FINAL GU/STIs Flashcards
Who is at risk of UTIs/
premature newborns
prepubertal children
sexually active and pregnant women
women treated with antibiotics that disrupt vaginal flora
spermicide users
estrogen-deficient postmenopausal women
individuals with in-dwelling catheters
persons with diabetes mellitus, neurogenic bladder, or urinary tract obstruction.
Complicated vs uncomplicated UTI
Uncomplicated = UTI in a person with normal urinary tract, typically will be mild and without complications
A complicated UTI develops when there is an abnormality in the urinary system or a health problem that compromises host defences, such as human immunodeficiency virus (HIV), kidney transplant, diabetes mellitus, or spinal cord injury.
For what 2 reasons are mean less likely to get UTIs?
1) longer urethra
2) presence of prostatic secretions
What do you call inflammation of the bladder?
Cystitis
2 most common organisms to cause UTI?
The most common infecting microorganisms are uropathic strains of Escherichia coli and the second most common is Staphylococcus saprophyticus.
Bacterial contamination of the normally sterile urine usually occurs by retrograde movement of Gram ________ bacilli into the urethra and bladder and then to the ureter and kidney
NEGATIVE
Why do we feel like we have to pee all of the time with a UTI even though there’s only a wee bit of wee in there?
The inflammatory edema in the bladder wall
stimulates discharge of stretch receptors, initiating symptoms of bladder fullness with small volumes of
urine and producing the urgency and frequency of urination associated with cystitis
In urinalysis, in order to diagnose an uncomplicated UTI we need to see _____ and/or ______ on the dip stick
Leukocytes, nitrites
Define acute pyelonephritis
is an infection of one or both upper urinary tracts (ureter, renal pelvis, and interstitium).
Common Causes of pyelonephritis (not the bacteria but the conditions that led to pyelo)
1) kidney stones
2) vesicoureteral reflux (chronic reflux of urine up the ureter and into kidney during micturition)
3) Pregnancy
4) Neurogenic bladder
5) Instrumentation (introduction of organisms into urethra and bladder by catheter or scope)
6) Female sex trauma
How does pregnancy make a person susceptible to pyelo?
- Causes dilation and relaxation of ureter with hydroureter and hydronephrosis
- Partly caused by obstruction from enlarged uterus and partly from ureteral relaxation caused by higher progesterone levels
Define hydroureter
Abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder.
(is it saying that this occurs in pregnancy due to obstruction from the enlarged uterus? Not sure)
What is hydronephrosis
Hydronephrosis is the swelling of a kidney due to a build-up of urine
What 3 organisms are most commonly associated with pyelo?
E. coli, Proteus, or Pseudomonas
** The latter two microorganisms are more commonly associated with infections after urethral instrumentation or urinary tract surgery
Is urine acidic or alkaline?
Acidic
Why is a person with infection of E.Coli, Proteus, or Pseudomonas in their urinary tract more likely to form stones?
These microorganisms also split urea into ammonia, making alkaline urine that increases the risk for stone formation
T/F the only way a person gets pyelo is by uropathic organisms travelling up along the ureters
False - dissemination can also occur via bloodstream
T/F acute pyelonephritis commonly causes kidney failure
False - it rarely does
Patho of pyelo
1) Microorganisms get into kidneys (via urine or bloodstream)
2) Inflammation usually focal and irregular, primarily affecting pelvis, calyces, and medulla
3) WBCs invade medulla –> renal inflammation, renal edema, and purulent urine
4) If severe, localized abscesses form in medulla & cortex
5) Can cause necrosis of renal papillae
6) After acute phase, have healing with fibrosis & atrophy of affected tubules
In pyelonephritis, the _______ is usually most affected and the _______ is spared
(choose from: glomeruli and tubules)
**Tubules usually affected, glomeruli usually spared
S&S of acute pyelonephritis
Acute onset fever, chills, flank or groin pain
UTI symptoms (frequency, dysuria, costovertebral tenderness) may precede systemic symptoms
How do older adults present with pyelo?
Older adults may have nonspecific symptoms, such as low-grade fever
and malaise
Dx of pyelonephritis
- Differentiating symptoms of cystitis from those of pyelonephritis by clinical assessment alone is difficult.
- The specific diagnosis is established by urine culture, urinalysis, and clinical signs and symptoms.
- White blood cell casts indicate pyelonephritis, but they are not always present in the urine.
- Complicated pyelonephritis requires blood cultures and urinary tract imaging.
Tx of uncomplicated pyelo? What would make a patient susceptible to re-infection and antibiotic resistant organisms?
Uncomplicated acute pyelonephritis
responds well to 2 to 3 weeks of microorganism-specific antibiotic therapy
Follow-up urine cultures are
obtained at 1 and 4 weeks after treatment if symptoms recur.
