Urinary Tract Flashcards
___ is pain/burning w/ urination
Dysuria
___ is blood in the urine
Hematuria
___ is the sudden, strong urge to pass urine
Urgency
__ is the complaint of voiding too often
Frequency
__ is a UTI that is a recurrent infxn, generally w/ different organisms or the same organism, but different susceptibilities
Recurrent UTI
___ is a UTI where an organism never clears, frequently identical susceptibility profile
Persistent UTI
___ is a UTI that generally reflects inadequate tx (duration, drug choice)
Unresolved UTI
___ is a UTI in the context of features that increase risk of therapy failure
Complicated UTI
___ is a UTI in healthy/normal individual
Acute uncomplicated UTI (“acute cystitis”)
___ is bacteria in the urine, w/o significant host response/sx
Asymptomatic bacteriuria
What are some common infectious agents that can cause a UTI? Which organism is most common?
E. coli (80%)
Staph, Klebsiella, Proteus
What % of women report having had a UTI in the past?
50-60% of women
What are local S/s of a UTI? Systemic sx?
Dysuria SP pressure Frequency Urgency Cloudy/malodorous urine
Systemic: fever, malaise, flank pain
What is included in the w/u for a UTI?
Check for CVAT (costovertebral angle tenderness)
UA (cx)
(+/-) genital exam
What is included in the gross exam of a UTI?
Color (food, infxn, meds, blood)
Clarity/turbidity (infxn, post-prandial, phosphaturia)
What is included in the dipstick analysis? (many things!)
Specific gravity pH Blood Protein Glucose Ketones Nitrite Leukocytes
What is the range of normal pH for urine?
5.0-8.0
What is the nml range of blood in the urine?
What can cause a false positive?
What should you consider if you see dysmorphic RBCs?
0-3
Menses, highly concentrated urine, exercise
Glomerular dz
What is the normal range for protein in the urine?
0-4
T/F Some glucose in the urine is a normal finding
F: any amount of glucose in the urine is an abnormal finding
What can ketones in the urine signify?
Hunger or DM
What may cause a (+) nitrite result in a urine dipstick?
INFXN
90% specificity!
What is the normal range for leukocytes in the urine?
What does a (+) leukocyte finding indicate?
0-3+
Often (+) w/ infxn or contamination
T/F Epithelial cells (squamous cells) are an abnormal finding in the urine, especially in women
F: squamous/epithelial cells are commonly found in the urine of a female
___ are protein coagulum found in renal tubule that traps lumenal contents
Casts
What do RBC casts signify?
What do WBC signify?
RBC: Glomerular bleeding
WBC: Pyelonephritis, glomerulonephritis
What are urine crystals associated w/?
Stones!
Who needs a Urine cx?
All men
Women (if recent abx tx, early recurrence, DM, pregnant, surgical or anatomic complexity, sx >7 days)
What are some risk factors for UTI? Explain each. (x3)
Anatomy
- female, incomplete emptying (neurogenic bladder, DM), obstruction (BPH, stricture), phimosis, stones
Behavior
- sexual activity, spermicide use, wiping, baths
Environment
- introduction of contaminated FB
- colonization of chronic FB
- overgrowth due to alternation in normal flora
What are some tx options for UTI?
TMP/SMX (cheap) TMP (pts on warfarin, multiple allergies) Quinolones Nitrofurantoin (longer duration of use) Cephalexin (PCN sensitive) Amoxicillin
What are some non-antimicrobial strategies for tx of a UTI? What is the approximate efficacy of each?
Cranberry or lingonberry juice (20-30% effective)
Vaginal estrogens (30% effective)
Probiotics
Catheters are a problem due inevitable colonization of the bag or tubing, w/ subsequent extraluminal migration ___ % or intraluminal migration ___ % into the bladder
66%
33%
In an open system, __% of pts are bacteruric by 4 days
95%
Closed systems have an infection rate as low as __% per day of catheterization, but as high as __% at 7 days
5%
55%
___ is the combination of bacteria + matrix which results in obstruction or encrustation of catheter
The bacteria are usually ____
Biofilm
Urease-positive
___ is an infection of the renal parenchyma and collecting system
Pyelonephritis, (“upper UTI”)
What are common infectious organisms that can cause pyelonephritis? Which one is the most common?
