ICL 5.4: Ureter and Bladder Cases

Question 1

cystitis symptoms?

Answer 1

1. frequency
2. dysuria
3. uregency
4. suprapubic pain
5. hematuria
6. turbid, malodorous urine

Question 2

pyelonephritis symptoms?

Answer 2

1. costovertebral angle pain or tenderness
2. fever

3 chills

4. cystitis symptoms but might be be absent

Question 3

what is the differentia diagnosis of cystitis?

Answer 3

1. urethritis

usually caused by STDs but they’ll have discomfort that’s constant, worsened by urination, chalmydia, gonorrhea, trichomoniasis, HSV

2. vaginitis

dyspareunia, discharge, odor, pururitis caused by candida, trichomonas, bacterial vaginosis

3. PID

Question 4

which bacteria causes UTIs most often?

Answer 4

1. e. coli
2. Klebsiella
3. Proteas

Question 5

which bacteria can cause hematogenous UTIs?

Answer 5

1. s. aureus

2. candida

Question 6

when would you get a culture for a UTI vs. when wouldn’t you?

Answer 6

don’t send a culture and just treat it empirically if it’s uncomplicated cystitis

send a culture if:
1. complicated cystitis

2. in no réponse to empiric treatment
3. recurrent UTI
4. pyelonephritis
5. sepsis

Question 7

what is the genetic preidpsoition for UTIs?

Answer 7

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

Question 8

what are the risk factors for UTIs?

Answer 8

1. genetic predisposition
2. intercourse
3. spermicide use
4. pregnancy

for postmenopausal women, the most important risk factor is having a UTI at younger age

Question 9

when do men usually get UTIs?

Answer 9

urethra compression usually by prostate hyperplasia when they’re old

Question 10

what are the predisposing factors to UTI?

Answer 10

1. lack of circumcision (neonates, young men)
2. urinary retention / obstruction, neurogenic bladder, incomplete bladder emptying
3. instrumentation and catheterization (biofilm formation on indwelling catheters)**
4. renal transplantation
5. uncontrolled diabetes, sodium-glucose cotransporter 2 inhibitors use (canagliflozin)
6. advanced age – prostate enlargement in men and vaginal atrophy in postmenopausal women (loss of vaginal lactobacilli); bladder prolapse

Question 11

what is urinalysis?

Answer 11

dipstick leukocyte esterase test is a rapid cheap screening test

1. urine microscopic exam for identifying pyuria: >5-10 WBC/hpf in sediment of centrifuged urine (2000 rpm X 5 minutes)
2. microscopic hematuria present also with renal calculi, tumor, vasculitis, glomerulonephritis
3. nitrite
4. 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)

Question 12

how do you treat asymptomatic bacteriuria?

Answer 12

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

Question 13

why don’t you treat asymptomatic bacteriuria?

Answer 13

treatment of ASB doesn’t prevent UTIs

also antibiotics have lots of undesirable effects

Question 14

what happens if you treat asymptomatic bacteriuria?

Answer 14

the patients treated with antibiotics had more recurrent UTIs!

Question 15

who should be treated for asymptomatic bacteria?

Answer 15

1. prior to urologic procedures
2. pregnancy

results in lower incidence of pyelonephritis and reduction in low birth weight

3. question benefit within 1 month of renal transplant but none afterwards

Question 16

how do you treat uncomplicated cystitis?

Answer 16

1. nitrofurantoin for 5 days
2. trimethoprim/sulfamethoxazole for 3 days
3. fosfomycin single dose
4. floroquinolones for 3 days for people who ‘cant tolerate other drugs
5. B-lactams for 7 days

don’t do pre or post cultures unless symptoms’ dont resolve

Question 17

how do you treat pyeloneprhtisi?

Answer 17

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

2. TMP/SMX only if organism is known to be susceptible
3. oral beta-lactams are less effective than the above
4. minoglycosides (can be given IM as first dose before culture is back)
5. IM/ IV cephalosporins, IV piperacillin/tazobactam (inpatient)

Question 18

what are renal abscess?

Answer 18

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

Question 19

how do you treat renal abscess?

Answer 19

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

Question 20

what is acute bacterial prostatitis?

Answer 20

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

Question 21

what do crumbs at the bottom of a foley bag indicate?

Answer 21

1. 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

2. any child < 5 or any male child >5 with a UTI needs an evaluation of the GU tract for structural abnormalities
3. fungus (Candida) in the bladder is often due to colonization but may represent true infection in certain subsets (eg – uncontrolled Diabetics)
4. pneumaturia and polymicrobial cultures – suspect fistula (radiation, pelvic surgery)
5. proteus: splits urea and raises urine pH
   can promote struvite (magnesium ammonium phosphate) stones
6. staghorn calculi - type of stone (often struvite, cystine, or uric acid) which fills the renal pelvis
   can serve as a nidus for chronic infections