Problems with Elimination Urinary Flashcards
An Uncomplicated UTI is what?
Uncomplicated
- Healthy person w/normal urinary tract system,
- Treatment with oral antibiotics
A COMPLICATED UTI is what?
COMPLICATED:
- Having an underlying condition that increases the risk of failing therapy. Multiple UTI’s.
- A person w/structural (prostate) or functional system (retention), immunocompromised
- Treatment: Parenteral therapy (IV) often indicated.
What are some predisposing factors for UTIs?
- Women’s risk is higher due to short urethra in younger years and low estrogen related dilation in later years.
- Predisposing factors
- Hygiene (in women, wiping back to front)
- Trauma
- Instrumentation
- Sexual intercourse
- Neurologic factors
- Obstruction with stones
- Bubble bath/hot tub
- Uncircumcised penis
- Catheterization
- Anomalies: Vesicoureteral Reflux (from lower urinary to upper urinary system)
- Douching
Incidence of UTI
- Men 15 to 50 YO rarely develop UTI -antibacterial substances in prostatic fluid, longer urethra
- More than 50% of women (by 30 YO) will have one UTI
Signs and Symptoms of UTI:
NOTE: Symptoms and signs of cystitis can be subtle in the very young and very old.
- Burning with urination (dysuria)
- Frequency
- Urgency
- Incontinence
- Suprapubic, abdominal, flank (CVA) discomfort: pyelo
- Hematuria
Collecting the history:
What should you ask to discern that a patient may have a UTI?
- Onset, course, duration of symptoms
- Other genital problems, discharge, STI
- Review predisposing factors
- Hx of urinary tract problems
- What do they drink, amount, type of drink
- Other pertinent medical history (Diabetes, sickle cell, neurological disorder)
Completing the Physical:
What would you examine for suspected cystitis (UTI)?
- VS
- Heart and lung
- Palpate abdomen
- Palpate back for costovertebral angle (CVA) tenderness
- Inguinal lymph nodes
- *Women**
- *-Pelvic exam: inspect external genitalia, Possibly milk urethra for discharge, assess rectal area, speculum exam, bimanual for cervical motion tenderness, mass.**
- *Men**
- *-Inspect penis, scrotum**
- *-Retract foreskin (smegma)**
- *-Palpate (check for epididymitis, tenderness, masses)**
- *-Prostate exam (very gently)**
What diagnostic tests would you order for suspected cystitis?
- Urinalysis, micro as indicated.
- In most cases, positive leukocyte esterase (WBCs) and nitrates (from bacteria) indicate infection. Usually positive for blood.
- WBC casts in the urine are indicative of kidney inflammation
- Bacteria w/o pyuria usually due to contamination
- pH normal around 6 (acidic), infection often increases pH
- STI testing (GC and Chlamydia)
- Wet prep in females if indicated (BV, trich, yeast)
- Imaging
- *-Ultrasound**
- *-VCUG (voiding cystourethrography)**
- *-Urodynamic testing**
What are some potential differentials for cystitis?
- Vaginal/pelvic infection
- Prostatitis, epididymitis
- Bladder tumor
- Interstitial cystitis
- Benign prostatic hyperplasia (BPH-) nocturia, stream changes
- Over-active bladder/urge incontinence
- Pelvic organ prolapse
- Irritant urethritis
What is the most common pathogen associated with UTIs?
