- urethritis - cystitis - pyelonephritis -UTI = bacteriuria + symptoms

Investigate for: - tumor - stone - diabetes

- most common: e coli - other agents: KEEPS - klebsiella, e coli, enterococcus, proteus/pseudomonas, staph saprophyticus - group D strep, chlamydia, TB -anaerobes don't do well in urine

- dysuria, frequency, gross hematuria, fever and CVA tenderness markedly increase likelihood of UTI - other sx: urgency, hesitancy, suprapubic discomfort - suprapubic discomfort is more predictive than dysuria -flank pain, CVA tender, renal tenderness, f/c, n/v, prostration are all common with acute pyelonephritis

-women: sit facing back of toilet, spread labia, clean from front to back with wipe, pass some urine then catch the rest - men: clean urethral meatus, retract foreskin, obtain midstream urine - for urethritis in men, first-stream urine should be collected - bacteria double each hour in the urine at room temp - cath specimens if need be, but 1-2% of pts develop a UTI after a single catheter insertion

- >90% specificity for bacteria that convert nitrate to nitrite eg. coliform bacteria (e. coli) - low sensitivity (50%) - enterococcus, pseudomonas, acinetobacter do not convert nitrate and are not detected by nitrite test

- UTI - vaginitis/cystitis - urethritis - trauma - allergy - rectol/colon d/o - nephrolithiasis - urethral stricture/obstruction - fistulas - FB - urethral diverticulum - cystocele - chronic d/o

S10C94 - UTI and Hematuria Flashcards by Jerusha Millar

UTI encompasses:

urethritis
cystitis
pyelonephritis

-UTI = bacteriuria + symptoms

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RF for young healthy girls for UTI:

sexual activity
increased sexual activity in past month
spermicide
diaphragm use
new sex partner in past 12mo
age of first UTI

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Uncomplicated UTI: defn

-UTI w/o structural/functional abnormalities without relevant comorbidities that place the pt at risk for more serious adverse outcome and not assoc with instrumentation

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Complicated UTI: defn

-UTI with functional/anatomically abnormality or an infxn in the presence of comorbidities that place the pt as risk for more serious adverse outcome

more likely to be infected with a resistant organism
pts with pyelo may be uncomplicated but they generally get treated as if they were complicated

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Risk factors for ocmplicated UTI

male
anatomic abnormality (catheter, stent, stone, neurogenic bladder, PCKD, instrumentation)
recurrent UTI (>3/yr)
older men
nursing home
neonate
comorbidities (DM, SCD)
pregnancy
immunosuppressed
neurologic dz
atypical pathogen (non e coli infxns)
resistant bug

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Asymptomatic Bacteriuria

presence of bacteria in urine on 2 successive urine cultures in a pt w/o symptoms
pts: pregnant, catheters, nursing home

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Relapse

-recurrence of UTI Sx w/in 1 month with same organism

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Reinfection

-dvpt of symptoms 1-6mo after tx, usually by a different bug

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> 3 UTI in one year

Investigate for:

tumor
stone
diabetes

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UTI pathogens

most common: e coli
other agents: KEEPS
klebsiella, e coli, enterococcus, proteus/pseudomonas, staph saprophyticus
group D strep, chlamydia, TB

-anaerobes don’t do well in urine

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Sexual intercourse risk of UTI: pathophys

-due to milking action of urethra during intercourse, concentration of bacteria in the bladder increases by 10 fold

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UTI symptoms

dysuria, frequency, gross hematuria, fever and CVA tenderness markedly increase likelihood of UTI
other sx: urgency, hesitancy, suprapubic discomfort
suprapubic discomfort is more predictive than dysuria

-flank pain, CVA tender, renal tenderness, f/c, n/v, prostration are all common with acute pyelonephritis

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Urine collection

-women: sit facing back of toilet, spread labia, clean from front to back with wipe, pass some urine then catch the rest

men: clean urethral meatus, retract foreskin, obtain midstream urine
for urethritis in men, first-stream urine should be collected
bacteria double each hour in the urine at room temp
cath specimens if need be, but 1-2% of pts develop a UTI after a single catheter insertion

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Nitrite

> 90% specificity for bacteria that convert nitrate to nitrite
eg. coliform bacteria (e. coli)
low sensitivity (50%)

-**enterococcus, pseudomonas, acinetobacter do not convert nitrate and are not detected by nitrite test

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Leukocyte esterase reaction

sensitivity of approx 77%

- specificity of approx 54%

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Urine culture

-do for: complicated UTI, pregnant women, children, adult males, pts with relapse/reinfection

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Imaging: u/s

-do for: male, elderly, diabetic, severely ill pts with pyelo

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DDx: dysuria

UTI
vaginitis/cystitis
urethritis
trauma
allergy
rectol/colon d/o
nephrolithiasis
urethral stricture/obstruction
fistulas
FB
urethral diverticulum
cystocele
chronic d/o

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Acute cystitis and uncomplicated UTI: Tx

e coli is pathogen most of the time
usually can be treated with a 3d course
septra DS 1 tab BID x3d is good choice but ++ resistance in some places
cipro 250mg BID x3d
levo 250mg OD
macrobid XR 100mg BID x5-7d is good except doesn’t work for saprophyticus
fosfomycin 3g PO once

