UTI Flashcards
urinary tract infection: lower vs upper
Lower urinary tract- urethritis and cystitis
-typically a superficial infection limited to mucosal surfaces
-localized symptoms- dysuria, urgency, frequency
Upper urinary tract:
-pyleonephritis
-prostatitis**- is lower but presents as upper (tissue invasion)
-intrarenal abscess
-perinephric abscess
-tissue invasion by bacteria -> systemic
-fever, visceral pain (ache)
-N/V
epidemiology
-acute community acquired:
-Between 7-8 million office visits/yr
-Prior to sexual activity 1-3% girls/yr
-Sexually active females 0.5 to 0.7 UTIs/year
-1-2 UTI for females its normal -> if more -> work up
-MC- gram neg bacteria
-uncomplicated UTI- escherichia coli seen in 80% cases**
-proteus, klebsiella, and enterobacter less common
most common isolates from renal calculi**
-Proteus spp.- Urease production
-Klebsiella spp.- Produce extracellular slime and polysaccarides
gram positive cocci
-Staphylococcus saprophyticus
10-15% of uncomplicated UTI in young women
-Enterococci and S. aureus
Typically seen post procedure (ie. Cystoscopy)
-S. aureus in other patients should raise concern of bacteremia
urine found to be sterile: rule out STI
-Chlamydia trachomatis
-Neisseria gonorrhoeae
-Herpes simplex virus
normal physiology
Bladder environment:
-Dilutional effect of urine
-Antibacterial properties- High UREA concentration and OSMOLARITY
-Polymorphonuclear leukocytes
women:
-Vaginal flora: Diphtheroids, streptococcal and staphylcoccal species, and lactobacilli
men:
-Prostatic secretions
-Physical distance- to anus, urethra length
All these have protective effects against UTIs, changes in any of these increase risk for UTI
pathogenesis: issues regarding female gender
anatomy issues:
-Length of the female urethra ~ 4cm
-Proximity to the anus
-Termination under the labia
Sexual intercourse: Causes bacteria to be introduced; Temporal association with UTI
-> Voiding post-coitus decreases incidence
Spermicides:
-Alters normal flora
-Increases incidence of E. coli colonization
pathogenesis: issues regarding male gender
-Prostatic hypertrophy- Urethral obstruction leading to stagnation
Rectal intercourse
Circumcision status
pathogenesis: pregnancy
-2-8% of pregnant women will have a UTI
-20-30% with asymptomatic bacteriuria develop pyelonephritis
Physiologically caused by:
-Decreased ureteral tone and peristalsis
-Incompetence of vesicoureteral valve
UTI in pregnancy leads to increased risk:
-Low-birth weight baby
-Premature delivery
-Newborn mortality
-ALL UTIs (symptomatic and asymptomatic MUST be treated during pregnancy!
