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Y5 Urinary System > List I - Act Core Conditions > Flashcards

List I - Act Core Conditions Flashcards

1
Q

What is a lower UTI?

A
  • Infection of the bladder also known as cystitis, usually caused by bacteria from the GI tract
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2
Q

What is an uncomplicated UTI?

A
  • UTI caused by typical pathogens in people with a normal urinary tract and kidney function and no predisposing co-morbidities
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3
Q

What is a complicated UTI?

A
  • UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection
  • RF’s include:
  • Structural or neurological abnormalities of the urinary tract, urinary catheters, virulent or atypical infecting organisms and co-morbidities such as poorly controlled DBM or immunosuppression
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4
Q

What is an upper UTI?

A
  • Infection of the upper part of the urinary tract - ureters and kidneys (pyelonephritis)
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5
Q

How is recurrent UTI defined?

A
  • Two or more episodes of UTI in 6 months or 3 or more episodes in one year
  • More common in women and can be due to:
  • Relapse - infection due to the same strain of organism or
  • Reinfection - infection due to a different organism
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6
Q

What is a catheter associated UTI?

A
  • Symptomatic infection of the bladder or kidneys in a person who is catheterised or who has had a urinary catheter in place within the previous 48 hours
  • The longer a catheter has been in situ the more likely bacteria will be found in the urine - asymptomatic bacteriuria in non-pregnant women does not routinely need treatment
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7
Q

What is bacteriruria?

A
  • Presence of bacteria in the urine - the person may or may not by symptomatic
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8
Q

What is asymptomatic bacteriuria?

A
  • Presence of significant levels of bacteria in the urine in a person without signs or symptoms of UTI
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9
Q

What are the main bacteria causing UTI?

A
  • E. coli >70% of community acquired, <40% hospital acquired
  • Proteus mirabilis 12%
  • Staphylococcus saprophyticus/epidermis 8% (30% in young females)
  • Entercoccus faecalis 6% (commoner in hospitals)
  • Klebsiella aerogenes (commoner in hospitals)
  • Enterobacter
  • Acinetobacter
  • Pseudomonas aeruginosa
  • Serratia marascens
  • Candida albicans
  • Staphylococcus aureus
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10
Q

What are the risk factors for UTI?

A
  • General
  • Immunosuppression (iatrogenic/DM)
  • Female
  • Urinary tract obstruction
  • Catheterised patient
  • Congenital malformation
  • Acquired fistula
  • Sexual intercourse
  • Pregnancy
  • Exposure to spermicide in females
  • Renal calculi
  • Menopause
  • Cystitis
  • Poor bladder emptying
  • Urinary stasis/obstruction
  • Bladder stones
  • Epithelium of bladder damaged in past
  • Pyelonephritis
  • Preceding cystitis
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11
Q

How common is pyelonephritis?

A
  • 117 F v 24 M / 100,000

* M:F 1:5

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12
Q

How common is asymptomatic bacteriuria?

A
  • 30% >65 years
  • 50% nursing home residents
  • 100% long term catheters (only if costovertebral tenderness, rigors, new onset delirium/fever)
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13
Q

What is the pathophysiology of a UTI?

A
  • Infecting organisms ascend the urinary tract (if into renal pelvis, calyces and renal parenchyma: pyelonephritis
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14
Q

What are the complications of lower UTI?

A
  • Lower UTI ascending infection leading to pyelonephritis, renal and peri-renal abscess, impaired renal function, renal failure and urosepsis
  • UTI in pregnancy is associated with pre-term delivery and low birth weight
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15
Q

What are the risk factors for developing a complicated UTI?

A
  • Pregnancy
  • Older age (post menopause)
  • Healthcare associated UTI
  • Presence of symptoms for more than a week before presentation
  • Urological instrumentation (including urinary catheter)
  • Pre-existing urological conditions such as childhood or recurrent urinary tract infections, neurogenic bladder, polycystic kidney disease, renal transplant, urolithiasis, or urinary obstruction
  • DBM and immunosuppression
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16
Q

What are the symptoms of cystitis?