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Pyelo (uncomplicated): Tx

cipro 500mg BID (7-14d)
levo 500mg OD x14d
septra DS 1 tab BID x14d
amox clav BID x14d

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Ofloxacin 400mg BID x 14d

-treats all UTI pathogens as well as chlamydia and gonorrhea (although gonorrhea is developing resistance)

Pyelo: complications

acute papillary necrosis
ureter obstruction
septic shock
perinephric abscess
emphysematous pyelonephritis

UTI and HIV

often septra resistant b/c used for prophylaxis

- fluoroquinolones should be first line tx

Empiric Tx for Pyelo and complicated UTI

cipro 400mg IV q12h
CTX 1g IV OD
cefotaxime 1-2g IV q8h
gentamicin 3mg/kg/d divided q8h +/- ampicillin 1-2g q4h
piptaz 3.375g IV q6h
cefepime 2g IV q8h
imipenem 500mg IV q8h
meropenem 1g IV q8h

Gross hematuria: how much blood is in pee?

-takes 1cc of whole blood in 1L of urine to cause visible hematuria

Asymptomatic Microscopic hematuria: defn

>3 RBCs/HPF in 2 of 3 urinalysis specimens

Causes of hematuria in men:

- prostate Ca - BPH - infxs - inflammatory - prostatis - seminal vesiculitis - urethritis - STI - epididymo-orchitis - stones - TB - testicular Ca - hemophilia - AC tx - severe HTN - lymphoma - scurvey

Hematuria and stage of micturition:

- initial suggest urethral etiology - stains on panties with clear urine suggests distal urethra or meatus - total hematuria (throughout micturition) suggests kidney, ureter, bladder - terminal hematuria, bladder neck or prastatic urethra

Hematuria in younger pts: etiology

-glomerulonephritis -immune complex d/o -goodpasture syndrome -HSP -wilms tumor in children sickle cell trait -schistosomiasis -poststreptococcal glomerulonephritis

Poststrep glomerulonephritis

- children - follow throat or skin infxn - occurs 7-14d after primary infxn - tx of primary infxn does not prevent it

Risk factors for uroepithelial cancers:

- >40yo - excessive analgesic use - smoking - occupational exposures to dyes, benzenes, aromatic amines - pelvic irradiation - cyclophosphamide use

Hematura >40yo

requires close f/u and further w/u

++back pain and hematuria: dx

-AAA

Hematuria DDx: anywhere

``` Anywhere: -iatrogenic/instrumentation, trauma -infxn -stone -erosion or obstruction by tumor ```

Hematuria DDx: ureter

-stricture

Hematuria DDx: bladdre

- TCC - vascular lesion - chemical/radiation cystitis

Hematuria DDx: prostate

-BPH, prostatis

Hematuria DDx: urethra

- stricture - diverticulosis - FB - endometriosis

Hematuria DDx: glomerular

- glomerulonephritis - IgA nephropathy - lupus nephritis - hereditary nephritis - toxemia of pregnancy - serum sickness - erythema multiforme

Hematuria DDx: non-glomerular

- interstitial nephritis - pyelonephritis - papillar necrosis: SCD, DM, NSAID use - vascular: AV malformation, emboli, aortocaval fistula - malignancy - PKD - medullary sponge dz - TB - renal trauma

Hematuria DDx: hematologic

- coagulopathy - meds - SCD

Hematuria DDx: miscellaneous

- eroding AAA - malignant HTN - renal vein thrombosis - exercise-induced hematuria - cantharidin poisoning - spanish fly - bites/stings

Causes of false hematuria

- munchausen, malingering, drug seeking - meds: NSAIDs, phenytoin, pneothiazines, quinine, rifampin, sulfasalazine - beets, berries, rhubarb - serratia marcescens infxn - amorphous urates - hemoglobinuria, myoglobinuria, porphyrins

Asymptomatic Hematuria

- should have repeat u/a w/in 2w of first episode/treatment | - if hematuria persists pt should be referred to urology

Asymptomatic hematuria >40yo

-with risk factors for urologic cancer they should be referred to a urologist for expeditious outpt w/u w/in 2w

Asymptomatic microscopic hematuria

- no increased risk of urologic malignancy | - however if microscopic hematuria occurs in a high-risk pt (eg. older men) they should be referred fro further w/u

Bladder irrigation for hematuria

- if intravesical clot formation occurs bladder outlet obstruction might occur and may need irrigation - goal is for slightly pink-tinged drainage - may require urology to remove clot

Cancer risk factors for pts with microscopic hematuria:

- smoker - occupational exposure (benzenes, aromatic amines, dyes) - hx of gross hematuria - age >40y - previous urologic hx - hx of recurrent UTI - analgesic abuse - hx of pelvic irradition - cyclophosphamide use - pregnancy - known malignancy - SCD - proteinuria - renal insufficiency

Complications of glomerulonephritis

- pulmonary edema - volume overload - azotemia - hypertensive emergency

Pregnant women with hematuria: ddx

- consider: - preeclampsia - pyelonephritis - obstructing nephrolithiasis