L29: Dysuria and UTI

Question 1

History

Answer 1

• Sexual contact? barrier contraception
• Frequency, urgency, incontinence (bladder dysfunction?)
• Supra-pubic cramping (strangury)?
• Back pain or systemic symptoms e.g. fever (pyelonephritis)
• Purulent discharge (gonorrhoea)

Question 2

Cystitis

Answer 2

Infection of bladder, common

High risk in females, increased post-menopause due to less oestrogen supporting protective bacteria

Question 3

Risk factors for cystitis

Answer 3

• Females = past UTI, sexual intercourse, diaphragm use, pregnancy, diabetes, instrumentation (e.g. catheter)
• Males = lack of circumcision, AIDS, MSM
• Important in older people = bladder dysfunction, neurological disease

Question 4

Factors contributing to recurrent cystitis

Answer 4

1. Intercourse - void after intercourse, complete bladder emptying
2. Contraception - avoid diaphragm, spermicides
3. Abnormal urinary tract - prophylactic antibiotics

Question 5

Diagnosis of cystitis

Answer 5

• Typical symptoms = high frequency, urgency and cramping pain
• Dipstick of mid-stream urine (WBCs present = inflammation in bladder)
• If pyruria and typical symptoms then treat
• In case of further problems send urine to lab to perform dipstick, microscopy, culture (if significant then test for susceptibility to antibiotics)

Question 6

Causative organisms of cystitis

Answer 6

• E.coli 80% of cystitis
• Staphylococcus saprophyticus colonises urethra, common in young women, never causes pyelonephritis
• Candida albicans common in urinary catheters

Question 7

Treatment of cystitis

Answer 7

(most cases resolve over many months)

• Only prescribe when symptoms present
• Broad spectrum antibiotics = oral trimethoprim for 3 days or nitrofuratoin for 3 days
• Nitrofurantoin more effective but needs to be taken 4 times a day
• For serious infections = co-trimoxazole

Question 8

Trimethoprim

Answer 8

• Inhibits folate synthesis (inhibits dihydrofolate synthetase enzyme)
• Interferes with division = bacteriostatic
• Avoid use in pregnancy (inhibits folate production)
• Long periods can suppress bone marrow function
• Allergies, e.g. Stevens-Johnson - rash affecting skin and mucosal surfaces (mostly caused by sulphur drugs)

Question 9

Pyelonephritis

Answer 9

Infection of kidneys
Bacteraemia (15-30%), mortality (10%)
Usually caused by enteric gram negative bacteria

Question 10

Presentation of pyelonephritis

Answer 10

• Severe flank pain radiating to groin (not always present)
• Dysuria, haematuria
• Fever, nausea, tachycardia

Question 11

Management of pyelonephritis

Answer 11

• Many patients admitted and treated in hospital
• Investigate with blood and urine cultures
• Blood tests to determine organ impairment (renal function)
• Xray or US not needed for diagnosis but useful if: abnormality of urinary tract suspected, deterioration despite treatment, failure to improve in 48hrs

Question 12

Treatment of pyelonephritis

Answer 12

• Often IV first then rapid change to oral treatment when responding (7-10 days in uncomplicated)
• IV gentamicin
• Cefuroxime or augmentin useful alternatives
• Be watchful of signs and symptoms of septic shock