Renal Approach to hematuria, dysuria, and nocturia Flashcards
upper DDx of Hematuria
Renal malignancy Renal cysts Urinary stones Glomerulonephritis UTI -pyelonephritis -Cystitis
lower DDx of hematuria
Bladder cancer Bladder stone Hemorrhagic cystitis (cyclosphamide) BPH Prostate cancer Urethritis Urethral trauma (urinary cather)
what is an uncomplicated UTI
acute cystitis or pyelonephritis in a non pregnant outpatient woman without any anatomic abnormalities or urinary instrumentation
what are complicated UTI and some examples
UTIs that are associated with factors increasing colonization and decreasing efficacy of therapy
- Pregnancy
- Urinary retention or obstruction
- renal failure
- renal transplant
- Males
- Anatomic abnormalities
- Urinary catheter or urinary instrumentation
- immunocomprimised
Some references include all pyelonephritis cases
what is definition of recurrent UTI
> 2 infections in six months or >3 infections in one year
what is the definition pf asymptomatic bacteriuria
Bacteriuria present on urine culture but no clinical UTI symptoms present in patient
what is definition of Catheter-associated UTI (CA-UTI)
UTI associated with placement of urinary catheter or within 48 hours of removal
what are the major risk factors for UTIs
Female sex Hx of UTI Sexual activity Condom/diaphragm/spermicide use Vaginal infection Indwelling urinary catheters DM Obesity Immunosuppression Urinary tract abnormalities
what is the pathogenesis of UTIs
Uropathogenic bacteria colonizing the GI tract, perineium, or vagina inoculate the urethra and ascend into the bladder
Common UTI pathogens
Gram Negative:
- E Coli
- Klebsiella pneumonia
- Proteus mirabillis
- pseudomonas aeruginosa
Gram Positive:
- Enterococcus species
- Staphylococcus saprophyticus
- Group B streptococcus
Classic presentation of cystitis
Dysuria
Urinary frequency
Urinary urgency
suprapubic abdominal pain
gross or microscopic hematuria
Classic presentation of Pyelonephritis
Fever/chills/rigors Flank pain CVA tenderness on exam Fatigue Nausea/vomitting and anorexia
what is a common presentation of UTI in older adults
Altered mental status
what are some complications of UTIs
Sepsis and septic shock AKI Perinephric abscess Emphysematous pyelonephritis Papillary necrosis
what are the diagnostic tools of UTIs
Urine dipstick
- Leukocyte esterase
- Nitrates
- Blood
- color is cloudy
Urinalysis with urine microscopy
- Hematuria
- pyuria
- WBC cast
- Bacteria present
Urine culture with sensitivities
what is seen on Urine culture with sensitivities to know a true UTI
True UTI have > 10,000 CFU (colony forming units/ml)
what is the treatment of Uncomplicated cystitis?
Nitrofurantoin
Trimethoprim-sulfamethoxazole DS
Fosfomycin
second line antibiotics
- Fluoroquinolones
- B-lactams
what is the treatment of acute pyelonephritis or complicated UTI?
what is the treatment of asymptomatic bacteriuria?
if no hospitalization is required oral antibiotics
if hospitalization is required treat with IV antibiotics
no treatment is needed of asymptomatic bacteruria unless patient is pregnant
how soon should Urinary catheters be removed?
AS SOON AS POSSIBLE
what is prostatitis and what are the risk factors
infection of the prostate gland
-more common in young and middle aged men
risk factors:
- functional or anatomical anomalies
- Urinary tract instrumentation
- UTIs
- Diabetes
- Smoking
- HIV
what are the typical bacteria in Prostatitis
Gram negative bacilli:
- E.Coli
- Klebsiella pneumonia
- proteus mirabilis
- pseudomonas aeruginosa
Gram positive cocci
- entercococcus species
- normal skin flora
Classic presentation of acute bacterial prostitis
Patients typically appear acutely ill
-fever chills, malaise, N/V, and even signs of sepsis
Irritate voiding symptoms
Obstructive symptoms
suprapubic or perineal pain
classic presentation of chronic bacterial prostatitis
Patients typically present with more subtle signs and symptoms compared to acute prostatitis
symptoms of recurrent UTIs
Obstructive symptoms
suprapubic or perineal pain
pain with ejaculation or blood in semen
what is the diagnosis of acute or chronic prostatitis
Acute:
- digital rectal exam
- urinalysis and urine culture
Chronic prostatitis
- digital rectal exam
- urinalysis and urine culture
- diagnostic standard is prostatic massage (4 glass test or 2 glass test
What is the treatment of prostatitis and for how long?