Most common = E. coli
Proteus, Pseudomonas, Klebsiella
What is more common in pyelonephritis: Ascending spread or Descending spread?
Ascending
What are some predisposing factors for pyelonephritis? (x7)
Prolonged catheter Renal calculi Obstruction DM Immunosupressive Congenital anomalies Pregnancy (PROD ICP)
What are clinical S/s of pyelonephritis?
Fever, chills, malaise, N/V
Flank pain, CVAT on affected side
Dysuria, urgency, frequency
What is included in the w/u for pyelonephritis?
UA+ Cx Blood Cx CBC Chem-8 Renal sonography (excludes obstruction)
What is the tx for pyelonephritis?
IV abx, hydration, blood glucose monitoring
obstruction: decompress via percutaneous tube or urethral stent
**providers should have a low threshold for hospitalization!
___ is a calculi w/in the urinary tract, anywhere from renal calyces to the urinary bladder
Urinary lithiasis
What are etiologies of urinary lithiasis?
Which etiologies are most common?
Ca++ stones (80%) Uric acid stones (5-10%) Struvite stones Cystine stones (1-5%) Mucinex stones/HIV drug stones ** infection stones (15-20%) **see study guide for details
What are predisposing factors for urinary lithiasis?
Environmental factors (chronic FB, factory worker)
Functional abnormalities (high-pressure neurogenic bladder)
Anatomic abnormalities (horseshoe kidney, congenital UPJ obstruction, stenosed infundibulum)
__% of men and __% of women will have at least 1 symptomatic stone by 70 y/o
12%
5%
What are the S/s of urinary lithiasis?
Pain (that waxes and wanes)
hematuria, N/V, UTI sxs, fever
What kind of pain might a pt experience if a stone is located in the following locations:
Kidney? Proximal ureter? Distal ureter? UVJ? Bladder?
Kidney – often asymptomatic
Proximal ureter – flank pain (sharp, intermittent, severe)
Distal ureter – groin/inguinal pain, can radiate to ipsilateral testicle/labium
UVJ – urinary hesitancy, urgency
Bladder – frequently asymptomatic
What is included in the w/u for urinary lithiasis?
A pH level <5.5 suggests ____
A pH level >8 suggests ____
Workup: UA + Cx Chem -8 (renal fxn) imaging - US (if prenant) - KUB (90% stones are radiopaque) - IVP/IVU (intravenous pyelogram) - CT (w/o contrast)
<5.5 = uric acid stone >8 = infection
Where are 3 “tight spots” in the urethra?
Ureteropelvic junction (UPJ) Iliac vessels/pelvic brim Ureteropelvic junction (UVJ)
What is the likelihood of stone passage in relation to stone size?
90% stone in distal ureter and <4mm will pass
50% 4-5.9mm will pass w/o surgery
20% >6mm will pass w/o surgery
What is the tx for urinary lithiasis?
Medical expulsive therapy with α-blocker (Flomax)
- Flomax is not FDA-approved for stones but widely used to facilitate passage of mid- to distal ureteral stone
Strain all urine in anticipation of stone passage
Pain control w/ narcotics, NSAIDs
Urology referral for illness, renal failure, unyielding pain/N/V
What are some indications for surgery for a urinary lithiasis?
Ureteral stone too large to pass Persistent/severe pain Recurrent UTI High risk non-compliance with expectant management Staghorn calculi
**see study guide for specific procedures
What subsequent eval and tx may be required for urinary lithiasis?
Stone composition
Recurrent stone formers need metabolic work-up
What are general recommendations for pts w/ urinary lithiasis?
Increase hydration
Decrease dietary sodium/oxalate/animal protein
How do you tx the following pts post-metabolic w/u from urinary lithasis?
Hypercalciuria?
Hypocitraturia?
Hyperoxaluria?
Uric acid stone?
Hypercalciuria: loop diuretics (HCTZ)
Hypocitraturia: citrate supplementation (Avoid excess Vit-C)
Hyperoxaluria: calcium supplementation!
Uric acid stone: urinary alkalinization for low urine pH, allopurinol
