Hyperplasia treatment

Answer 22

• Asymptomatic pts
  
  • do not require treatment
• those with complications of urethral obstruction
  
  • such as inability to urinate, renal failure, recurrent urinary tract infection, hematuria, or bladder stones clearly require surgical extirpation of the prostate
    
    • usually by transurethral resection (TURP)
• However, the approach to the remaining pts
  
  • should be based on the degree of incapacity or discomfort from the disease and the likely side effects of any intervention.
• If the pt has only mild symptoms
  
  • watchful waiting is not harmful and permits an assessment of the rate of symptom progression.
• If therapy is desired by the pt, two medical approaches may be helpful:
  
  • terazosin
    
    • an α1-adrenergic blocker
      
      • relaxes the smooth muscle of the bladder neck and increases urine flow
  • finasteride or dutasteride
    
    • inhibitors of 5α-reductase
      
      • block the conversion of testosterone to dihydrotestosterone and cause an average decrease in prostate size of
• TURP has the greatest success rate but also the greatest risk of complications.
• Transurethral microwave thermotherapy (TUMT) may be comparably effective to TURP. Direct comparison has not been made between medical and surgical management.

Question 23

Prostate cancer key info

Answer 23

• The disease is more common in blacks than whites.
• Symptoms are generally similar to and indistinguishable from those of prostate hyperplasia
  
  • but those with cancer more often have
    
    • dysuria
    • back or hip pain.
• On histology
  
  • 95% are adenocarcinomas.
• In contrast to hyperplasia, prostate cancer generally originates in the
• *periphery of the gland**
  
  • may be detectable on DRE
    
    • as one or more nodules on the posterior surface of the gland
    • hard in consistency and irregular in shape.

Question 24

Prostate cancer approach to diagnosis

Answer 24

Question 25

Prostate Carcinoma treatment

Answer 25

• For pts with stages A through C disease
  
  • surgery (radical retropubic prostatectomy)
    and radiation therapy (conformal 3-dimensional fields)
• Pts treated surgically for localized disease who develop rising PSA
  
  • may undergo Prostascint scanning (antibody to a prostate-specific membrane antigen).
  • If no uptake is seen, the pt is observed.
  • If uptake is seen in the prostate bed, local recurrence is implied
    
    • and external beam radiation therapy is delivered to the site.
• For pts with metastatic disease
  
  • androgen deprivation is the treatment of choice
  • Surgical castration is effective
  • but most pts prefer to take leuprolide plus flutamide (an androgen receptor blocker).
• For palliation in prostate cancer
  
  • Chemotherapy is used
• Prostate Cancer Prevention
  
  • Finasteride and dutasteride
  • shown to reduce the incidence of prostate cancer by 25%