-ONLY POPULATION WE SCREEN
pathogenesis: iatrogenic
-catheter induced
-Bacterial biofilm ascends the intraluminal surface of catheter
-Biofilm ascends extraluminal surface periurethral mucus
-Bacterial aggregate attach to intravesicular portion
-Free-floating present in urine
-Bacteria adhere to bladder wall, which causes symptomatic bladder-associated infection
-Bacteria wash down the catheter
causes of UTI: urinary stasis
-obstructive causes
-neurogenic bladder
causes of UTI: vesicoureteral reflex
-Reflux of urine from bladder up through the ureters
-Most common in children
work up: US, then cystourethrogram
primary VUR: congenital short ureter
secondary VUR: caused by high pressure in the bladder (obstruction vs neurologic)
symptoms comparison of urinary infections
Urethritis:
-Dysuria
-Frequency
Cystitis:
-Dysuria
-Frequency
-Urgency
-Suprapubic pain
Acute pyelonephritis:
-Rapid onset
-Fever
-Chills
-Nausea
-Vomiting
-Malaise
-SEPTIC APPEARANCE
-tachycardia
-myalgia
-+/- symptoms of cystitis
prostatitis:
- fever
- chills
- dysuria
- tense/boggy prostate
- purulent dischange on massage
- positive culture or sterile
urethritis
-Dysuria or no symptoms
-No level suprapubic tenderness
Low bacterial count or sterile urine on cx
-Evaluate for STI
-E. coli UTI favored if:
-Gross hematuria
-Abrupt onset
-Duration < 3 days
-Hx of previous UTI
cystitis:
+ suprapubic pain
+ WBCs and bacteria on microscopy
E. coli UTI favored if: (urethritis)
-Gross hematuria
-Abrupt onset
-Duration < 3 days
-Hx of previous UTI
cystitis
Findings include:
-Cloudy, malodorous urine
-WBC and bacteria on microscopy
-Suprapubic tenderness and frequency typically present
May also see:
-Genital lesions – r/o STI
-Fever
-Nausea
-Vomiting
acute pyelonephritis sx
-Rapid onset
-Fever > 101F
-Shaking chills
-N/V/D
-Tachycardia
-Myalgias
-Septic appearance
-Abdominal/Flank pain
-CVA tenderness
acute pyelonephritis lab findings
Hematuria
UA:
-WBC
-Bacteria
-Leukocyte casts
-Leukocytosis
Gram staining
Culture
prostatitis
Acute disease usually affects young men
Signs & Symptoms
-Fever
-Chills
-Dysuria
PE:
-Tense/boggy prostate
-Purulent discharge on prostate massage
-Culture positive- Most commonly gram-negative organism (E. coli or Klebsiella)
symptoms of different age groups
Newborns:
-Fever or Hypothermia
-Decreased feeding
Infants:
-Vomiting / Diarrhea
-Fever
-Decreased feeding or failure to thrive
Children:
-Irritability
-Change in urinary habits
-Poor appetite
Elderly:
-Fever or Hypothermia
-Poor appetite
-“Change in Mental Status”
diagnostic testing
-Urinalysis
-Urine Culture
-Complete Blood Cell Count
-Basic Metabolic Profile
-Imaging Studies
basic guidelines: tx of UTI
-tx is directly related to level of infection
-In most females, treatment may be started without testing
-Any other case, Urine culture must be done. Use empirical antibiotics while waiting
-In male and children, follow-up investigation must be done after first UTI
-Differential diagnosis always includes STI
-Confirmation by urine culture for eradication must be done 3-7 days after treatment is finished for:
-Pregnant women
-Children
-Dx of pyelonephritis
-Obstruction must be identified and treated
asymptomatic bacteriuria: prevalence and who to screen
Prevalence:
-0.5 % men
-1-4% girls
-5-10% women
-Only screen for and treat during pregnancy!!!!!!!!!!!
acute cystitis duration of tx
-Gauge treatment duration on duration of symptoms
-3-5 days: short duration of symptoms
- 5 days: pregnant
-5-7 days: anomaly of urinary tract
-7 days: male patient
-Antibiotic should be chosen based on local resistance status
-Healthy young females may be treated empirically
cystitis/urethritis antibiotics
Nitrofurantoin x 5-7 days (pregnant)
Quinolones
-Levofloxacin x 3 day
-Ofloxacin x 3 days
-Ciprofloxin x 3 days
TMP/SMX x 3 days
Special situations:
-If previous medications are contraindicated: Cephalexin 5-7 days (pregnant)
-enterococcus: Amoxicillin x 5-7 days (pregnant)
cystitis during pregnancy
-Treatment is 5 days
-*Eradication must be confirmed!