A
  • Frequency
  • Dysuria
  • Urgency
  • Strangury
  • Pyuria
  • Haematuria
  • Subprapubic pain
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17
Q

What are the symptoms of prostatitis?

A
  • Few urinary symptoms
  • Flu like symptoms
  • Low back ache
  • Swollen/tender prostate on PR
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18
Q

What are the symptoms of pyelonephritis?

A
  • High fever
  • Rigors
  • Vomiting
  • Loin pain/tenderness (insidious, constant, does not usually radiate to groins, may be bilateral - usually one worse than the other)
  • Haematuria
  • Oliguria (if renal failure)
  • Frequency
  • Dysuria
  • Urgency
  • Systemic upset (if renal abscess develops (in lumbar triangle)
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19
Q

What are the symptoms of UTI in the elderly?

A
  • Confusion
  • Incontinence
  • Nocturia
  • Vague systemic upset
  • Delirium
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20
Q

What are the symptoms of sepsis (uro)?

A
  • Fever
  • Rigors
  • Confusion (off legs)
  • Rash
  • Vomiting
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21
Q

What are the symptoms of genito-urinary TB?

A
  • Dysuria
  • Flank pain
  • Perineal pain
  • Scrotal fistula
  • Haematuria
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22
Q

What are the signs of UTI?

A

General

  • Warm peripheries
  • Fever
  • Tacycardia

Urinary system

  • Loin/abdo/suprapubic tenderness
  • Foul smelling urine
  • Distended bladder (occasionally)
  • Enlarged prostate
  • Vaginal discharge (non-gonococcal urethritis)
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23
Q

What are the worrying signs in a patient with a UTI?

A
  • Reduced BP/shock
  • Temperature >40c
    (elderly patients can be afebrile but very bacteraemic)
  • New renal impairment
24
Q

What are the differential diagnoses for UTI?

A
  • Urethritis
  • Cystitis
  • Prostatitis
  • Pyelonephritis
  • Epididymitis
  • Chlamydial infection
  • Genitourinary TB
  • Pelvic inflammatory disease
25
Q

What are the differentials according to MSU/CSU dipstick findings from a urine sample?

A
  • Nitrites - gram -ve UTI (e.coli)
  • Leucocytes - from inflammation of the kidneys/urinary tract
  • UTI
  • Stones
  • Trauma
  • Neoplasia
  • Infection of related structures (prostate, appendix)
  • Renal disease
  • Blood
  • with RBC’s on microscopy
  • Myoglobinuria
  • UTI
  • Bladder tumour
  • Stones
  • Recent catheterisation
  • Clotting abnormality
  • Prostate hypertrophy
  • Glomerulonephritis
  • Increased BP
  • TB
  • Endocarditis
  • Sickle cell disease
  • Strenuous exercise
  • PV bleed
  • without RBC’s on microscopy
  • Haemoglobinuria
  • Haemolytic anaemia
  • Myositis
  • Rhabdomyolysis
  • Trauma
  • Ischaemia
  • Protein - albumin (should not be in urine)
  • Glucose - DBM
  • Ketones
  • DKA
  • Fasting
  • Low CHO diets
  • Acute illness
  • pH - normal 4.5-8
  • Systemic acidosis/alkalosis
  • Specific gravity
26
Q

What are the differentials according to microscopy for urine?

A
  • White cells >10/mm3 is abnormal
  • Bacteria - if seen on microscopy - highly suggestive of UTI (still needs to be cultured)
  • Red cells >2/mm3 is abnormal
  • Casts - hyaline/non-granular (not significant) red cell/epithelial (renal disease), white cell (pyelonephritis)
27
Q

What are the differentials according to urine culture?

A
  • Takes 48 h
  • Pure growth >10(5) cfu/ml - UTI likely
  • Mixed - suggests contamination of urine
  • Sterile pyuria
  • TB
  • Treated UTI <2wks
  • Inadequately treated UTI
  • Appendicitis
  • Calculi
  • Prostatitis
  • Bladder Ca
  • UTI with fastidious culture requirement
  • Papillary necrosis (DM/analgesic excess)
  • Tubulointerstitial nephritis
  • PCKD
  • Chemical cystitis e.g. cyclophosphamide
28
Q

What are the blood investigations for a person with a UTI?

