Renal Tract Conditions Flashcards
What is a urinary tract infection
Infection of the urinary tract system (bladder, urethra, kidneys), generally caused by bacteria (especially E. coli)
How common are UTIs
Lifetime incidence of UTIs in adult women is 50% to 60%
Who are affected by UTIs
Women are at high risk due to a shorter urethra and the proximity of the anal and genital regions
Prevalence increases with age with women over 65 x2 as likely as rest of female population
Children with chronic constipation
What causes UTIs
Bacteria:
Infection ascends from the urethra to the bladder and can ascend further to the ureters and the renal pelvises (pyelonephritis)
E. coli is usually the causative organism
Staph Saprophyticus is 2nd
Viral:
Immunocompromised ptx and children most susceptible
Adenovirus, cytomegalovirus and BK virus are commonly involved in haemorrhagic cystitis
Yeast:
Rare (usually Candida species)
Abacterial:
Intersitial cystitis
What are the risk factors for UTIs
Sexual intercourse Indwelling urinary catheres Pregnancy Abnormalities of the urinary tract - prevent bladder emptying - resulting in urinary stasis - EG Urinary bladder diverticulum, Benign prostatic hyperplasia, congenital malformations causeing vesicoureteral reflux
How do UTIs present
Clinical findings depend on which part of the tract is affected and who is presenting
Lower:
- Dysuria
- Haematutia
- Suprapubic pain
- Urinary urgency
- Increased urinary frequency
Upper:
- Same symptoms as above plus the following
- Fever
- Flank pain
- Fatigue/malaise
- Nausea and vomiting
In males they may have prostatic/perineal area pain
In children:
- Urinary incontinence
- Malodorous urine
- Irritability
- Poor feeding
- Failure to thrive
In elderly:
- Delirium/ acute confusion
What are potential signs on examination of those with suspected UTI
Pyuria (white blood cells can cause cloudiness)
Bacteriuria
Positive leukocyte esterase and nitrites on urinalysis
What are the differentials of UTi
If experiencing the fever and flank pain then take this as a sign of more serious infection eg pyelonephritis
Interstitial cystitis (painful bladder syndrome)
Asymptomatic bacteriuria
Vaginitis
Pelvic inflammatory disease
Prostatitis
Trauma
How would a patient with suspected UTI be investigated
Urinalysis Urine culture Imaging: - CT without contrast - Ultrasound
How would UTI be explained to the patient and what would be discussed
Infection of the urinary tract system (bladder, urethra, kidneys), generally caused by bacteria (especially E. coli)
Easily treatable
Pregnant women need immediate antibiotics no matter severity of symptoms
Non-pregnant women can be given antibiotics if sever symptoms or a back up prescription to take if symptoms do not start to improve within 48 hours or if they worsen
Self-care:
- Drink enough fluids to not feel thirsty
- Take paracetamol or ibuprofen for pain relief
Safety net:
- Call healthcare services if
- Shivering, chills muscle pain
- Confusion, or drowsiness
- No urine passed in 24hrs
- Vomitting
- Blood in urine
- Temp high (>38) or low (<36)
- Kidney pain in back or under ribs
- Worsening UTI symptoms
- No improvement after 48hours of antibiotics
What is the treatment for a UTI
First-line empiric antibiotic therapy for uncomplicated UTIs includes outpatient therapy with oral trimethoprim-sulfamethoxazole, nitrofurantoin or fosfomycin for up to 7 days
For complicated UTIs antibiotic therapy should be extended for 7-14 days
Pregnant women with cystitis should be screened and treated if positive for asymptomatic bacteriuria
What is pyelonephritis
A severe infectious inflammatory disease of the renal parenchyma, calcices and pelvis that can be acute, recurrent or chronic.
Refers specificaly to infections in the kidney
Who is affected by pyelonephritis
Hospitalisation as a result of acute is 5x more common in women than men however women show a much lower mortality rate.
Complicated acute pyelonephritis tends to occur in med, older people, pregnant women and those with underlying anatomical or physiological abnormalities, immunosuppression, obstruction, catheteriation, incorrect abx selection and usage and resistant organisms
Slightly more than 20% of renal transplant patients suffer from acute pyelonephritis within 2 months of surgery.