- Escherichia coli (75 to 95 percent), with occasional other species of Enterobacteriaceae, such as Proteus mirabilis* and *Klebsiella pneumoniae, and other bacteria such as Staphylococcus saprophyticus
Detecting Contamination in a specimen:
In healthy, non-pregnant woman - organisms such as lactobacilli, enterococci, Group B streptococci, and coagulase-negative staphylococci (other than S. saprophyticus) from voided urine most commonly represents contamination
NON-PHARMACOLOGICAL treatments for UTI:
- Increase fluid intake avoiding foods/fluids that irritate bladder: caffeine, etoh, tomato, citrus, spicy
- Cranberry supplements to change pH (cranberry juice can contain too much sugar which increases infection so can use unsweetened)
- -Prevents e-coli from adhering to uroepithelial cells
PHARMACOLOGICAL therapy for UTI
- Empiric should cover all likely pathogens
Uncomplicated:
First line:
- Nitrofurantoin (Macrobid) 100 mg BID x 5d
- Trimethoprim/Sulfamethoxazole (Bactrim DS) one DS tab BID x 3d
- Fosfomycin (Monurol) 3 gm orally in single dose
Second line:
- Ciprofloxacin 250 mg BID x 3 d
- Levofloxacin (Levaquin) 250 mg BID x 3 d
Complicated:
- ciprofloxacin : 500 mg orally BIDx 7 days (7 to 14 d in men)
- levofloxacin : 750 mg orally BIDx5 days (500mg daily for 7-14d in men)
- trimethoprim/sulfamethoxazole: 160/800 mg orally BIDx7-14 days
When should clinical manifestations respond to antimicrobial therapy?
Within 48 hours
In the interim, for some patients with cystitis, a urinary analgesic such as over-the-counter oral phenazopyridine (AZO) three times daily as needed may be useful to relieve discomfort due to severe dysuria.
A two-day course is usually sufficient.
It will turn your urine neon orange and it stains.
When should follow up be scheduled for cystitis (UTI)?
- If still symptomatic after completing medication or after 48 to 72 hr of appropriate antibiotic therapy.
- If Symptoms reoccur within 2 weeks: Do a Urine culture then treat with different agent for 7 d.
What is asymptomatic bacteriuria?
- Asymptomatic bacteriuria refers to patients who have no symptoms of UTI (dysuria, urinary frequency or urgency, suprapubic pain in patients with simple cystitis and fevers with cystitis symptoms, flank pain, or costovertebral angle tenderness in patients with acute complicated UTI).
–Symptoms are different if patient has neurogenic bladder (check for malaise, fevers, increased spasticity)
What is the Epidemiology of asymptomatic bacteriuria?
- Increase w/advancing age in healthy females
1% school age
>20% older than 80 years - Correlates w/sexual activity and diabetes.
Greater among premenopausal married women - It is transient; it rarely lasts longer than a few weeks
- Rare among healthy young males
6-15% among males older than 75 years - Bacteriuria is extremely common among patients with indwelling catheters
How is asymptomatic bacteriuria diagnosed?
- Presence of at least 100,000 organisms per ml of urine and no symptoms
- The high quantitative threshold is intended to increase the likelihood that bacteriuria reflects bladder bacteriuria rather than urethral, vaginal, or fecal contamination.
- Pyuria may be present
- Prevalence of pyuria in patients w/diabetes mellitus and asymptomatic bacteriuria is almost 80 percent
- Generally, no role for routine screening (non pregnant population)
- Females, a second specimen should be obtained (preferably within two weeks) to confirm growth of the same organism over the same quantitative threshold.
- Males, a single urine specimen meeting the criteria is sufficient for making the diagnosis.
What is the treatment for asymptomatic bacteriuria?
- No antibiotics, self limiting
- The unnecessary treatment of ASBU can lead to antibiotic resistance, adverse drug effects, C. difficile infection, and contribute unnecessarily to the costs of medical care
- Treatment (even in immunocompromised) does not appear to reduce the frequency of symptomatic infection or prevent other adverse outcomes
- Necessary to screen and treat in pregnancy, recent renal transplant patient and patients undergoing urinary tract surgeries.
What is acute pylonephritis?
- Upper urinary tract infection of the renal pelvis, tubules, and/or interstitial tissue
- Can lead to scarring to kidney, kidney failure, abscess formation, sepsis.
- Less common and more serious than lower tract infections.
- Subjective data and exam same as UTI
*interesting fact: approx. 75-80% of pyelo cases occur on right side
True or False: Most cases of acute pyelonephritis occur from undiagnosed UTIs.