-Antibiotic:
-Nitrofurantoin 75mg PO BID
-Amoxicillin 500mg PO TID
-First generation cephalosporin:
-Cefadoxil 500mg PO BID
-Cephalexin 500mg PO TID
acute pyelonephritis tx
-May be managed as outpatient
Hospitalize if:
-Intractable vomiting
-Evidence of shock
-Severe dehydration
-Initiate treatment in the hospital for pregnant females
-Treatment should last at least10 days
-Follow-up 3-5 days after treatment completion
-Obtain urine culture prior to treating
-However, do not wait for culture report prior to treating…
-You can modify the treatment later if needed
pyelonephritis antibiotics
Quinolones x 10 days
-Levofloxacin
-Norfloxacin
-Ciprofloxacin
Cefuroxime IV:
-If unable to tolerate PO
-May be changed to a PO med when able
TMP/SMX 160/800mg PO daily x 14 days
-Only after sensitivity known (high rate of resistance)
Acute prostatitis vs chronic prostatitis
acute:
- + bacterial culture
- tx: 2-4 wks (quinolones preferred)
chronic:
- negative bacterial culture
- positive culture of prostatic secretions
- tx: 4-6 wks (quinolones preferred)
pyelonephritis during pregnancy tx
-Initiate treatment with IV or IM in hospital
-IV hydration may be required
Abx:
-Cefuroxime IV
-Ceftriaxone 1mg IM daily may be used
- afebrile patient: take oral meds x 10 days
-Ensure eradication of organism with repeat Urine culture** 5 days post tx**
UTI in nursing home pt
-High levels of resistance seen
-Use urine culture and sensitivity
-Local hospitals may report an antibiogram
-Treat using narrow spectrum antibiotics
-Pseudomonas, enterococci, staphylcocci, and candida species are more common than in the outside population…
-E. coli is seen in 50% (however tend to be resistant strains)
UTI in male patients: workup and what abx to give?
Prostatic hyperplasia should be evaluated
-Digital rectal exam
-Ultrasound: prostate and residual bladder volume measured
-PSA
Obtain urine culture (and blood culture if considering prostatitis) prior to treatment
If febrile, quinolones are the drug of choice -> This class attains the best concentration in prostate
acute prostatitis tx
-Antibiotic options
-Quinolones
-Ciprofloxacin or norfloxacin
-Treatment of choice if not contraindicated
-TMP/SMX (Check sensitivities prior due to resistance)
-Duration of treatment
-Acute infection: 2-4 weeks
-Chronic infection: 4-6 weeks
chronic prostatitis
-70% of cases have sterile urine
-Culture urine and treat initially
-If there is pyuria “without bacteria”- Test for Chlamydia
candiduria risk factors and tx
Complication that affects patients that have:
-Indwelling urinary catheter (long term)
-ICU patient treated with broad spectrum Abx
-Comorbidity of DM or immune suppression
Tx
- Remove catheter (resolves 1/3 of cases)
-Fluconazole 200-400mg/day for 14 days
-Flucytosine and Amphotericin B (if resistant)
-Untreated may lead to sepsis
prevention of candiduria
-Frequent bladder emptying
-Post coital voiding
-Every 3-4 hours during day
-Good hygiene
-Manage constipation
-Think of the overall picture with your patient
epididymitis
Symptoms:
-Fever
-Painful Voiding Symptoms
-enlargement of epididymis
-very painful to touch
-tenderness in the posterolateral aspect
Causes:
-Sexually transmitted:
-Chlamydia
-Gonorrhea
-Non-sexual caused:
-Associated with prostatitis and gram negative organisms
Treatment:
-Bed rest
-Scrotal elevation
-Treat the underlying pathogen
benign prostatic hyperplasia
-MC benign tumor
-over 80 years of age -> >90% chance
-Symptoms are based on progression of disease
-Endocrine relation with genetic and race connections likely
-Hyperplastic process
Nodular growth pattern
-Treatment likely works with or against the components affected
-Alpha-blocker- smooth muscle component
-5-alpha-reductase inhibitors- epithelium component
