L18: Cystitis + Pyelonephritis Flashcards
Upper tract infections
Pyelonephritis
Lower tract infections (3)
- Cystitis
- Prostatitis
- Urethritis
in men aged 20-50, most UTIs are
Urethritis
Prostatitis
In women aged 20-50, most UTIs are
cystitis
pyelonephritis
how do 95% of UTIs occur
ascending bacterial infection
remaining are hematogenous
Causes of most UTIs
E coli
UTI risk factors: reduced urine flow
- Urine outflow obstruction
- inadequate fluid intake
- neurogenic bladder
UTI risk factors: promote colonization
- sex
- spermicide
- recent abx
UTI risk factors: facilitate ascent
- Catheters
- Urinary incontinence
- Fecal incontinence
Acute complicated UTI
acute UTI + extension of infection beyond the bladder
what symptoms might suggest a UTI is complicated?
Fever > 99.9 Chills, rigor, fatigue/malaise Flank pain CVA tenderness Pelvic or perineal pain (men)
who is more at risk for complicated UTI
Pregnant women Men Comorbidities Immunocompromised Urologic abnormalities
Irritative voiding symptoms of acute cystitis
*** Dysuria Urinary frequency Urinary urgency ***
+/- hematuria, suprapubic discomfort
Physical exam of acute simple cystitis
TYPICALLY NORMAL
Women +/- suprapubic tenderness
Urine dipstick acute simple cystitis
+ Leukocyte esterase and nitrites
Urine microscopy acute simple cystitis
Pyuria: >10 leukoctyes/micrL
Bacteriuria
When to do a urine culture for acute simple cystitis
Atypical presentation Diagnosis uncertain Suspect complicated Sx do not resolve/recur Suspect abx resistance Special populations
Diagnostic urine culture for UTI
> 1000 CFU
Diagnostic urine culture in women with typical UTI sx
> 100 CFU
Symptomatic relief for UTI
Phenazopyridine (pyridium)
2 days
When to avoid TMP-SMX for acute simple cystitis
more than 20% of local e coli are resistant
When to avoid nitrofurantoin and fosfomycin
early pyelonephritis
due to low renal concentrations
3 primary therapies for acute simple cystitis
- Nitrofurantoin 100 mg po BID 5 days
- TMP-SMX 160/800 mg po BID 3 days
- Fosfomycin 3 g PO single dose
- men: 7 days
- comorbidies, immunocompromised, urologic abnormalities: 1-2 weeks
Alternative therapies for acute simple cystitis
Beta-lactams (augmentin, cefdinir)
Fluoroquinolones (ciprofloxacin, levaquin)
When can nitrofurantoin and TMP-SMX be used in pregnant women
“use/avoidance based on trimester”
Options for pregnant women
Augmentent
Cephalexin
Cefpodoxime
Fosfomycin
DON’T give to pregnant women
Fluoroquinolones (ciprofloxacin, levaquin)
**
who needs follow up cultures in acute simple cystitis or pyelonephritis
pregnant women
symptoms do not resolve on abx
pyelonephritis cause
ascent of bacteria up ureters from bladder to the kidneys
Symptoms of pyelonephritis
UTI symptoms Flank pain Fever, chills, malaise GI: N/V/A, abdominal pain Fever CVA tenderness
what differentiates pyelonephritis from UTI on UA?
same findings except pyelonephritis has white blood cells casts
Positive urine culture for pyelonephritis
> 10^5 CFU/ml (100,000)
when is a CBC and BMP necessary for acute pyelonephritis
hospitalized patients
CBC of pyelonephritis
leukocytosis with left shift
BMP of pyelonephritis
assess renal function, hydration, lytes
when to do imaging for acute pyelonephritis
Severely ill
symptoms 48-72 hours after abx
suspect obstruction
recurrence
image of choice for pyelonephritis
CT A/P with and without contrast
other: US, MRI if contrast/radiation undesirable
mild-moderate outpatient pyelonephritis tx
Fluoroquinolones:
Ciprofloxacin 500 mg PO BID x 5-7 days
Ciprofloxacin ER 1000 mg PO once daily x5-7 days
Levofloxacin 750 mg PO once daily x 5-7 days
Acute pyelonephritis: Mild/Moderate, outpatient, fluoroquinolone-resistant E coli: tx
Initial IV/IM dose of Ceftriaxone 1gm + fluoroquinolone therapy
Acute pyelonephritis: Mild/Moderate, outpatient: uropathogen known to be TMP-SMX susceptible
TMP-SMX 160/800 mg PO BID x 7-10 days
what must an outpatient pyelonephritis case do
MUST FOLLOW UP IN 24-48 HOURS
***to check abx susceptibility studies and
who to hospitalize for pyelonephritis
Critically ill/hemodynamic instability
Fever >103 F
Persistent pain/marked debility
Suspected or documented urinary tract obstruction
Metabolic derangements (renal dysfunction)
Unable to take liquids by mouth
Concerns with follow up compliance as outpatient
