Urinary tract conditions Flashcards
What is cystitis
Inflammation of the bladder
What are the causative pathogens of UTI
E. coli
Proteus
Pseudomonas aeruginosa
Enterococcus faecalis
What is the most common causative pathogen of UTI
E. coli
What is the most common causative pathogen of UTI in an immunosuppressed patient / patients with catheters
Pseudomonas aeruginosa
What is the most common causative pathogen of UTI acquired in hospitals
Enterococcus faecalis
Risk factors of UTI in adults
Female
Catheterised patients
Why are females more susceptible to UTI
Shorter, wider urethra
Urethra close to anus
What are the risk factors of UTI in children
Girls
Incomplete bladder emptying
Poor hygiene
Vesicoureteric reflux
What can cause incomplete bladder emptying in children
Infrequent peeing
Obstruction due to constipation
Neuropathic bladder
What is vesicoureteral reflux
Condition in which urine flows backward from the bladder to the ureters
What are the 2 routes of spread of infection for UTI
Ascending
Haematogenous
Describe the ascending route of UTI infection
Bacteria from bowel -> perineal skin -> enter the lower urethra -> spread into the bladder -> ureter -> kidneys
Describe the haematogenous route of UTI infection
Bacteraemia / septicaemia affecting the kidneys
What is considered as uncomplicated UTI
Anatomy of the urinary tract is normal, renal imaging is normal
No underlying condition causing the infection
What is considered as complicated UTI
Occurs in urinary tracts with stones
Recurrent infection + stone can cause kidney damage
Symptoms of UTI in adults
Dysuria (pain when urinating)
Urinary frequency
Urinary urgency
cloudy / offensive smelling urine
Haematuria
Lower abdominal pain
What symptoms may suggest lower UTI spreading to upper urinary tract
Loin pain
Fever
Investigations for UTI
Midstream specimen of urine (MSU)
Urine dipstick if indicated
Urine culture if indicated
When is urine dipstick indicated
Women <65
who do not have risk factors for complicated UTI
When is urine culture indicated
Women >65
Recurrent UTI (2 episodes in 6 months)
Pregnant women
Men
Visible / non-visible haematuria
What urine dipstick result can suggest UTI
positive for nitrite or leukocyte and red blood cells
What are the symptoms of UTI in children
Abdominal pain
Dysuria
Haematuria
Urinary frequency
What symptoms of UTI may show in infants
Fever (less common in above 1 year old)
Poor feeding
Vomiting
Irritability
Investigations for UTI in children
Urine dipstick
Urine culture with appropriately collected urine
How should urine culture be collected from a child
Clean catch
If not possible -> urine collection pads
Suprapubic aspiration is only used if the methods above do not work
What should not be used to collect urine sample from a child
Cotton wool balls / sanitary towels
Management of lower UTI in non-pregnant women
Trimethoprim or nitrofurantoin for 3 days
Send culture if >65 / visible or non visible haematuria
Management of lower UTI in pregnant women
Send culture in all cases
1. Nitrofurantoin UNLESS close to TERM
2. Amoxicillin / cefalexin in THIRD term
Why isn’t trimethoprim used in pregnant women for lower UTI
it is teratogenic in the first trimester
Management of lower UTI in men
Send culture in all cases
Trimethoprim / nitrofurantoin for 7 days
Management of lower UTI in catheterised patients
Do not treat asymptomatic patients
Antibiotics for 7 days if symptomatic
Change catheter
Management of lower UTI in children
Refer immediately if <3 months old
Oral trimethoprim / nitrofurantoin
What are the complications of lower UTI
Acute bacterial prostatitis
Acute pyelonephritis
Symptoms of bacterial prostatitis
Symptoms of UTI +
lower abdominal pain
Penile pain
Perineal pain
Tender prostate on palpation
Investigations for bacterial prostatitis
MSU for culture
Management of bacterial prostatitis
Ciprofloxin for 28 days
Management of acute pyelonephritis
Cephalosporin (cefuroxime) / quinolone (ciprofloxacin/ofloxacin) for 10-14 days
What are the types of renal stones
Calcium oxalate and phosphate
Magnesium ammonium phosphate
Uric acid
Cystine
Which type of renal stone is the most common
Calcium oxalate (calcium phosphate is less common)
What are the risk factors for renal stones
Males
20-50
Hypercalciuria
Hypercalcaemia
Hyperparathyroidism
Dehydration
Renal tubular acidosis
Uric acid renal stones can occur in patients with
gout
Causes of calcium oxalate stones
Mostly idiopathic hypercalciuria
Hyperparathyroidism
High intake of dietary oxalate - rhubarbs, cabbages
Increase in oxalate due to malabsorption in small intestine
Drugs
What drugs may increase risk of calcium stones
Loop diuretics
Steroids
Acetazolamide
Magnesium ammonium phosphate renal stones often occur
After infection
Where are the common sites of obstruction due to renal stones