benign prostatic hyperplasia: obstructive uropathy findings and DDx
Findings may include:
-Distension of urinary bladder
-Enlarged palpable prostate
-Hydronephrosis
-enlarged, boggy prostate
-no nodules or odd feeling
IF THERE IS PROSTATE CANCER- enlarged, nodular, firm prostate
IF THERE IS PROSTATISTIS- hot, enlarged, tender
urinary incontinence types
Stress
-Pelvic floor is unable to prevent passage of urine
-Occurs with coughing, sneezing, laughing
Urge
-Involuntary loss of urine with sudden sensation to urinate
Overflow
-Constant ‘dribbling’ of urine at all times or for a time period after urinating
Structural
-Typically related to fistulas in women
causes of urinary incontinence
-Delirium
-Infection
-Atrophic urethritis/vaginitis
-Pharmaceuticals
-Psychological disorders (depression)
-Excessive urine output
-Restricted mobility
-Stool impaction
erectile dysfunction
-Definition: the inability to achieve or maintain an erection sufficient for satisfactory sexual performance
-May be a marker of cardiovascular disease
-Risk factors include:
-Age
-CV disease
-Smoking
-DM
-Pelvic surgery/radiation
-Drugs/Alcohol
ED tx
-Medications
-Phosphodiesterase Type 5 Inhibitors -> Sildenafil, Tadalafil, Vardenafil (oral); Alprostadil (Injected)
-Testosterone replacement- sex drive not ED
-Evaluate for current medications as a side effect causing ED
-surgical
-non-surgical- vacuum therapy
infertility in male pts: history and genital exam
-Prior fertility?
-STD history
-Steroid/testosterone use
-Surgeries
-Injuries
-Physical activity
-Birth history (if known)
-Secondary sexual characteristics present
-Gynecomastia
-Eunuchoid habitus
Male genital exam:
-Urethral meatus position
-Testicular size
-Epididymis
-Pampiniform plexus
-Vas deferens
infertility in male pts: ethiology and semen analysis
etiology:
-Abnormal Sperm production
Obstruction of ductal outflow tract
semen analysis:
-count
-motility
-morphology
-serologic testing:
-horomones- testosterone, FSH
-genetic testing
differential with testicular complaints: painful vs nonpainful
PAINFUL
-testicular torsion- ER
-epididymitis
-inguinal hernia
-trauma
-tumor
non-painful causes
-varicocele: bag of worms
-hydrocele: positive transillumination
-spermatocele
-inguinal hernia
-tumor
varicocele vs hydrocele
Varicocele
-running athletes
-bilateral varicocele: surgery to prevent infertility
-unilateral- is fine!!!!
-tortuous mass
-veins that contain inadequate valves
Hydrocele: positive transilluminates
Polycystic Kidney Disease: Key Points
-Genetic disorder
-Fluid filled cysts cause:
-Kidney enlargement that displaces normal structure
-Reduced kidney function then occurs
-1/3 of patients with polycystic kidney disease progress to end-stage renal disease and require renal replacement
-“Simple” cysts in kidneys or liver does not equal PKD absolutely
-autosomal recessive PKD is less common (10%)- born with it, high mortality, HTN
-autosomal dominant PKD is MC (90%)- 20s, HTN
polycystic kidney disease: autosomal dominant vs recessive
DOMINANT
-90% of PKD
-Onset: age 30-40
-Cysts may start in childhood but progress to clinical significance in adulthood
-HTN is commonly found in late 20s
-Imaging will make dx
RECESSIVE
-10% of PKD
-Onset: during fetal development
-HTN and UTIs in childhood
-Growth failure
-Liver failure
-May need both liver and kidney transplantation
-30% neonatal mortality rate
in AD PKD
-Usually clinically silent – incidental finding
-Patient may present with: HTN, hematuria, proteinuria, renal insufficiency
-May lead to Chronic Renal Failure- Most common genetic cause of CRF
polycystic kidney disease- tx ds
-Treatment options
-Control of HTN- First line ACE-inhibitors or ARBs to decrease RAS system activity
-Limit sodium in diet