True.
- Most cases of acute pyelonephritis are the consequence of an undiagnosed UTI
- Annual rates in women are 15-17 cases/10,000
- Annual rates in men are 3-4 cases/10,000
What are some signs and symptoms of pyelonephritis?
Note: The symptoms and signs of pyelonephritis can be subtle in the very young and very old. Confusion, irritability etc.
Signs and symptoms:
- Symptoms of cystitis may or may not be present
- Fever (>38ºC; 100.4º F), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting.
- In some cases, the presentation may mimic pelvic inflammatory disease. Patients with acute complicated pyelonephritis may present with sepsis, multiple organ system dysfunction, shock, and/or acute renal failure.
- In some cases, complicated pyelonephritis may be associated with weeks to months of insidious, nonspecific signs and symptoms such as malaise, fatigue, nausea, or abdominal pain.
What are some diagnostic tests used for pyelonephritis?
- Suggestive of pyelonephritis
- Symptoms of cystitis + fever or other signs of systemic illness
- -Systemic illness: fever, chills, rigors, or acute mental status changes
- CVA tenderness w/pyuria and bacteriuria
- Fever or sepsis w/pyuria and bacteriuria.
- Urinalysis (either by microscopy or by dipstick) and urine culture with susceptibility data
- Obtain prior to therapy
- White cell casts suggest a renal (kidneys) origin for pyuria. See picture of the casts at http://www.medical-labs.net/white-cells-casts-in-urine-419/
- CBC w/diff
- If indicated: blood culture, ESR, GC/Chlamydia, wet prep (vaginal smear)
What are some imaging diagnostic tests that can be done for pyelonephritis?
- Imaging of upper urinary tract if there are persistent clinical symptoms after 48 to 72 hrs of appropriate antibiotic therapy for acute uncomplicated urinary tract infection.
-CT abdomen and pelvis w/ and w/o contrast to detect anatomic of physiologic factors
–Contrast needed to assess renal perfusion
–Non contrast to assess for calculi, gas forming infections, hemorrhage, obstruction or abscess
–May be normal in mild cases - Renal ultrasound though not study of choice
A kidney ultrasound can show:
–Something abnormal in the size or shape
–Blood flow to kidneys
–Signs of injury or damage - Imaging also if the patient is severely ill or has symptoms of renal colic or history of renal stones, diabetes, history of prior urologic surgery, immunosuppression, repeated episodes of pyelonephritis, or urosepsis.
-CT scan-preferred
-Ultrasound
-Voiding cystourethrogram (VCUG)
Potential differentials for pyelonephritis include:
- Appendicitis, acute abdomen
- Cholecystitis
- Pancreatitis
- Diverticulitis
- Pneumonia
- Prostatitis
- Epididymitis
- PID (Pelvic Inflammatory Disease)
- Nephrolithiasis
PHARMACOLOGICAL THERAPY FOR PYELONEPHRITIS
- Oral fluoroquinolone
- Ciprofloxacin (500 mg orally twice daily or 1000 mg extended release once daily)
- Levofloxacin (750 mg orally once daily) for five to seven days.
*NOTE: Patients with complicated pyelonephritis should be managed initially as inpatients. Broad-spectrum parenteral antibiotics should be used.
Pyelonephritis Follow up should occur when…
Note: Symptoms should improve promptly if antimicrobial therapy is effective.
- Those treated as outpatients, should have close follow-up either face-to-face or by telephone within 48 to 72 hours.
- Any patients who have worsening symptoms following initiation of antimicrobials, persistent symptoms after 48 to 72 hours of appropriate antimicrobial therapy, or recurrent symptoms within a few weeks of treatment should have additional evaluation, imaging, and repeat urine C & S.
- For patients who had hematuria on initial presentation, a urinalysis should be repeated several weeks following antimicrobial therapy to evaluate for persistent hematuria.
