Urinary Tract Infections to include epididymitis, prostatitis and pylonephristis Flashcards
True/False
Urinary tract infections are among the most common entities encountered in medical practice.
True
What is the most common causative agent for UTI
Coliform bacteria
Escherichia coli- being the most common
What is the most common route for UTI
Ascending infection from the urethra
True/False
Hematogenous spread to the urinary tract is common
False
Uncommon
Infection of the bladder is known as what?
Cystitis
Acute Cystitis
most commonly do to what type of bacteria?
coliform bacteria
(a) Especially E coli
(b) Occasionally gram-positive bacteria (enterococci).
Uncomplicated cystitis in men is rare and implies a pathologic process such as what requiring further investigation?
infected stones,
prostatitis,
chronic urinary retention
Signs and symptoms of what issue?
(a) Irritative voiding symptoms
1) Frequency
2) Urgency
3) Dysuria
(b) Suprapubic discomfort
(c) Women may experience hematuria and symptoms often appear following sexual intercourse
(d) Usually afebrile
(e) P.E. may elicit suprapubic tenderness with palpation
Acute Cystitis
Acute Cystitis Differential Diagnosis
(a) Women
(a) Men
(a) Women
1) Vulvovaginitis
2) Pelvic inflammatory disease
(b) Men
1) Urethritis (urethral discharge)
2) Prostatitis (prostatic tenderness)
These issues can cause what type of cystitis?
1) Pelvic irradiation
2) Chemotherapy
3) Bladder carcinoma
4) Interstitial cystitis
5) Voiding dysfunction disorders
6) Psychosomatic disorders
Noninfectious cystitis
Acute cystitis
Laboratory Findings
(a) Urinalysis may reveal:
1) Pyuria
2) Bacteriuria
3) Various degrees of hematuria
Acute cystitis
Laboratory Findings
Urinalysis may reveal:
1) Pyuria
2) Bacteriuria
3) Various degrees of hematuria
Urine culture is positive for the offending organism
Acute cystitis
Follow-up imaging using CT scanning is warranted if
pyelonephritis,
recurrent infections,
anatomic abnormalities are suspected
Imaging
Because uncomplicated cystitis is rare in men, elucidation of the underlying problem with appropriate investigations, such as ________________, is warranted.
abdominal ultrasonography or cystoscopy (or both)
Acute cystitis treatment
1) antibiotic therapy
-Ciprofloxacin (Cipro) 250 mg every 12 hours, PO for 3 days
-Nitrofurantoin (Macrobid) 100 mg every 12 hours PO for 5-7 days
2) analgesics
Phenazopyridine (Pyridium) - urinary analgesic
100-200 mg every 8 hours as needed, PO for a MAX of 3 days
3) Sitz baths may provide symptomatic relief.
Women who have more than ______ episodes of cystitis per year are considered candidates for prophylactic antibiotic therapy to prevent recurrence after treatment of urinary tract infection.
-Prior to institution of therapy, a thorough urologic evaluation is warranted to exclude any what?
- three
- anatomic abnormality (eg, stones, reflux, and fistula).
The three most commonly used oral agents for prophylaxis are what?
1) Trimethoprim-sulfamethoxazole (40 mg/200 mg) daily
2) Nitrofurantoin (100 mg) daily
3) Cephalexin (250 mg).
**Single dosing at bedtime or at the time of intercourse is the recommended schedule for all three.**
Acute cystitis
Infections typically respond rapidly to therapy.
-Failure to respond suggests what?
- resistance to the selected medication or
- anatomic abnormalities requiring further investigation.
Referral to Urology is indicated when:
1) Suspicion or radiographic evidence of anatomic abnormality.
2) Evidence of urolithiasis.
3) Recurrent cystitis due to bacterial persistence.
This defines what?
Infectious inflammatory disease involving the kidney parenchyma and renal pelvis.
Pyelonephritis
Common causative agents for Pyelonephritis
Gram-negative bacteria are the most common ***
(a) E coli,
(b) Proteus,
(c) Klebsiella,
(d) Enterobacter,
(e) Pseudomonas.
Gram-positive bacteria
(a) Enterococcus faecalis
(b) Staphylococcus aureus
Pyelonephritis infection usually ascends from the lower urinary tract with the exception of what through which route?
S aureus, which usually is spread by a hematogenous route (blood stream).
