Hematuria, Dysuria, Nocturia Flashcards
Hematuria: Upper DDX
Renal CA Renal cysts Stones Glomerulonephritis UTI Pyelo
Hematuria: Lower DDX
Bladder CA Bladder stone Hemorrhagic cystitis due to cyclophosphamide BPH Prostate CA Urethritis Urethral trauma
Difference between uncomplicated and complicated UTI
Uncomplicated: cystitis or pyelo in nonpreg female, no nanatomic issues or urinary instrumentation
Complicated: all others (pregnancy, exposure to abx, BPH, renal failure, males, catheter, immuno)
What do some references include in their definition of complicated UTI
Pyelo!
Pathogenesis of UTI’s
Uropathogenic bacteria colonizing GI Tract, Perineum, or Vagina inoculate urethra and ASCEND into the bladder. The bacteria can evade the innate and adaptive immune systems.
What is the most common UTI pathofen for both uncomplicated and complicated UTI
UPEC!!! (E. Coli, a gram neg bacilli)
UTI presentation
- Irritative voiding sx (Dysuria, Frequency, Urgency)
- Suprapubic tenderness
- Hematura (gross or micro)
Pyelo presentation
-Irritative voiding sx
-Fever/chills/rigors
Unilateral flank pain
CVA tenderness
Fatigue
N/V, anorexia
Common presentation of UTI or pyelo in elderly?
AMS
UTI complications
- Sepsis/shock due to bacteremia
- AKI
- Perinephric abscess (seen w/ pyelo)
- Emphysematous pyelonephritis
- Papillary necrosis
Dysuria DDx
- Vaginitis
- Urethritis
- PID
- Cystitis
- Pyelo
- Prostatitis
- Epididymitis
- Interstitial cystitis
What’s interstitial cystitis?
Irritative voiding sx but no evidence of infxn
UTI dipstick findings
- Leukocyte esterase: a sign of pyuria (leukocytes in urine)
- Nitrites: sign of bacteria in urine
PRESENCE OF EITHER HAS 75% SENS. AND 82% SPEC. FOR UTI’S
What does a WBC cast on UA w/ microscopy suggest
Pyelo or AIN
What will a urine culture w/ sensitivities show if there is a trace UTI
> 10^3 CFU (colony forming units/mL)
When should you image a pt w/ a UTI. What do you order?
If they are acute and complicated and/or if you’re concerned for pyelo. Order a CT Abd/Pelvis w/ and w/o contrast
Pyelo findings on CT?
- Perinephric abscesses or stranding
- Ares of decreased contrast enhancement
- Emphysematous pyelonephritis
Uncomplicated UTI tx
- Nitrofurantoin
- Bactrim
- Fosfomycin
If pt cannot take the recommended antimicrobials?
Take second line abx:
- Fluoroquinolones OR
- B-lactams (avoid ampicillin or amoxicillin alone)
Complicated UTI tx
- Not hospitalized? Oral abx
- Hospitalized? IV abx: broad then narrow based on culture
4 classifications of prostatitis
- Acute Bacterial
- Chronic Bacterial: >3 mo
- Chronic pelvic pain syndrome: pain but no detectable infxn
- Asx: infxn but asx
How does bacteria move into the prostate?
Bacteria in the urethra will migrate via the prostatic ducts into the prostate gland
Most common bacteria of prostatitis?
E. coli, a gram negative bacilli
Acute bacterial prostatitis presentation
- Acutely ill
- Irritative voiding sx
- Obstructive sx
- Suprapubic or perineal pain
Chronic bacterial prostatits presentation
- Less acute illness
- Sx of recurrent UTIs
- Obstructive sx
- Suprapubic or perineal pain
- Pain w/ ejaculation or blood in semen
Acute prostatits dx
- Usually clinical
- DRE: tenderness
- UA and culture: +
- Test for gonorrhea and chlamydia in high-risk pt’s
CHronic prostatits dx
- DRE
- UA ad culture: usually not diagnostic
- Dx standard is prostatic massage
Abx for prostatitis
Fluoroquinalones ex. Cipro
Bactrim
Tx for 4-6 weeks!!!
Prostatitis complications
- Bacteremia and sepsis
- EPididymitis
- Prostatic abscess
- Chronic prostatiits
- Chronic pelvic pain
BPH is due to what cellular processes?
Increased total number of stromal and glandular epithelial cells within the prostate
LUTS is due to what?
Both bladder outlet (BOO) obstruction from BPH and detrusor muscle overactivity secondary to BOO
What are LUTS (lower urinary tract sx)
- Storage sx: frequency, urgency, nocturia, incontinence
- Voiding sx: slow, dribbling, intermittiency
How do BPH pt’s present?
Usually w/ storage sx
How can you diagnose BPH?
- Usuallu clinical (AUA sx index)
- DRE (enlarged contender prostate)
- UA
- BMP to ensure normal Cr
- PSA
- Post void residual US
MOA a-1 blockers for BPH tx
Block sympathetic adrenergic-receptor mediated contraction of prostatic smooth muscle cells and bladder neck. Results in 1-2 weeks.
MOA 5-a reductase inhibitors for BPH tx
Decrease conversion of testosterone to dihydrotestosterone to shrink the prostate. Results in 6- 12 mo.
MOA anticholinergic agents for BPH tx
Inhibits muscarinic receptors in detrusor to decrease contraction. Use in pt’s w/ an overactive bladder but a normal PVR.
MOA PDE 5 inhibitors for BPH tx
Inhibits PDE 5 to increase cAMP and cGMP leading to smooth muscle relaxation; anti=proliferative effects. Used in pt’s w/ ED and LUTS
Surgical tx of BPH
- TURP (transurethral resection of prostate; most common)
- Simple prostatectomy
BPH complications
- Acute urinary retention
- UTI’s
- Bladder stones
- Bladder diverticuli
- Acute or chronic renal failure from hydronephrosis; usually involves both kidneys
Nocturia DDX
- Urinary incontinence
- Diuretics
- BPH
- UTIs
- Primary polydipsia
- Polyuria
- Sleep apnea
What are most kidney stones made of?
Calcium oxolate. Next most common is mixed (calcium oxalate + calcium phsophate) then calcium phosphate
What can help inhibit stone formation?
Citrate
Sx of nephrolithiasis? What are they usually due to?
Usually from urinary obstruction.
- Intermittent severe flank pain rad. to groin
- Hematuria
- Gravel passage
- NV
Complications of nephrolithiasis
-Hydronephrosis
-AKI or CKD
0Recurrent UTI if stone becomes infected
Imaging for nephrolithiasis?
Non-con (the dye would obstruct the stone bc both show up white!) CT Abd/pelvis. AKA renal stone protocol.
If pregnant, do a renal and bladder US
Which stones are radiopaque vs. radiolucent
Radiopaque: calcium oxalate.phosphate and struvite
Radioluscent: uric acid and cystine
Medical therapy for nephrolithiasis
- Fluids
- Pain control
- Antiemetics
- Expulsive therapy to dilate ureter (alpha-blocker tamsulosin / ca channel blocker nifedipine)
