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nephrology > UTI > Flashcards

UTI Flashcards

1
Q

urinary tract infection: lower vs upper

A

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

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2
Q

epidemiology

A

-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

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3
Q

most common isolates from renal calculi**

A

-Proteus spp.- Urease production
-Klebsiella spp.- Produce extracellular slime and polysaccarides

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4
Q

gram positive cocci

A

-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

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5
Q

urine found to be sterile: rule out STI

A

-Chlamydia trachomatis
-Neisseria gonorrhoeae
-Herpes simplex virus

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6
Q

normal physiology

A

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

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7
Q

pathogenesis: issues regarding female gender

A

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

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8
Q

pathogenesis: issues regarding male gender

A

-Prostatic hypertrophy- Urethral obstruction leading to stagnation
Rectal intercourse
Circumcision status

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9
Q

pathogenesis: pregnancy

A

-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

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10
Q

UTI in pregnancy leads to increased risk:

A

-Low-birth weight baby
-Premature delivery
-Newborn mortality
-ALL UTIs (symptomatic and asymptomatic MUST be treated during pregnancy!
-ONLY POPULATION WE SCREEN

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11
Q

pathogenesis: iatrogenic

A

-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

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12
Q

causes of UTI: urinary stasis

A

-obstructive causes
-neurogenic bladder

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13
Q

causes of UTI: vesicoureteral reflex

A

-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)

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14
Q

symptoms comparison of urinary infections

A

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

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15
Q

urethritis

A

-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

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16
Q

E. coli UTI favored if: (urethritis)

A

-Gross hematuria
-Abrupt onset
-Duration < 3 days
-Hx of previous UTI

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17
Q

cystitis

A

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

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18
Q

acute pyelonephritis sx

A

-Rapid onset
-Fever > 101F
-Shaking chills
-N/V/D
-Tachycardia
-Myalgias
-Septic appearance
-Abdominal/Flank pain
-CVA tenderness

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19
Q

acute pyelonephritis lab findings

A

Hematuria

UA:
-WBC
-Bacteria
-Leukocyte casts
-Leukocytosis

Gram staining
Culture

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20
Q

prostatitis

A

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)

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21
Q

symptoms of different age groups

A

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”

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22
Q

diagnostic testing

A

-Urinalysis
-Urine Culture
-Complete Blood Cell Count
-Basic Metabolic Profile
-Imaging Studies

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23
Q

basic guidelines: tx of UTI

A

-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

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24
Q

asymptomatic bacteriuria: prevalence and who to screen

A

Prevalence:
-0.5 % men
-1-4% girls
-5-10% women
-Only screen for and treat during pregnancy!!!!!!!!!!!

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25
Q

acute cystitis duration of tx

A

-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

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26
Q

cystitis/urethritis antibiotics

A

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)

27
Q

cystitis during pregnancy

A

-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

28
Q

acute pyelonephritis tx

A

-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

29
Q

pyelonephritis antibiotics

A

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)

30
Q

Acute prostatitis vs chronic prostatitis

A

acute:
- + bacterial culture
- tx: 2-4 wks (quinolones preferred)

chronic:
- negative bacterial culture
- positive culture of prostatic secretions
- tx: 4-6 wks (quinolones preferred)

31
Q

pyelonephritis during pregnancy tx

A

-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**

32
Q

UTI in nursing home pt

A

-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)

33
Q

UTI in male patients: workup and what abx to give?

A

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

34
Q

acute prostatitis tx

A

-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

35
Q

chronic prostatitis

A

-70% of cases have sterile urine
-Culture urine and treat initially
-If there is pyuria “without bacteria”- Test for Chlamydia

36
Q

candiduria risk factors and tx

A

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

37
Q

prevention of candiduria

A

-Frequent bladder emptying
-Post coital voiding
-Every 3-4 hours during day
-Good hygiene
-Manage constipation
-Think of the overall picture with your patient

38
Q

epididymitis

A

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

39
Q

benign prostatic hyperplasia

A

-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

40
Q

benign prostatic hyperplasia: obstructive uropathy findings and DDx

A

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

41
Q

urinary incontinence types

A

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

42
Q

causes of urinary incontinence

A

-Delirium
-Infection
-Atrophic urethritis/vaginitis
-Pharmaceuticals
-Psychological disorders (depression)
-Excessive urine output
-Restricted mobility
-Stool impaction

43
Q

erectile dysfunction

A

-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

44
Q

ED tx

A

-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

45
Q

infertility in male pts: history and genital exam

A

-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

46
Q

infertility in male pts: ethiology and semen analysis

A

etiology:
-Abnormal Sperm production
Obstruction of ductal outflow tract

semen analysis:
-count
-motility
-morphology
-serologic testing:
-horomones- testosterone, FSH
-genetic testing

47
Q

differential with testicular complaints: painful vs nonpainful

A

PAINFUL
-testicular torsion- ER
-epididymitis
-inguinal hernia
-trauma
-tumor

non-painful causes
-varicocele: bag of worms
-hydrocele: positive transillumination
-spermatocele
-inguinal hernia
-tumor

48
Q

varicocele vs hydrocele

A

Varicocele
-running athletes
-bilateral varicocele: surgery to prevent infertility
-unilateral- is fine!!!!
-tortuous mass
-veins that contain inadequate valves

Hydrocele: positive transilluminates

49
Q

Polycystic Kidney Disease: Key Points

A

-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

50
Q

polycystic kidney disease: autosomal dominant vs recessive

A

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

51
Q

in AD PKD

A

-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

52
Q

polycystic kidney disease- tx ds

A

-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

53
Q

nephrolithiasis

A

-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

54
Q

nephrolithiasis: composition of stones

A

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

55
Q

nephrolithiasis: struvite stones

A

-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

56
Q

nephrolithiasis: signs and symptoms

A

-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

57
Q

nephrolithiasis: dx evaluation

A

-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

58
Q

nephrolithiasis: Tx options

A

-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

59
Q

cryptorchidism

A

-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

60
Q

cryptorchidism if not corrected

A

-If not corrected leads to increased risk for:
-Testicular torsion
-Testicular trauma
-Infertility
-Increased risk for malignancy

61
Q

cryptorchidism dx

A

-Physical finding
-Ultrasonography vs exploratory surgery
-US less sensitive but used initially (r/o DSD)

62
Q

cryptorchidism management and tx

A

-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

63
Q

vesicoureteral reflux (VUR)

A

-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)

64
Q

vesicoureteral reflux (VUR) dx + tx

A

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

nephrology (7 decks)

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