Signs and symptoms of what issue
(a) Fever
(b) Flank pain
(c) Irritative voiding symptoms (urgency, frequency, dysuria)
(d) Shaking chills
(e) Associated nausea and vomiting
(f) Diarrhea
(g) Tachycardia
(h) Costovertebral angle tenderness is usually pronounced.
Pyelonephritis
Pyelonephritis DDx
(a) Acute cystitis or a lower urinary source
(b) Acute intra-abdominal disease
1) Appendicitis
2) Cholecystitis
3) Pancreatitis
4) Diverticulitis
(c) In males
1) Epididymitis
2) Acute prostatitis
(d) Lower lobe pneumonia
Laboratory Findings Pyelonephritis
(a) Complete blood cell count
(b) Urinalysis
(c) Urine culture
(d) Blood culture
a) Leukocytosis (elevated WBC) and a left shift
b) Pyuria, Bacteriuria, Varying degrees of hematuria.
c) Heavy growth of the offending organism
d) Blood culture may also be positive.
Imaging for pyelonephritis
Renal Ultrasound
1) May show hydronephrosis from a stone or other obstruction
Treatment for pyelonephritis
Antimicrobial Therapy
- Inpatient (severe illness, risk for complicated disease)
- -Ampicillin, and gentamicin
- —IV antibiotics are continued for 24 hours after the fever resolves and oral antibiotics are then given to complete the 14 day course of therapy.
- Outpatient
- -Ciprofloxacin (Cipro), 750 mg every 12 hours, PO, (7- 14 days)
- -Levofloxacin 750 mg daily, PO (7-14 days)
- Pain
- -Phenazopyridine (Pyridium), 100- 200 mg every 8 hours as needed, PO for a MAX of 3 days
Pyelonephritis
-Fevers may persist for up to __ hours even with appropriate antibiotics
72 hours
Complications for pyelonephritis
a) Sepsis and shock can occur.
b) Inadequate therapy could result in abscess formation.
c) Catheter drainage may be necessary if urinary retention exists
Follow up
Your pyelonephritis pt has one or more of these issues what is the disposition?
1) Evidence of complicating factors
a) Urolithiasis
b) Obstruction
2) Severe infections or complicating factors
3) Evidence of sepsis
4) Need for parenteral antibiotics
5) Absence of clinical improvement in 48 hours with oral antibiotics.
6) Need for radiographic imaging
7) Need for drainage of urinary tract obstruction
MEDEVAC (urology or infectious diseases)
Follow up
(a) Prompt diagnosis and appropriate treatment, acute pyelonephritis carries a ____ prognosis
(b) Follow-up urine cultures following the _______ is ideal
a) good
b) completion of treatment
Definition of what
Inflammation and infection of the prostate gland
Acute Prostatitis
Acute Prostatitis
Usually caused by______
Less commonly by______
gram-negative rods,
(a) Especially E coli and Pseudomonas species
gram-positive organisms
(a) E,g., enterococci
Acute Prostatitis
The most likely routes of infection include:
(a) Ascent up the urethra
(b) Reflux of infected urine into the prostatic ducts.
(c) Lymphatic and hematogenous routes are rare.
a MALE pt is coming to clinic with these Sign and Symptoms what issue would you suspect?
(a) Perineal, sacral, or suprapubic pain,
(b) Fever, High
(c) Irritative voiding symptoms
(d) Varying degrees of obstructive symptoms may occur as the acutely inflamed prostate swells,
1) May lead to urinary retention
(e) Warm and often exquisitely tender prostate is detected on examination.
Acute Prostatitis
Prostatitis
1) Care should be taken to perform a gentle rectal examination, since vigorous manipulations may result in _____.
2) Prostatic massage is ______
1) septicemia
2) contraindicated
Prostatitis DDx
(a) Acute pyelonephritis
(b) Acute epididymitis
(c) Acute diverticulitis
(d) Urinary retention from benign or malignant prostatic enlargement
Imaging for prostatitis
none
Laboratory Findings
(a) Complete blood count
(b) Urinalysis
(c) Urine cultures
(a) Complete blood count
1) Leukocytosis and a left shift
(b) Urinalysis
1) Pyuria,
2) Bacteriuria,
3) Varying degrees of hematuria
(c) Urine cultures
1) Demonstrate the offending pathogen
Treatment for prostatitis
a) Antimicrobial Therapy
- inpatient
- -Ampicillin, 1 g every 6 hours, and gentamicin, 1 mg/kg every 8 hours, IV
- –antibiotics are continued for 24-48 hours after the fever resolves and oral antibiotics are then given to complete the 4-6 week course of therapy.