Acute pyelonephritis: complicated/severe, inpatient tx
IV abx: Fluoroquinolone Extended spectrum cephalosporin or penicillin Carbapenem: Vabomere Aminoglycoside: Zemdri
Supportive care for Acute pyelonephritis: complicated/severe, inpatient
Analgesics/Antipyretics
Antiemetic
IV fluids
all the names for bladder pain syndrome
bladder pain syndrome
interstitial nephritis
painful bladder syndrome
who gets interstitial nephritis
Women >40 +/- fibromyalgia, IBS
bolded thing about interstitial nephritis
Impacts psychosocial funtioning and quality of life
-sleep dysfunction, sexual dysfunction, depression
Pathophysiology of interstitial nephritis
Altered urothelium: multifactorial: +/-
Disruption of glycosaminoglycan layer
Bladder urothelial injury
Secretion of proinflammatory substances, mast cell activation, fibrosis
Neural hypersensitivity
Neuropathic pain & voiding dysfunction
Presentation of interstitial nephritis
HIGHLY VARIABLE:
Suprapubic/bladder pain, often worse with filling, relieved with voidinG
+/- urgency, frequency, nocturia
+/- pain: pelvic, perineum, urethra, lower abdomen/back
+/- dyspareunia, vaginal burning
Presentation of interstitial nephritis in men
pelvic pain with concomitant sexual dysfunction
interstitial nephritis history
Gradual onset of sx >6 weeks
Triggers: food/beverages, stress, activities, menstruation
# of void/day
Validated symptom scales: assess severity, monitor progress
Prior/recurrent UTIs, pelvic trauma/surgery/radiation
Physical exam of interstitial nephritis should include
Abdominal exam
Women: bimanual
Men: rectal
Physical exam of interstitial nephritis may show
variable tenderness +/- pelvic floor muscle spasm
How is interstitial nephritis diagnosed?
diagnosis of exclusion:
UA, microscopy are unremarkable
Get a urine cytology in interstitial nephritis patients with
smoking history (cancer)
if an interstitial nephritis UA comes back with hematuria:
do urine cytology and cystoscopy
Postvoid residual urine volume is used to rule out
bladder outlet obstruction
neuro disorders
Cystoscopy if indicated
if in doubt of interstitial nephritis diagnosis
done to detect glomerulations (submucosal hemorrhage)
bladder hydrodistention
what would cystoscopy show for interstitial nephritis?
altered urothelium
glomerulations
hunner lesions
Refer interstitial nephritis when
Hematuria
Complex symptoms (pain with incontinence)
Incomplete bladder emptying
Neurologic disorder that affects bladder function
Prior pelvic radiation or surgery
Has not responded to oral meds
1st line interstitial nephritis tx
Self-care/behavioral modifications
Diet modifications: avoiding citrus, acidic/spicy foods, caffeine, EtOH, carbonation
Bladder retraining: increase voiding intervals
Low-impact exercise
Psychotherapy, support groups
Urinary analgesics for flares: Pyridium
2nd line interstitial nephritis tx
Oral medication:
→ Tricyclic antidepressant (amitriptyline)
Pentosan polysulfate (elmiron) (takes months to respond)
Antihistamines: Hydroxyzine
Intravesical medication: lidocaine
Pelvic physical therapy
3rd line interstitial nephritis tx
Cystoscopy + short duration low pressure bladder hydrodistention under anesthesia
Intravesical instillation of glycosaminoglycans
Intravesical dimethyl sulfoxide (DMSO)
4th line interstitial nephritis tx
Intradetrusor botulinum toxin
Sacral neuromodulation
5th line interstitial nephritis tx
Cyclosporine
6th line interstitial nephritis tx
Urinary diversion surgery
what line of tx for interstitial nephritis is pyridium?
1st line for flares
what line of tx for interstitial nephritis is pelvic physical therapy?
2nd line
Amitriptyline
Tricyclic antidepressant
Pentosan
Tricyclic antidepressant
Hydroxyzine
Antihistamine
Lidocaine is given
intravesically (2nd line)
what line of tx for interstitial nephritis are tricyclic antidepressants
2nd line
what line of tx for interstitial nephritis is intravesical lidocaine
2nd line
what line of tx for interstitial nephritis are antihistamines?
2nd line
what line of tx for interstitial nephritis is Cystoscopy + short duration low pressure bladder hydrodistention under anesthesia
3rd line
what line of tx for interstitial nephritis is intravesical instillation of glycosaminoglycans
3rd line
what line of tx for interstitial nephritis is intravesical Dimethyl sulfoxide (DMSO)
3rd line