Antibiotic-resistant microorganisms or re-infection may occur in cases of urinary tract obstruction or reflux. Intravenous pyelography and voiding
cystourethrography identify surgically correctable lesions.
What is chronic pyelonephritis? What do we know about the cause of it?
= a persistent or recurrent infection of the kidney leading to scarring of one or both kidneys.
The specific cause of chronic pyelonephritis is difficult to determine. Recurrent infections from acute pyelonephritis may be associated with chronic pyelonephritis. Generally, chronic pyelonephritis is more likely to occur in individuals who have renal infections associated with some type
of obstructive pathological condition, such as renal stones and vesicoureteral reflux.
Outline how chronic urinary tract obstruction leads to CKD
prevents eliminiation of bacteria –> Progressive inflammation, alterations in renal pelvis and calyces, destruction of tubules, atrophy or dilation and diffuse scarring & impaired urine-concentrating ability –> leads to CKD
S&S of chronic pyelo?
The early symptoms of chronic pyelonephritis are often minimal and may include hypertension, frequency, dysuria, and flank pain.
Progression can lead to kidney failure, particularly in the presence of
obstructive uropathy or diabetes mellitus.
Diagnostics for chronic pyelo
Urinalysis, intravenous pyelography, and ultrasound are used diagnostically. Treatment is related to the underlying cause. Obstruction must be relieved
What demographic most often gets bladder cancer? (sex and age)
men older than 60 years
What is the most common type of bladder cancer? Are tumors typically superficial or deep?
Transitional cell (urothelial) carcinoma is the most common bladder malignancy, and tumours are usually superficial
(More advanced tumours are muscle invasive)
Risk factors for bladder CA
- smoking
- exposed to metabolites of aniline dyes
- high levels of arsenic in drinking water
- heavy consumption of phenacetin (pain/fever med that was discontinued in 1970s)
- have uroepithelial schistosomiasis infection (is a parasite that apparently is 2nd only to malaria in its impact worldwide!)
Where does bladder CA most commonly metastasize to?
lymph nodes, liver, bones, or lungs.
What is secondary bladder cancer
develops by invasion of cancer from bordering
organs, such as cervical carcinoma in women or prostatic carcinoma in men.
________ is the archetypal clinical manifestation of bladder cancer.
Gross painless hematuria
Other S&S for bladder CA?
- Episodes of hematuria tend to recur
- often accompanied by bothersome lower urinary tract symptoms including daytime voiding frequency, nocturia, urgency, and urge urinary incontinence (particularly for carcinoma in situ)
- Flank pain may occur if tumour growth obstructs one or both ureterovesical junctions.
Dx of bladder CA
- Cystoscopy with tissue biopsy confirms the diagnosis of bladder cancer. - Urine cytological study (pathological analysis of sloughed cells within the urine) is used for screening high-risk individuals.
Tx of bladder CA
Transurethral resection or laser ablation, combined with intravesical chemotherapy or biological therapy,
is effective for superficial tumours. Radical cystectomy with urinary diversion and adjuvant
chemotherapy is required for locally invasive tumours.
What is urethritis?
Urethritis is an inflammatory process that is usually, but not always, caused by a sexually transmitted microorganism.
Most likely causes of urethritis. How do we classify causes that are due to or not due to gonorrhea?
Infectious urethritis caused by Neisseria gonorrhoeae is often called gonococcal urethritis (GU); urethritis caused by other microorganisms is called nongonococcal urethritis (NGU).
Nonsexual origins of urethritis include inflammation or infection as a result of urological procedures, insertion of foreign bodies into the urethra, anatomical abnormalities, or trauma.
Non infectious urethritis is rare but does happen. What causes this?
Associated with the ingestion of wood or ethyl alcohol or turpentine. It is also seen with reactive arthritis
S&S or urethritis?
- urethral tingling or itching or a burning sensation
- frequency and urgency with urination
- may note a purulent or clear mucouslike discharge from the
urethra.
Dx of urethritis?
Nucleic acid detection amplification tests (NAAT) allow early detection of N. gonorrhoeae and Chlamydiatrachomatis in urine studies.
Tx of urethritis?
Treatment consists of appropriate antibiotic therapy for infectious urethritis and avoidance of future exposure or mechanical irritation.
True or false: Gonorrhea is the second more common reportable STI in Canada.
True. Chlamydia is first. Syphillis and HIV are other reportable STIs.
True or false: Gonorrhea cases continue to increase
True
Name risk factors for gonorrhea
Risk factors: sexual contact with new partner without barrier protection, sexual contact with someone who has gonorrhea, sexually active <25y, being born to person with gonorrhea, MSM, exchange of sex for money or drugs, street involvement, substance use
What is the incubation period for gonorrhea?