A
  • Culture if systemically unwell - urosepsis
  • FBC - WCC neutrophils
  • U and E’s - increased urea, creatinine, outflow tract obstruction
  • CRP - very high and GU TB
  • Glucose - DKA/DM, PSA
29
Q

What are the urine investigations for a person with a UTI?

A
  • Dipstick 1st if symtpoms
  • 2+ nitrites, leucocytes, blood, protein
  • If early morning sample mycobacteria - think GU TB
  • MC and S to microbiology
  • If +ve for nitrites, leucocytes, blood, protein or -ve despite clinical suspicion of UTI or if male/child/immunosuppressed
  • Pure growth of >10 (5)/ml is diagnostic
  • Significant is pure growth of <10 (5)/ml but pyruria (WCC >20/mm3)
  • Repeat MC and S 1 week post therapy to ensure resolution of infection
30
Q

What imaging can be done to investigate UTI further?

A
  • USS - useful to identify hydronephrosis 2nd to urinary obstruction/renal abscess or drainable collection
  • Indications - if child, M, fail to respond to therapy, recurrent UTi >2yrs, pyelonephritis
  • Abdominal x-ray
  • CT KUB
  • Radio-opaque calculi as source of infection
  • Unusual organism
  • Persistent haematuria
  • Evidence of renal impairment
  • 6-8 weeks after therapy
  • IV urogram/renogram
  • Cystoscopy
  • DMSA - radio-isotope scan - for children <5 yrs
  • Micturating cystourethrogram - if <1yr old
31
Q

What are the principles of management of a UTI in non-pregnant women?

A
  • Trimethoprim or nitrofurantoin for 3 days
  • Send a urine culture if
  • Aged >65 years
  • Visible or non-visible haematuria
  • Follow local anti-biotic guidelines if they are available
32
Q

What are the principles of management of a UTI in a pregnant woman?

A
  • Symptomatic
  • Urine culture should be sent in all cases
  • Treated with an antibiotic
  • First line - nitrofurantoin (avoided nearer term)
  • Second line - amoxicillin or cefalexin
  • Asymptomatic bacteriuria in pregnant women
  • Urine culture should be performed routinely at the first antenatal visit
  • NICE recommend an immediate prescription of either nitrofurantoin (avoided near term), amoxicillin or cefalexin - 7 day course
  • Further urine culture should be performed routinely at the first antenatal visit
  • Rationale for treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
33
Q

What are the principles of treatment for men with a UTI?

A
  • Immediate antibiotic prescription should be offered
34
Q

What are the principles of treatment of a UTI in catheterised patients?

A
  • Do not treat asymptomatic bacteria in catheterised patients
  • If the patient is symptomatic they should be treated with an antibiotic
  • 7 day rather than a 3 day course should be given
35
Q

What are the principles of management of acute pyelonephritis?

A
  • Hospital admission should be considered

* Broad spectrum antibiotics - cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

36
Q

What is the prognosis of a UTI?

A
  • Pyelonephritis
  • Renal/perinephric abscess (may also be from haematogenous spread)
  • Urinary obstruction
  • Hydronephrosis
  • Recurrent UTI
  • Commonly Klebsiella or Proteus mirabilis
  • Chronic UTI
  • Pyelonephritis
  • Prostatitis
  • Epididymo-orchitis
  • Urethral stricture
  • Scarring of urinary tract
  • Including kidneys
  • Chronic renal failure

Mortality
* Pyelonephritis - in patient 1.7% (M) and 0.7% (F) - most make an uneventful recovery

37
Q

What are the preventative measures/patient education for UTI?