- outpatient
- -Ciprofloxacin (Cipro), 750 mg every 12 hours, PO, (4-6 weeks)
- -Levofloxacin (Levaquin), 750 mg daily, PO, (4-6 weeks)
- -Trimethoprim- sulfamethoxazole (Bactrim DS), 160/800 mg every 12 hours, PO (4-6 weeks)
b) Acetaminophen (Tylenol)
c) NSAIDS
d) Stool softeners
Prostatitis tx IF If urinary retention develops
Percutaneous suprapubic tube is required
*Urethral catheterization is CONTRAINDICATED*
Prostatitis patient hase one or more of these issues what is the disp?
1) Evidence of urinary retention
2) Signs of sepsis
3) Need for surgical drainage of bladder prostatic abscess
4) Evidence of chronic prostatitis.
5) Absence of clinical improvement in 48 hours with oral antibiotics
MEDEVAC to Urology
Definition of what issue?
(1) May evolve from acute bacterial prostatitis
(2) Many men have no history of acute infection.
(3) Gram-negative rods are the most common etiologic agents
(4) Only one gram-positive organism (Enterococcus) is associated with chronic infection
Chronic Bacterial Prostatitis
Can chronic bacterial prostatitis be managed by the IDC alone?
No
Signs and Symptoms of what issue?
(a) Variable degree of irritative voiding symptoms
(b) Low back and perineal pain
(c) Suprapubic discomfort
(d) History of urinary tract infections
(e) Physical exam often unremarkable
1) Prostate may be
a) Normal
b) Boggy
c) Indurate
Chronic Bacterial Prostatitis
Chronic bacterial prostatitis Treatment
Antimicrobials
-Trimethoprim-sulfamethoxazole (Bactrim DS) 160/800 mg every 12 hours
-Ciprofloxacin (Cipro), 250-500 mg every 12 hours, PO
-Levofloxacin (Levaquin), 750 mg daily, PO
-(Optimal duration of therapy is controversial, ranging from 6-12 weeks)
Symptomatic relief
-NSAIDS
-Sitz baths
What category of Epididymis?
a) Typically occur in men under 40 years
b) Associated with urethritis
c) Result from Chlamydia trachomatis or Neisseria gonorrhoeae
Sexually transmitted forms
What category of Epididymis?
a) Typically occur in older men
b) Associated with urinary tract infections and prostatitis
c) Caused by gram-negative rods (E-coli, Klebsiella)
Non-sexually transmitted forms
Route of infection for Epididymis is probably what?
via the urethra to the ejaculatory duct
Route of infection for Epididymis is probably what?
via the urethra to the ejaculatory duct
Signs and symptoms of what issue?
(a) May follow acute physical strain (heavy lifting), trauma, or sexual activity.
(b) Associated symptoms of
1) Urethritis
2) Cystitis
(c) Pain develops in the scrotum and may radiate along the spermatic cord or to the flank.
(d) Fever
(e) Scrotal swelling is usually apparent.
(f) Early in the course
1) the epididymis may be distinguishable from the testis
(g) Later
1) The two may appear as one enlarged, tender mass
(h) The prostate may be tender on rectal examination.
(i) Prehn sign may be helpful but is not reliable
Epididymitis
What is Prehn sign?
elevation of the scrotum above the pubic symphysis improves pain from epididymitis
What imaging is useful for epididymitis?
Scrotal ultrasound
Symptomatic relief for epididymitis
1) Bed rest
2) Scrotal support
3) Ice packs
4) Anti-inflammatory analgesics
Antimicrobial therapy for Sexually Transmitted epididymitis
-Ceftriaxone (Rocephin) 250 mg IM x1 dose
PLUS
Doxycycline 100mg BID for 10 days
Antimicrobial therapy for Non-Sexually Transmitted epididymitis
- Trimethoprim/sulfamethoxaz ole (Bactrim) 160 mg TMP PO q 12 hours for 3 weeks
- Ciprofloxacin (Cipro) 250-500mg PO BID for 3 weeks
- Levofloxacin (Levaquin) 750 mg daily, PO (3 weeks)
Delayed or inadequate treatment of epididymitis may result in what issues?
1) Epididymo-orchitis
2) Decreased fertility
3) Abscess formation
When would you refer your epididymitis patient to Urology?
1) Persistent symptoms and infection despite antibiotic therapy
2) Signs of sepsis or abscess formation