What causes pyelonephritis
Acute:
- Enteric bacteria (eg E coli) that ascend from the lower urinary tract or that spread haematogenously to the kidney
Complicated infections can result from:
- Underlying medical problems (eg diabetes, HIV)
- Genitourinary anatomical abnormalities
- Obstruction (eg benign prostatic hypertrophy, calculi)
- Multi-drug-resistant pathogens
What are the risk factors for pyelonephritis
Strong:
- UTI
- Diabetes
- Stress incontinence
- Foreign body in urinary tract (eg calculus, catheter)
- Anatomical/ functional urinary abnormality
- Immunosuppressive state
- Pregnancy
- Frequent sexual intercourse
Weak:
- Maternal family history of UTI
- New sex partner
- Spermicide use
- Age between 18 and 50 years
- Age >60years
How does pyelonephritis present
Fever Presence of risk factors Nausea and vomiting Dysuria, frequency, or urgency Flank pain or costovertebral angle tenderness
Which other conditions present similarly to pyelonephritis
Chronic vs acute pyelonphritis
Pelvic inflammatory disease
Pelvic pain syndrome
Cystitis
Acute prostatitis
Lower lobe pneumonia
How is suspected pyelonephritis investigated
1st line investigations:
- urinalysis
- gram stain
- urine culture
- full blood count
- erythrocyte sedimentation rate
- CRP
- procalcitonin
- blood culture
Investigations to consider:
- renal ultrasound
- contrast enhanced spiral computed tomography
- magnetic resonance imaging
Emerrging tests:
- interleukin
- copeptin
How would pyelonephritis be discussed with patient
If taken abx then follow and complete regimen so recurrent infection is prevented
Should be aware and alert their doctor of concerning symproms such as fever or flank pain
If pregnant, UTI may ascend to the kidney and may be sever so important to seek routine antenatal testing and treatment in such situations
How is pyelonephritis treated
Goals of treatment are infection control and symptom reduction
Indications for hospitalisation:
- Inability to maintain oral hydration or adherence to meds regimen
- Hypotension
- Vomiting
- Dehydration
- Sepsis
- High WBC count
- Temp >39
- Severly ill with multiple comorbidities
- Pregnancy
- Uncertain about diagnosis
- Older and/or immunocompromised
Start abx before results of blood or urine cultures are returned in order to prevent ptx deterioration
Mild to moderate and uncomplicated pyelonephritis:
- Oral antibiotics:
- Fluoroquinolones
- Cephalosporins
- Sulphonamides
Severe and complicated pyelonephritis and pregnant ptx:
- hospitalisation and treatment with IV agents
- Choice of abx regimen based on blood/urine cultures and localised resistence patterns
- Possible regimens:
- Fluoroquinolones
- Extended spectrum cephalosporins
- Aminoglycosides with or without ampicillin
- Aminopenicillins
- Antipseudomonal penicillins
- Carbapenems
- Two week course of IV abx often sufficient
What is the prognosis of pyelonephritis
Complications:
- obstruction requiring catheterisation
- spesis
- renal failure
- abscess formation
- antibiotic failure
Recurrence:
- Usually occurs within 1-2 weeks
- Most likely cause is insufficient duration of initial treatment
What is hydronephrosis
Swelling of a kidney due to a build up of urine. It happens when urine cannot drain out from the kidney to the bladder froma blockage or obstruction. Can occur in one or both kidneys
How common is hydronephrosis
Prevalence in general population is 0.15% to 0.67%
What causes hydronephrosis
Usually caused by another underlying illness or risk factor:
- Kidney stone
- Congenital blockage
- Blood clot
- Scarring of tissue due to injury or previous surgery
- Tumor or cancer (bladder, cervical, colon, or prostate)
- BPH
- Pregnancy
- UTI
What are the risk factors for hydronephrosis
Renal calculi
External compression from abdominal and pelvic masses and tumors
Diabetes
Neurogenic bladder
Congenital anomalies of kidneys and urinary tract
How does hydronephrosis present
Pain in back or side (may be sudden and sever or may be a dull ache that comes and goes over time) (may get worse after drinking lots of fluid)
UTI symptoms
Haematuria
Decrease in urinary frequency or with a weaker stream
Does not tend to cause symptoms in babies
What are the differential diagnoses for hydronephrosis
Renal sinus cysts
Extrarenal pelvis
Pseudohydronephrosis
How is suspected hydronephrosis investigated
Ultrasound usualling confirms diagnosis Can also use Xray, CT or MRI Cystoscopy FBC U and E CRP LFT Urinalysis