A

UTI

  • Drink >2 L fluid/day
  • Void at 2-3 h intervals
  • Double voiding before bedtime and after sexual intercourse
  • Wipe from front to back after micturation/defecation

Recurrent UTI

  • Avoidance of constipation which may impair bladder emptying
  • Avoidance of bubble bath or other irritants in bath water
  • Abx prophylaxis (trimethoprim/nitrofurantoin continuously/post coital to reduce infection rates in females with recurrent infection
  • Cranberry juice/lingo berry juice 200-700ml/day can reduce infection rates by 10/20% as it inhibits adherence of bacteria to uroepithelium - avoid if on warfarin
38
Q

What is acute urinary retention?

A
  • When a person suddenly becomes unable to voluntarily pass urine (over a period of hours)
  • Most common urological emergency
39
Q

How common is acute urinary retention?

A
  • Common in men, rare in women
  • M:F 13:1
  • Mostly occurs in men over 60 years of age and incidence increases with age
  • Has been estimated that around 1/3 of men in their 80’s will develop acute urinary retention over a 5 year period
40
Q

What are the causes of acute urinary retention?

A
  • In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia - enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty
  • Other urethral obstructions including urethral strictures, calculi, cystocele, constipation or masses
  • Medications such as anticholinergics, tricylic antidepressants, antihistamines, opioids and benzodiazepines
  • Less common - neurological cause
  • In patients with predisposing causes a UTI can lead to acute urinary retention
  • Acute urinary retention often occurs postoperatively and in women post partum - usually secondary to a combination of risk factors
41
Q

What are the presenting features of acute urinary retention?

A
  • Inability to pass urine
  • Lower abdominal discomfort
  • Considerable pain or distress
42
Q

What are the signs of acute urinary retention?

A
  • Palpable distended urinary bladder either on an abdominal or rectal exam
  • Lower abdominal tenderness
  • All men and women should have a rectal and neurological examination to assess for the likely causes above
  • Women should also have a pelvic examination
43
Q

What investigations are required for acute urinary retention?

A
  • Urine sample which should be sent for urinalysis and culture
  • May only be possible after urinary catheterisation
  • Serum U and E’s and creatinine should also be checked to assess for any kidney injury
  • FBC and CRP should be performed to look for infection
  • PSA is not appropriate in acute urinary retention as it is typically elevated
44
Q

What is the management of acute urinary retention?

A
  • To diagnose AUR a bladder USS should be performed
  • Volume of >300 cc confirms the diagnosis
  • AUR is managed by decompressing the bladder via catheterisation
  • Catheterisation can be performed in patients with suspected acute urinary retention - volume drained in 15 mins is measured
  • Volume of <200 confirms that the patient does not have AUR and a volume over 400 cc means the catheter should be left in place - in between these volumes - depends on the case
45
Q

What is the approach to further investigations for AUR?

A
  • Should target the likely cause
  • UTI - treatment of the infection is sufficient and further investigation not necessary
  • Men not diagnosed with BPH should be further evaluated by a urologist
  • Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist
  • Where no likely cause is identified patients should be evaluated by a urologist for anatomical and urodynamic causes
46
Q

What is the normal/mild raised/moderate and severe range of potassium in the blood?

A
  • Normal - 3.5 - 5 mmol/L
  • Mild - 5-6 mmol/L
  • Moderate - 6.1-6.9 mmol/L
  • Severe >7 mmol/L
  • Emergency >6.5 mmol/L or evidence of myocardial hyper-excitability
47
Q

What are the causes of hyperkalaemia?

A WEAKER

A
  • Artefact - haemolysis (difficult venepuncture, patient clenched fist), contamination with K+ EDTA anticoagulant in FBC bottles (do FBC after U and E’s), thrombocytopenia (K+ leaks out of platelets during clotting), delayed analysis (K+ leaks out of RBC’s), taken from limb infused with IV fluids containing K+
  • “Whack” - rhabdomyolysis, trauma, burns, tumour cell necrosis
  • Excess K+ therapy - Addisons (or hyperaldosteronism due to NSAID’s/ACEi), metabolic acidosis e.g. DKA
  • K - K+ sparing diuretics (spironolactone, amiloride), ACEi, suxamthonium, beta-blockers
  • Excess blood - massive blood transfusion
  • R - Oliguric renal failure
48
Q

What are the ECG findings on a patient with hyperkalaemia?

