Incontinence, Cystitis, Pyelonephritis - GU Flashcards
Incontinence
-Involuntary loss of urine
Types
-Stress – cough, sneeze, exertion: Intra-abdominal pressure greater than sphincter control, no bladder contraction
-Urge – urgency and leakage: detrusor overactivity, bladder contraction
-Mixed – mix of stress and urge
-“Overflow” – Incomplete emptying: Vague term, preferable – name symptoms, Obstruction, detrusor underactivity, impaired contractility
-Overactive Bladder – overactive destrusor activity; frequency; nocturia; without other disorder – w/ or w/0 incontinence
-Other: continuous, nocturnal enuresis, intermittent stream
-“Functional” – not due to lower urinary tract dysfunction
- Mostly seen in women; if in men, consider prostate issue, blockage, nerve damage, etc
- Continence involves cognition, manual dexterity, environmental factors, etc
Incontinence - etiology
Stress: anatomic issue
-Childbirth - parity, NSVD, episiotomy
-Damage to pudendal and pelvic nerve
Urge: neurogenic or myogenic source causing error in normal voiding process
-Hold urine: relaxed bladder, constricted sphincters
-Urinate: contract bladder, relax sphincters
Any
-Stroke, obesity, chronic constipation, neurological damage (Parkinson’s)
Incontinence Dx
History
-Dysuria, trouble starting or stopping urine flow, straining to urinate, nocturia, urinating >1 to empty bladder
-Sudden onset – neurological or neoplasm, need w/u, +/- specialist
-Precipitants – caffeine, EtOH, laughing, putting hands in water
-Bowel and sexual function
-Medications – diuretics, antihistamines, antidepressants, CCBs
-Have patient complete bladder diary if symptoms, frequency, amount, etc are unclear. Helpful for the “over-waterer”.
Physical
-Abdomen and back exam – masses, CVAT, abdominal pain
-Rectal exam – check rectal tone, sensation; rectal mass
-Pelvic exam – urine in vagina: fistula, inflamed urethra, pale mucosa: decreased estrogen, cystocele
-Check for leakage – cough and valsalva while supine or sitting over urine hat
Incontinence labs
Post void volume:
- Catheterization
- Ultrasound
Urinalysis
- Glucosuria
- Cystitis
Refer to urologist for urodynamic studies
Incontinence - Tx
Lifestyle Modifications
-Limit water, caffeine, alcohol, carbonation, nighttime fluids
-Lose weight – stress incontinence
-Bladder training – mild/mod urge, Void q2h, To decrease urgency, follow training instructions on next page
-Kegel – urge, stress, mixed
Medications
-Anticholinergics with antimuscarinic effects: Increase bladder capacity, decrease urgency
-Give medications 4 weeks to work before increasing dose
-Side effects: Drying – dry mouth, constipation, dry eyes, Contraindicated – dementia patients, glaucoma, gastric retention
Stress Incontinence
-Pseudoephedrine 15-50 mg PO tid
-Surgery – Retropubic suspension – suspend and stabilize urethra; less adverse events, Sling – most successful, more adverse events - UTIs
Urge Incontinence
-Oxybutynin 2.5-5mg PO bid-tid; 5mg ER qd and titrate up (Ditropan)
-Tolterodine 1-2 mg PO bid (Detrol)
-Neuromodulation – percutaneously decrease detrusor activity
-OnabotulinumtoxinA – inject toxin into bladder wall
Follow-up/Complications
-Biggest difficulty – no cure, or solutions not 100% effective
-Biggest complication – 2/2 surgery
UTI vs Cystitis
UTI – urinary tract infection
-Can be an infection anywhere from the urethra, through the bladder, up to the kidneys
-Used in the field to mean cystitis – but don’t get caught doing this with your attending!
Cystitis
-Infection of the bladder
Pyelonephritis
-Infection of the kidneys
Cystitis
- Infection of the bladder
- Young, sexually active females
- Complicated: male, pregnant, Foley, recurrent UTIs, abnormal bladder anatomy, recent procedure to bladder, failed abx course, hx of resistant bacteria, DM, immunocompromised
- Uncomplicated: none of the above
- Causes: E. coli in 80%, Staphylococcus saprophyticus, Klebsiella pneumoniae, Pseudomonas, Enterococcus, Enterobacter, GBS
- Sex, contamination from GI tract, cystoscopy, catheterization
Cystitis - Dx
History -Dysuria, urgency, frequency -Screen for vaginal symptoms -Red Flags: fever, back/flank pain, nausea/vomiting, hematuria, abd pain, previous ssx AFTER abx treatment Physical -Suprapubic tenderness \+/- CVAT - pyelonephritis -Abdominal pain, fever, chills -Consider pelvic and wet mount
Cystitis - Labs
Urinalysis
-Dip UA, micro UA
+ Hematuria and nitrites diagnostic for UTI
-Pyuria - +leukocyte esterase on dipstick indicates +WBCs
-Casts indicate pyelonephritis
Urine Culture
-Indicated if positive UA, or if recurrent UTIs
-Will identify causative organism – in about 3 days
Hcg
-Consider if there is any possibility of pregnancy
-If any of the red flags, or other characteristics that would make the case complicated, must do a UA/UC
Cystitis - Tx
-Can consider treating without UA or a visit
-1999 Cleveland Clinic Journal of Medicine – uncomplicated UTIs can be treated over the phone
1st Line - Uncomplicated
-TMP/SMX 160/800 mg PO bid x 3 d
-Nitrofurantoin 100 mg PO bid x 5 d
-Some discussion on efficacy of TMP/SMX, if your area shows high resistance, use alternative: Ciprofloxacin 250 mg PO bid x 3 d, Pregnancy: Nitrofurantoin 100 mg PO bid x 7 d
1st Line – Complicated
-Levofloxacin 250 mg PO qd x 7-14 d
-Ciprofloxacin 250 mg PO bid x 7-14 d
Symptomatic relief
-Phenazopyridine 200 mg PO tid x 2 d prn (OTC – Azo)
Cystitis - Follow-up/Complications
-If complicated UTI – consider post-treatment UA
Chronic or recurrent UTI
-TMP/SMX 50 mg qd or post-coitally
-Cranberry – high doses from pills/capsules show 20-30% decrease in UTI rates (no evidence juice is effective)
-Patient-initiated treatment: Trustworthy patients with recurrent UTIs, Unable to come into clinic, Set up time to reassess, don’t overlook new ssx
Prevention
-Push fluids, urinate post-coitally, avoid spermicide when appropriate
Pyelonephritis
Etiology
- Infection of the kidney
- Cystitis that spreads up into kidney or hematogenously
- Obstruction
- Anatomical anomaly of kidneys/ureters
Pyelonephritis - dx
History -Urinary symptoms -Urgency -Frequency -Dysuria PLUS other symptoms -Fever, chills -Flank pain -Nausea/vomiting Physical -Fever -Tachycardia \+ CVAT Labs -UA – pyuria, bacteriuria, hematuria, +casts – renal origin -CBC
Pyelonephritis - tx
-Consider hospitalization in extreme cases: unable to keep in fluids, high fever, high WBC, vomiting/dehydration, sepsis
Antibiotics
-Ciprofloxacin 500 mg PO bid x 7-14 d
-Cefixime 400 mg PO qd x 14 d
-IV: Ceftriaxone 1 gIV qd
-Adjust as needed after culture returns with sensitivity results
Follow-up/Complications
-Symptoms should resolve within 48 hours of starting antibiotics, if no resolution, f/u in clinic, repeat UA
-If left untreated, can cause kidney damage and renal failure