Usually 2-7 days. Can be 1-14
Stacey was diagnosed with gonorrhea and took all her antibiotic treatment as prescribed. She states she is glad that she will never have to deal with this again! What do you say to this statement?
Re- infection rates are high and regular testing is encouraged. Can teach about risk factors and how to decrease risk of infection.
True or false: Gonorrhea is viral in nature
False. Caused by bacteria Neisseria gonorrhea
How is gonorrhea transmitted?
Through contact with exudate from mucous membranes of person with gonorrhea. Passed through sexual contact (vaginal, oral, anal). Bacteria can be found in body fluids including semen, pre-ejaculate, vaginal, and anal fluids.
Where can gonorrhea infection occur?
Penis or external genitals, vagina or internal genitals, anus, pharynx, and eye
How does Neisseria gonorrhea actually infect?
Bacterial attaches to epithelial cells and invades; can also attach to sperm, leading to tranmissino from males to uninfected sexual partners. Results in localized infection at site of innoculation.
What are the symptoms of gonorrhea?
Often asymptomatic (Screening is critical for case finding) but can include
* Penis/ external genitals: abnormal discharge, painful or itchy sensation, dysuria or difficult urination, pain or mild swelling in testicles
* Vagina/ internal genitals: abnormal discharge, abnormal bleeding (after intercourse or between menstrual periods), lower abdominal pain, pelvic pain, pain during sex. Infection of Bartholin’s glands can lead to labial swelling, abscess formation, and pain.
* Anus: abnormal discharge, generalized pain
* Throat: rare to have symptoms, may have sore throat
* Eye: swelling or abnormal discharge (acute redness, purulent discharge and crusting, conjunctivitis)
Complications of untreated gonorrhea include
PID, increase risk of co-infection with other STIs (including HIV), PID, epididymitis, infertility, ectopic pregnancy, chronic pelvic pain, reactive arthritis, disseminated infection
Who is screening for gonorrhea recommended for?
for asymptomatic sexually active people under 25y, all pregnant people, neonates born to mothers with gonorrhea, and other people with risk factors for STI and blood borne infections *critical for case finding as infection is frequently asympomatic
What is used to confirm clinical suspicion of gonorrhea?
Swabs (NAAT/ nucleic acid ampligication test- high specificity) (C&S)
-vaginal, cervical, urethral, conjunctival
First catch urine
True or false: in order to collect the best possible swab to test for gonorrhea, the swab must be inserted at least 0.5 inches into the urethra
False false false false. Do not insert the swab into the urethra, collect swab from discharge of meatus.
Describe the treatment of gonorrhea
-Administer on initial visit based on historical factors/ clinical exam suspicion after collecting swabs (do not wait for test results)
-Combination therapy abx (i.e., cefixime and azithro or ceftriaxone and azithro)- due to high potential for antibiotic resistance and co-infection with chalmydia (treatment covers both infections)
You have diagnosed a patient with gonorrhea, collected the appropriate swabs, and administered appropriate antibiotic treatment. What discharge teaching should you provide before they go?
-Do not have sex (even with a condom) for 7 days after start of treatment
-All sexual partners in the last 2 months should be tested and treated for gonorrhea (or, if no sexual contact in last 2 months, follow up should occur for last sexual contact)
-Use of condoms decreases chances of getting/ transmitting gonorrhea
-Regular testing encouraged
What is pelvic inflammatory disease?
Acute inflammatory process caused by infection of female reproductive organs
Risk factors for PIC?
Infection by a previous STI that was not treated (delaying treatment increases complications from PID); having multiple sex partners or a sex partner who has had multiple sex partners or a previous PID; being sexually active at age 25 or younger; using douches; and using an IUD for birth control.
-Other causes of infection include spontaneous or induced abortions, normal or abnormal deliveries (called puerperal infections), or other surgical procedures; these infections are often polymicrobial.
True or false: PID only involves the fallopian tubes and ovaries
False! May involve any organ, or combination of organs, in the upper genital tract: uterus, fallopian tubes, or ovaries
True or false: normal vaginal flora can contribute to PID
Kind of true-
Many infectious disorders that affect the vulva and vagina are sexually transmitted, such as chlamydia and gonorrhoea that migrate from the vagina to the uterus, fallopian tubes, and ovaries.
However, microorganisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also are implicated with PID. The anerobic bacteria can increase risk for PID through altering pH and integrity of mucous blocking the cervical canal.
Additionally, cytomegalovirus (CMV), Mycoplasma hominis, Ureaplasma urealyticum, and Mycoplasma genitalium may be associated with PID.
Describe the pathophysiology of PID
Pathological microbes ascend from infected cervix to affect the uterus and adeneaxe (uterine appendages). Initial infection usually involves endocervical mucosa, but can start in the Bartholins glands or other flands.
It then moves up to the fallopian tubes and ovarian region.