Fluoroquinolones
Trimethoprim-Sulfamethoxazole
duration of antibiotics is 4-6 weeks
what are the risk factors of BPH
age metabolic syndrome Obesity genetic susceptibility excessive coffee or caffeine intake
Pathogenesis of BPH
results from increased total number of stromal and glandular epithelial cells within the prostate
pathogenesis of Lower urinary tract symptoms
Bladder outlet obstruction (BOO) from BPH
and detrusor muscle overactivity secondary to BOO
Clinical presentation of BPH and LUTs
Storage symptoms:
-urinary frequency, urgency, nocturia, and urinary incontinence
Voiding symptoms
-slow urinary stream, straining to void, urinary intermittency (starting/stopping micturition), splitting of voiding stream, terminal dribbling
Diagnosis of BPH
Digital rectal exam Urinalysis BMP Prostate specific antigen -often elevated in BPH
Post void residual U/S
Pharmacologic Treatment of BPH
A1-blockers
- tamsulosin, alfuzosin, doxazosin
- improvement in 1-2 weeks
5a-reductase inhibitors
- finasteride, dutasteride
- improvement in 6-12 months
Anticholinergic agents
- oxybutynin, tolterodine, fesoterodine, darifenacin
- decrease detrusor muscle contraction
Phosphodiesterase 5-inhibitors
- used mainly in erectile dysfunction and LUTs
- tadalafil
what is a surgical treatment for BPH
Transurethral resection of prostate (TURP)
simple prostatectomy
- open
- laparascopic
- robotic-assisted
what is the DDx of Nocturia
Urinary incontinence Diuretics BPH UTIs Primary polydipsia Polyuria\-Diabetes insipidus
what is the likelihood of getting a symptomatic stone recurrence at 1, 5, and 10 years
15% at 1 year
35% to 40% at 5 years
50% at 10 years
what is the percentage of kidney stones that are calcium?
80%
what are the classical symptoms of Nephrolithisis
Intermittent, severe flank pain that radiates to groin
Hematuria
-gross of microscopic
Gravel passage or visualized stone passage
nausea/vomitting
What are complications of Nephrolithiasis
Hydronephrosis
can lead to AKI or CKD
recurrent urinary infections if stones become infected
what are the diagnosis of nephrolithiasis
Non-contrast CT abdomen and pelvis
-renal stone protocol CT
can do:
- Kidney Ureter bladder x ray
- renal and bladder U/S
- Urinalysis with microscopy
- strain urine
- Metabolic evaluation after stone
what stones are radioopaque and what are radiolucent?
radiopaque: calcium oxalate/phosphate and struvite
(can see)
Radiolucent: uric acid and cystine:
(cant see)
stone shapes: Cystine crystals? Uric acid crystals? Struvite? Calcium oxalate monohydrate? Calcium oxalate dihydrate?
Cystine crystals = hexagonal crystal
Uric acid crystals = Rhombic plates or rosette shaped crystals
Struvite (MAP) = coffin lid crystal
Calcium oxalate monohydrate = dumbell-shaped crystals
Calcium oxalate dihydrate = envelope shaped crystal
Medical therapy for Nephrolithiasis
Fluids Pain control Anti nausea medication Expulsive therapy (dilates ureter) -alpha blocker -calcium channel blocker (nifedipine)
Surgical therapy for Nephrolithiasis
- Extracorporeal sock wave lithotripsy
- ureteroscopy with basket stone extraction
- percutaneous nephrolithotomy (PUL) or open nephrolithotomy
