LUTS + UTI Flashcards
What are the risk factors for bacteriuria?
- Female, low oestrogen states (menopause), pregnancy
- Increasing age
- Diabetes
- In-dwelling catheters
- Stone disease
- Congenital malformation
- Voiding dysfunction
How can UTIs be categorised?
- Isolated UTI:
- at least 6 months between infections - Recurrent UTI:
- >2 infections in 6 months or 3 within 12 months
- Re-infection: infection by different organism
- Persistence: infection by same organism from a focus in urinary tract - Unresolved UTI:
- Inadequate therapy
- May be due to bacterial resistance
What are the symptoms of a lower UTI (cystitis)?
- Frequent, small-volume voids
- Urgency
- Suprapubic discomfort
- Dysuria
What investigations should be carried out for a lower UTI?
- Dipstick mid stream urine (presence of leukocytes ± nitrite)
- Urine microscopy
- AXR
- Renal USS
- Possibly IV/CT urogram (?structural abnormality)
How should a lower UTI be treated?
- uncomplicated: short course abx (e.g. trimethoprim)
2. complicated: 7-10 day course of augmentin + further investigation
What are the S+S of upper UTIs (pyelonephritis)?
- Flank/loin pain
- N+V
- Fevers + chill
- LUTS
What investigations should be carried out for an upper UTI?
- MSU: dipstick + send for culture
- Bloods: FBC, U+Es, blood cultures
- Imaging: AXR, renal USS, CT urogram
What bacteria usually cause upper UTIs?
- 80% = E Coli
- less common:
(i) enterococci
(ii) klebsiella
(iii) proteus
(iv) pseudomonas
How should an upper UTI be treated?
- Not systemically unwell: 10 days oral abx
2. Systemically unwell: admit for IV abx
What is a potential complication of pyelonephritis?
Perinephric abscess (abscess in Gerota's fascia) Microbiology: S aureis, E coli, Proteus
What is the treatment for a perinephric abscess?
- drainage of collection (radiologically or formal open incision)
- abx until resolution of infection
What microorganisms are associated with uncomplicated UTIs?
- E Coli (most common)
- Staph saprophytic
- Strep faecalis
- Proteus
- Klebsiella
uncomplicated = structurally and functionally normla urinary tract
What microorganisms are associated with complicated UTIs?
- E Coli (most common)
- Strep faecalis
- Staph aureus
- Staph epidermis
- Pseudomonas
What is 2nd line therapy for an uncomplicated lower UTI?
2nd line = required due to hypersensitivity reaction, side effects, failure of 1st line)
Treatment:
- urine culture sensitivty testing
- fluoroquinolone (ciprofloxacin 500mg BD or levofloxacin 250 mg OD)
- oral cephalosporins
What patients are at high risk of complicated lower UTIs?
- Males
- Recent urinary tract instrumentation
- Recent abx
- Diabetes
- immunosuppressed
- Obstruction
- Structural/functional abnormalities
What is the treatment for a complicated lower UTI? How is this different if the patient is immunocompromised?
- Empirical therapy: fluoroquinolone for 7-10 days
2. Immunocompromised: single-dose aminoglycoside (e.g. gentamicin 3-5mg/kg IVI or IMI)
Define a recurrent UTI.
> 4 culture-proven UTIs in a year
What investigations should be carried out for recurrent UTIs?
- MSU culture, urine microscopy
- Children: US to visulaise anatomical anomalies
- Men: referral to a urologist (those with haematuria shoudl be referred urgently)
- Women: urgent referral if recurrent UTIs associated with haematuria
- CT scan imaging of choice for underlying pathology in women
What are the different categories of LUTS? What symptoms fall into each category?
- Voiding:
- weak/intermittent urinary stream
- straining
- hesitancy
- terminal dribbling
- incomplete emptying - Storage:
- urgency
- frequency
- incontinence
- nocturia - Post-micturition:
- dribbling
What are the non-medical management options of men experiencing storage symptoms as a result of BPH?
- supervised bladder training
- advice on fluid intake
- lifestyle advice
- containment products (if needed)
What are the non-medical management options of men experiencing voiding symptoms as a result of BPH?
- intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation
- advise surgery is better than bladder training
What drug treatments are commonly used in BPH?
- Moderate to severe LUTs (+ no RFs for progression): alpha blocker
- LUTS and prostate estimated to be >30g or PSA >1.4 ng/ml (high risk of progression): 5-alpha reductase inhibitor
- Bothersome moderate to severe LUTS + prostate ~>30g or PSA >1.4ng/ml: alpha blocker + 5-alpha reductase inhibitor
- Overactive bladder: anticholinergic
What is the MOA of alpha blockers? What are the potential adverse effects?
MOA:
- blockade of alpha1 adrenergic receptors in prostate, urethra, bladder neck and detrusor muscle
- causes relaxation of smooth muscle
- = improved urinary flow
Adverse effects:
- postural hypotension
- retrograde ejaculation
What is the MOA of 5-alpha reductase inhibitors? What are the potential adverse effects?
MOA:
- decrease in dihydrotestosterone synthesis
- reduced androgenic drive of prostate
- reduction in prostate volume = improved outflow
Adverse effect:
- impotence
- Dutaseride = dual 5ARI
- Finasteride = mono 5ARI
How often must drug treatments for BPH be reviewed?
- Alpha blockers: at 4-6 weeks, then every 6-12 months
- 5-alpha reductase inhibitors: at 3-6 months, then every 6-12 months
- Anticholinergic: 4-6 weeks until stable, then every 6-12 months
What is the management of acute urinary retention in men?
- catheterise
2. alpha blocker (400 micrograms) before removing catheter
When in surgery indicated in BPH?
- Voiding symptoms are severe
- Drug treatment and conservative treatment have been unsuccessful/are not appropriate
- Storage symptoms that have not responded to conservation or drug management
What is the surgical management of BPH causing voiding symptoms?
- Prostate <30g:
- Transurethral incision of the prostate - Prostate >30g:
- Monopolar or bioplar transurethral resection of the prostate (TURP)
- Monopolar transurethral vaporisation of the prostate (TUVP)
- Holmium laser enucleation of the prostate (HoLEP)
- Open prostatectomy
What is the surgical management of BPH causing detrusor overactivity?
- cystoplasty
- bladder wall injection with botulinum toxin
- implanted sacral nerve stimulation
What is the surgical management of BPH causing stress urinary incontinence?
- implantation of an artificial sphincter
- intramural injectables, implanted adjustable compression devices and male slings