Main infectious causes of PID?
Chlamydia and gonorrhea
S&S of PID?
Variable and vague.
Asymptomatic to sudden, severe abdo pain with fever.
Usually, the first symptom is gradual onset low bilat abdo pain. Symptoms are more likely to develop during or immediately after menstruation and worse with movement or intercourse.
Other symptoms include dysruia and irregular bleeding
Diagnosis of PID
Vague symptoms make it difficult. Consider in sexually active person with female reproductive organs if they have abdominal or pelvic tenderness and one of the following: cervical motion tenderness, uterine tenderness, or adnexal tenderness.
Minimum Criteria (One or More Needed for Diagnosis)
* Cervical motion tenderness, or
* Uterine tenderness, or
* Adnexal tenderness
Additional Criteria That Increase Specificity of Diagnosis
* Body temperature >38.3°C (>101°F)
* Mucopurulent cervical or vaginal discharge
* Numerous white blood cells on saline wet prep
* Elevated C-reactive protein
* Elevated erythrocyte sedimentation rate
* Documented infection with Chlamydia trachomatis or Neisseria gonorrhoeae
Definitive Criteria (Not Needed for Treatment)
* Transvaginal ultrasound, magnetic resonance imaging, or
* Doppler studies showing thickened and fluid-filled tubes
* Laparoscopic visualization of PID-related abnormalities
What is the causative organism in Trichomonas? What type of organism is it?
Trichomonas vaginalis (anaerobic flagellated protozoan)= extracellular parasite
True or false – males and females are equally affected by Trichomonas?
False – females affected more often than males
Females can acquire the disease from both females and males, while males typically acquire the infection from females and do not usually transmit the infection to other males
How does a person get Trichomonas? Outline the patho
Trichomoniasis is virtually always sexually transmitted
Localized infection where the organism attaches to the squamous epithelium of the vaginal and urethral mucosa and to Bartholin glands, causing inflammation and itching of mucosa
Signs and symptoms of Trichomonas. Do they differ in men and women?
Active infection (for women): purulent, malodorous, thin vaginal discharge associated with burning, pruritus, dysuria, frequency, lower abdominal pain, dyspareunia
Men are usually asymptomatic, occasionally report mild urethritis
What should be done for diagnostic testing for Trichomonas?
Preferred diagnostic tests include nucleic acid amplification tests (NAATs) can be used for all patients or used selectively, such as for those with concerning symptoms and/or vaginal discharge but negative microscopy results.
Testing of vaginal pH and wet mount microscopy. Only performed on vaginal discharge and is not applicable to urethral or anal specimens.
True or false, only symptomatic individuals need treatment for Trichomonas
True or false, only symptomatic individuals need treatment for Trichomonas
What is the treatment for Trichomonas?
PO Metronidazole (Flagyl)
What is the most common cause of scrotal swelling?
Hydrocele
What is a hydrocele?
A collection of fluid between the layers of the tunica vaginalis in the scrotum
What are the two types of Hydrocele?
Communicating (fluid collection = peritoneal fluid)
Non-communicating (fluid comes from mesothelial lining of tunica vaginalis)
Who most often gets communicating hydrocele?
Occurs in male newborns (6%)
Due to failure of processus vaginalis closure during development
Malformation often resolves spontaneously in first year of life
What are causes of non-communicating hydrocele?
Idiopathic or due to infections (Epididymitis, orchitis)
Can also be caused by trauma, torsion or scrotal surgery
Major cause worldwide: filariasis (tropical disease, roundworms that cause impaired lymphatic drainage) *check for travel to tropical countries
True or False – Hydrocele is not associated with infertility
True
A man presents with hydrocele in his third or fourth decade of life – what should he be evaluated for?
Testicular Cancer
What are signs and symptoms of hydrocele?
Tense, smooth scrotal mass that transilluminates easily
Is Chlamydia viral or bacterial? What is the name of the microorganism?
Bacterial, caused by Chlamydia trachomatis (CT)
T/F Chlamydia is usually asymptomatic
True
90% of women asymptomatic
70% of men asymptomatic
If symptomatic, S&S of chlamydia
(will present very similar to Gonorrhea)
- conjunctivitis
- sore throat (throat infection is most often asymptomatic)
- urethral symptoms such as, discharge, itch or awareness
- painful (dysuria) or difficult urination
- testicular pain and/or swelling (symptoms of epididymitis)
- abnormal change in vaginal discharge
- abnormal vaginal bleeding: after intercourse or between menstrual period
- lower abdominal pain (PID)
- dyspareunia
- inflammation of the rectum, rectal pain and anal discharge (symptoms of proctitis)
When testing for chlamydia & gonorrohea, what body parts should you be swabbing?
Anywhere that you have sex:
vagina, anus, throat