A
  • Peaked or tall tented T waves (occurs first)
  • Loss of P waves
  • Broad complex QRS
  • Sinusoidal wave pattern
  • Ventricular tachycardia
49
Q

What is the approach to the management of a patient with (severe) hyperkalaemia?

A
  • Address precipitating factors - e.g. stop nephrotoxic drugs
  • Stabilise the cardiac membrane - IV calcium gluconate (does not lower serum potassium levels)
  • Short term shift in potassium from extra-cellular into intra-cellular fluid compartment
  • Combined insulin/dextrose infusion
  • Nebulised salbutamol
  • Removal of potassium from the body
  • Calcium resonium (orally or enema)
  • Enemas are more effective than oral as potassium is secreted by the rectum
  • Loop diuretics
  • Dialysis - haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia
50
Q

In terms of hospital care (Leeds Protocol) what is regarded severe hyperkalaemia?

A
  • Potassium K+ = or > 6.5 mmol/L
51
Q

What is the initial management protocol for a patient with severe (K+ > or = 6.5 mmol/L ?

A

Assessment

  • Urgent ECG and cardiac monitoring
  • Obtain IV access
  • If ECG changes are present treat as severe hyperkalaemia

Management

1) Administer 30ml of 10% calcium gluconate
- IV bolus over 10 minutes
- Repeat every 5 mins if ECG changes are present
- Repeat every 30 mins of K+ still 6.5
* Catheterise if AKI is present

2) Give IV insulin according to bedside capillary blood glucose
- <12 glucose - give 10 units Actrapid in 50 mls of 50% glucose over 10-15 mins
- Followed by 10% glucose infusion (500ml over 12 hrs)

  • > or = 12 - give 10 units Actrapid in 50 mls 0.9% sodium chloride over 1–15 mins
  • Monitor CBG every 30 mins
  • Once blood glucose < 12 give 10% glucose infusion
  • Repeat serum potassium (K+) 30 mins after each insulin infusion is completed

3) Consider nebulised salbutamol 10mg stat unless HR >130/min
- 20mg if patient taking regular b-blocker

52
Q

What is the next step after initial management of severe hyperkalaemia (K+ > or = 6.5 mmol/L)?

A

4) Assess fluid status
- Hypovolaemic - resuscitate with 0.9% sodium chloride
- Euvolaemic - slow IV 0.9% sodium chloride OR sodium bicarbonate 1.26% (e.g. 500mls over 4hrs)
- Hypervolaemic - appropriate diuretic e.g. 100mg IV furosemide

If metabolic acidosis present (HCO3 <16 mmol/L) and ECG changes give sodium bicarbonate 1.26% 250ml over 30 minutes

53
Q

If after the initial treatment for hyperkalaemia the patient develops rebound hyperkalaemia - how should this be managed?

A
  • Peak effect of insulin is after 30 to 60 mins - this may last for 4-6 hrs - rebound may occur after this
  • Administer sodium zirconium cyclosilicate in addition to the initial measures
  • 10g TDS (orally) for 24-48 hrs
  • Monitor potassium regularly and repeat calcium gluconate/IV insulin as above if indicated
  • If normokalaemia is not achieved within 48 hrs please discuss with the renal team
54
Q

When should transfer to HDU be considered in a patient with severe hyperkalaemia?

A
  • Hypervolaemia not responding to diuresis
  • Hyperkalaemia not responding to initial therapy
  • Significant renal failure (AKI or CKD)
55
Q

What is the guidance regarding the long term management of a patient with hyperkalaemia?

A
  • Maintain treatment of the underlying cause of hyperkalaemia as clinically indicated
  • All medications which can cause hyperkalaemia should be with-held or stopped
  • Oral calcium resonium 15g TDS may be considered in some slow resolving cases and should always be prescribed with lactulose or
  • Chronic use of oral sodium ziroconium cyclosilicate is available for limited indications

Y5 Urinary System (3 decks)

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