-Aggressive treatment of hypercholesterolemia
-Renal replacement
nephrolithiasis
-Solid crystal or concretion developed in kidneys
-Classified by location or composition
-Most will pass (usually without any symptoms)
-Pain occurs when stones are not able to pass and cause obstruction or if spasm of ureter occurs
nephrolithiasis: composition of stones
Calcium oxalate and
-Calcium phosphate- Starts with calcium phosphate concentrations that cause a ‘Randall’s Plaque’ that leads to calcium oxalate depositions and stone formation
Uric acid- Solubility pattern leads to deposition with persistently acidic urine
Struvite -Proteus mirabilis urease cleavage making urine alkaline leading to ‘staghorn calculus’
Cystine- Genetically caused by abnormal recessive gene for cystine transport
nephrolithiasis: struvite stones
-Urease producing organisms cleave urea to make NH4 and make urine alkaline, leading to phosphate deposition
-The deposition then becomes a site for continued growth of bacteria
-staghorn calculus
nephrolithiasis: signs and symptoms
-Flank pain
-Cramping, colic-like pain
-Moderate to severe intensity
-Nausea and Vomiting
-Absence of fever
-Labs:
-+ blood (whole cells present)
-+ protein
-+/- WBCs/infection
-CT: See the stones/obstruction
-Ultrasound: Hydronephrosis if obstruction
-Cystoscopy
nephrolithiasis: dx evaluation
-Non-contrast CT Abd/Pelvis
-Gold standard
-Finds the stone in 96% of cases
-Positive predictive value is 100%
-Negative predictive value is 97%
-Ultrasound
-1st imaging test in pregnant female but inferior to CT
nephrolithiasis: Tx options
-Dietary:
-Increase fluid intake
-Limit calcium intake
-Increase citrate-rick drinks
-Limit Vitamin C
-Limit protein
-Allopurinol (if uric acid)
-Analgesia- Opiate based is often needed
-Expulsion assistance- Alpha-blockers
-Lithotripsy
-Surgical options
cryptorchidism
-Condition in which the testis has not descended into the scrotum by 4 months old
-Absent or undescended
-Most common congenital abnormality of the GU tract in males
-Can be bilateral (10%) or unilateral
-Increased risk with premature births
-30% versus 2-5% in normal births
-Other risk factors:
-Low birth weight
-Prenatal exposure to hormonal disruptors
cryptorchidism if not corrected
-If not corrected leads to increased risk for:
-Testicular torsion
-Testicular trauma
-Infertility
-Increased risk for malignancy
cryptorchidism dx
-Physical finding
-Ultrasonography vs exploratory surgery
-US less sensitive but used initially (r/o DSD)
cryptorchidism management and tx
-Management
-If bilateral – assess for genetic/chromosomal abnormality and refer to a multidisciplinary team if DSD identified
-If no hormonal/chromosomal abnormality- Refer to pediatric urologist for exploratory surgery and orchiopexy
-Long term care
-Monthly self testicular examination and evaluation clinically due to increased lifetime risk of testicular cancer
vesicoureteral reflux (VUR)
-Retrograde flow of urine from bladder to upper urinary tract
-Increases risk for pyelonephritis
-Primary VUR
-Caused by incompetent closure of the ureterovesical junction
-Usually related to a congenital short ureter
-Secondary VUR
-Caused by high pressure in bladder (neurologic or obstructive)
vesicoureteral reflux (VUR) dx + tx
Dx:
-Start with US following initial UTI in children to assess for renal abnormalities
-Voiding cystourethrogram
Treatment:
-Antibiotic prophylaxis
-If neuropathic cause, attempt treatment of cause or catheterization to decrease bladder pressure
-Referral to urologist for surgical correction if continuing past 2-3 years old
-Surgical procedure is reimplantation of ureters to normal position resulting in decreased reflux
-Goals of Treatment:
-Decrease infection rates
-Limit injury to the kidneys