Uretopelvic junction
Vesicoureteric junction (most commonly obstructed)
These are natural constrictions of the ureter
Where is the vesicoureteric junction
Where the ureter joins the bladder
Symptoms of renal stones
Severe sharp, localised, intermittent loin to groin pain
Nausea and vomiting
Haematuria (negative haematuria DOES NOT exclude renal stone)
Sepsis
Investigations for renal stones
Non-contrast CT KUB
Urinalysis
Serum creatinine, U+E - check renal function
ultrasound KUB may be helpful in some
When is ultrasound KUB used
In pregnant women / children with suspected renal stones
But less effective than CT KUB
Why isn’t Xray really used for renal stones
Because not all stones are visible - uric acid and cystine stones are radiolucent
Management of renal stones
If <5mm - watchful waiting + NSAID +/- antiemetics
If >10mm - surgery
Urgent renal decompression + IV antibiotics if signs of obstruction and infection (may be sepsis)
What are the options for treating big renal stones
- Shock wave lithotripsy
- Percutaneous ureterolithotomy
If a patient with large renal stone is obese, what surgical method should be used
Percutaneous ureterolithotomy
Which analgesia is preferred for renal stones
NSAID - IM diclofenac for rapid relief
What are the methods to reduce risk of another calcium stone
High fluid intake
Low salt diet
Thiazide diuretics - increases distal tubular calcium resorption
Risk factors of urinary incontinence
Increasing age
Females
Previous vaginal delivery
Pregnancy
FH
Smoking - causes cough
Obesity
UTI
What are the types of urinary incontinence
Stress UI
Urge UI / overactive bladder
Mixed UI (urge + stress)
Functional incontinence
Outflow incontinence
What is stress UI
Small amounts of urinary leakage when intra-abdominal pressure is raised e.g. laughing, coughing, sneezing
What is urge UI
Urinary leakage due to detrusor overactivity / infection of the bladder (less common)
What is the detrusor muscle
Smooth muscle fibres that line the bladder wall
Classic symptom of urge UI
Urge to urinate quickly followed by uncontrollable leakage of urine
What is overflow incontinence
when you have the urge to urinate but can release only a small amount
What causes overflow incontinence
Bladder outlet obstruction - prostate enlargement / constipation
Underactivity of detrusor muscle
What is functional incontinence
when comorbidities impair the patient’s ability to get to a bathroom in time
What may cause functional incontinence
Sedating medications
Alcohol
Dementia
Investigations for urinary incontinence
Bladder diaries
Examinations - vaginal, abdominal, rectal
Urinalysis
Urodynamic studies - Xray/US when bladder fills and empties
Why do you do vaginal examination for females with urinary incontinence
To check for prolapse of pelvic organs
Check pelvic floor muscle strength
Why do you do rectal examination for patients with urinary incontinence
To check for prostate enlargement / constipation / rectal mass
Management of stress urinary incontinence
- Pelvic floor muscle training for 3 months
- Surgery
- Duloxetine if decline surgery
Function of duloxetine in managing stress UI
Stimulates urethral sphincter
Management of urge UI
- Bladder retraining for 6 weeks
- Antimuscarinics - Oxybutynin / tolterodine
- Beta agonist - Mirabegron
Function of oxybutynin / tolterodine (antimuscarinics) in managing UI
Inhibit contraction
Function of Mirabegron (beta agonist) in managing UI
Induce detrusor relaxation
When is mirabegron (beta agonist) used in managing UI
In frail elderly patients who should NOT use antimuscarinics because it is associated with causing confusion
Types of bladder malignancy
Urothelial carcinoma (transitional cell carcinoma)
Squamous cell carcinoma
Adenocarcinoma
Most common type of bladder cancer
Urothelial carcinoma
Risk factors for urothelial cancer
Smoking
Increasing age
Aromatic amines - used in dyes and rubber industries
What is the most common presentation of urothelial cancer
Papillary growth
Compare the prognosis of the different bladder cancers
Urothelial cancer - best prognosis
Others have worse prognosis because most present as higher grade tumour
Symptoms of bladder cancer
Painless macroscopic haematuria
Investigations for bladder cancer
Refer urgently if present with painless haematuria
CT urogram
Flexible cystoscopy
Management of bladder cancer
If early - TURBT (transurethral resection of bladder tumour)
If higher grade - intravesical chemotherapy
If muscle invasive - cystectomy
What staging of bladder cancer is muscle invasive
T2 and above
What causes urinary retention in men
Benign prostatic hyperplasia
Prostate cancer
Urethral stricture
What causes urinary retention in females
Pelvic prolapse
Pelvic mass
Management of urinary retention
Immediate catheterisation
