ICL 5.4: Ureter and Bladder Cases Flashcards
cystitis symptoms?
- frequency
- dysuria
- uregency
- suprapubic pain
- hematuria
- turbid, malodorous urine
pyelonephritis symptoms?
- costovertebral angle pain or tenderness
- fever
3 chills
- cystitis symptoms but might be be absent
what is the differentia diagnosis of cystitis?
- urethritis
usually caused by STDs but they’ll have discomfort that’s constant, worsened by urination, chalmydia, gonorrhea, trichomoniasis, HSV
- vaginitis
dyspareunia, discharge, odor, pururitis caused by candida, trichomonas, bacterial vaginosis
- PID
which bacteria causes UTIs most often?
- e. coli
- Klebsiella
- Proteas
which bacteria can cause hematogenous UTIs?
- s. aureus
2. candida
when would you get a culture for a UTI vs. when wouldn’t you?
don’t send a culture and just treat it empirically if it’s uncomplicated cystitis
send a culture if:
1. complicated cystitis
- in no réponse to empiric treatment
- recurrent UTI
- pyelonephritis
- sepsis
what is the genetic preidpsoition for UTIs?
women who are first degree relatives of women with recurrent UTIs are more likely to have recurrent UTIs
nonsecretors for ABH blood group antigen – stronger adhesion to vaginal epithelium
what are the risk factors for UTIs?
- genetic predisposition
- intercourse
- spermicide use
- pregnancy
for postmenopausal women, the most important risk factor is having a UTI at younger age
when do men usually get UTIs?
urethra compression usually by prostate hyperplasia when they’re old
what are the predisposing factors to UTI?
- lack of circumcision (neonates, young men)
- urinary retention / obstruction, neurogenic bladder, incomplete bladder emptying
- instrumentation and catheterization (biofilm formation on indwelling catheters)**
- renal transplantation
- uncontrolled diabetes, sodium-glucose cotransporter 2 inhibitors use (canagliflozin)
- advanced age – prostate enlargement in men and vaginal atrophy in postmenopausal women (loss of vaginal lactobacilli); bladder prolapse
what is urinalysis?
dipstick leukocyte esterase test is a rapid cheap screening test
- urine microscopic exam for identifying pyuria: >5-10 WBC/hpf in sediment of centrifuged urine (2000 rpm X 5 minutes)
- microscopic hematuria present also with renal calculi, tumor, vasculitis, glomerulonephritis
- nitrite
- an abnormal UA does not imply infection ! (patients with asymptomatic bacteriuria may have pyuria)
lack of epithelial cells (presence of epithelial cells is suggestive of contamination)
how do you treat asymptomatic bacteriuria?
whether true or due to poor collection practices, it reflects colonization not infection
it’s a positive culture in the absence of infection
p to 50% of elderly from long term facilities have ASB
<1% of children
up to 10% of pregnant women
women>men
why don’t you treat asymptomatic bacteriuria?
treatment of ASB doesn’t prevent UTIs
also antibiotics have lots of undesirable effects
what happens if you treat asymptomatic bacteriuria?
the patients treated with antibiotics had more recurrent UTIs!
who should be treated for asymptomatic bacteria?
- prior to urologic procedures
- pregnancy
results in lower incidence of pyelonephritis and reduction in low birth weight
- question benefit within 1 month of renal transplant but none afterwards
how do you treat uncomplicated cystitis?
- nitrofurantoin for 5 days
- trimethoprim/sulfamethoxazole for 3 days
- fosfomycin single dose
- floroquinolones for 3 days for people who ‘cant tolerate other drugs
- B-lactams for 7 days
don’t do pre or post cultures unless symptoms’ dont resolve
how do you treat pyeloneprhtisi?
longer treatment; 7-14 days
avoid nitrofurantoin and fosfomycin
antibiotic choice and route depends on previous exposure, local flora, presence of catheter, comorbidities and eventually on culture results; overall, a matter of clinical judgement
pyelonephritis treatment options include:
1. fluoroquinolones
- TMP/SMX only if organism is known to be susceptible
- oral beta-lactams are less effective than the above
- minoglycosides (can be given IM as first dose before culture is back)
- IM/ IV cephalosporins, IV piperacillin/tazobactam (inpatient)
what are renal abscess?
rare complication of upper UTI
usually occurs in patients with DM, abnormal urinary tract or with hematogenous route of infection
present with fever, chills, flank pain but onset and presentation can be insidious
CT or US to diagnose
you should suspect this if a patient isn’t responding in 48-72 hours to antibiotics
how do you treat renal abscess?
usually caused by E. coli or S. aureus
trx is direct against gram negatives and S. aureus so use extended spectrum b-lactams, ahminoglycosides and anti-staph pencilling or cephalosporin
surgical or percutaneous drainage usually needed
what is acute bacterial prostatitis?
usually see abrupt onset of fever, chills, low back/perineal pain with dysuria, frequency, urgency
avoid vigorous rectal exam (may induce bacteremia)
obtain urinalysis for bacteriuria/pyuria and urine culture to identify the organism
rule out STDs – GC/chlamydia PCR
treatment: TMP/SMX or quinolone for at least 14 days
failure to treat or ineffective treatments may lead to chronic bacterial prostatitis and prostate abscess
what do crumbs at the bottom of a foley bag indicate?
- renal tuberculosis
if someone who comes from an endemic area of TB and they have sterile pyuria but with symptoms of pyelonephritis, consider renal tuberculosis
- any child < 5 or any male child >5 with a UTI needs an evaluation of the GU tract for structural abnormalities
- fungus (Candida) in the bladder is often due to colonization but may represent true infection in certain subsets (eg – uncontrolled Diabetics)
- pneumaturia and polymicrobial cultures – suspect fistula (radiation, pelvic surgery)
- proteus: splits urea and raises urine pH
can promote struvite (magnesium ammonium phosphate) stones - staghorn calculi - type of stone (often struvite, cystine, or uric acid) which fills the renal pelvis
can serve as a nidus for chronic infections
