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Clinical Medicine II > UTI > Flashcards

UTI Flashcards

1
Q

20-50 yr old, UTIs are..

A

50x more common in women.. usually cystitis or pyelonephritis
*men of same age group, most UTIs are urethritis or prostatitis

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2
Q

while women 20-50 usually have cystitis or pyelonephritis UTI’s, men of same age usually have

A

urethritis or prostatitis

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3
Q

> 50 yo, incidence of UTI _____? but F:M ratio _____? why?

A

increases
decreases
*more bph and urinary instrumentation

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4
Q

Lower UTI include

A

urethritis, prostatitis, cystitis

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5
Q

Urinary tract is normally sterile so how do UTI’s occur

A

~95% of UTI’s are due to ascending bacterial infection (exposure to colonic bacteria)
*attempted defense is complete voiding of n

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6
Q

most common UTI pathogens

A

E coli 75-95%

  • G- (Kleb, Proteus, and rarely Pseudomonas
  • G+ (S saprophyticusis, enterococcus)
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7
Q

what are risk factors for UTI

A
  1. Reduced Urine flow (outflow obstruction, inadequate fluid intake, neurogenic bladder ie MS or stroke)
  2. Promote colonization (sex, spermicide, low estrogen, antibiotics)
  3. Facilitate ascent (cath, urinary incontinence, diaphragm, contraception)
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8
Q

are UTI in men usually complicated or incomplicated

A

usually complicated

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9
Q

what makes a UTI complicated

A

essentially complicated UTI is anything that makes antibiotic efficacy go down?

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10
Q

what are pt populations with complicated UTI

A 
hx childhod UTI
immunocompromised
Preadolescent or postmeno
pregnant
DM
Urologic abnormalities
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11
Q

what are s/sx of acute cystitis

A

Dysuria, frequency, urgency, +/- hematuria, +/-suprapubic discomfort

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12
Q

what is the likelihood of cystitis in woman that has any UTI sx? what about in a woman with dysuria, frequency but no dc or irritation?

A

probability >50% if any sx present

Probability >90% if dysuria and freq present

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13
Q

what is the PE usually in acute cystitis

A

typically normal

10-20% of women have suprapubic tenderness

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14
Q

what PE aspects should be performed on pt suspicious of having acute cystitis UTI

A 
Gen assessment
check signs dehydration
check CVA tenderness
ABD exam
\+/- pelvic exam if female
genital exam in men, +/- DRE
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15
Q

what is the most valuable dx test for UTI

A

pyuria on UA

  • present in almost all women with acute cystitis
  • abn if >10
  • may see hematuria
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16
Q

what does a urine dipstick detect and is it an appropriate alternative to UA and urine microscopy?

A

*detects leukocyte esterase (pyuria) - 75-95% sensitive, 94-98% specific
*detects Nitrate (presence of enterobacteriaceae)
.. false + with pyridium

YES it is appropriate in tx of acute UNcomplicated cystitis

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17
Q

are routine cultures recommended for women with acute uncomplicated cystitis

A

not necessary; only rec if complicated, acute pyelo, unresolving or recurring sx or atypical presentation
*pregnancy test may be appropriate

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18
Q

what colony count is dx of acute uncomplicated cystitis? what about for a woman with typical cystitis sx?

A

> 1000 for acute uncomplicated cystitis

> 100 if typical cystitis sx

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19
Q

ddx acute cystitis

A

vaginitis, urethritis, structural urethral abnormalities, interstitial cystitis, painful bladder syndrome, PID (pelvic inflammatory disease)

Men: prostatitis, urethritis

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20
Q

PID (pelvic inflammatory disease) PE exam

A

cervical motion tenderness

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21
Q

what is characteristic of interstitial cystitis/painful bladder syndrome

A

UTI sx but no signs of infection on testing

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22
Q

1st line treatment of acute uncomplicated cystitis in women

A
  1. Bactrim ds 160/800 BID x 3 d
    * avoid if resistance >20%
  2. Nitrofurantoin 100mg BID x 5 d
  3. Fosfomycin 3 g single dose
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23
Q

2nd line tx acute uncomplicated cystitis in women

A

*if allergy/resist/cost/avail prevents 1st line use:

FLUOROQUINOLONES (cipro, levo, oflox x 3 d)

24
Q

tx time for acute uncomplicated lower UTI seems to usually be

25
3rd line acute uncomplicated cystitis in women
Oral B-lactams (ie amoxicillin, cefdinir) x 7 days *consider Pyridium for pain but only for 2 d bc don't want to just mask UTI pain, we want it to get rid of the infection
26
1st line: acute COMPLICATED cystitis in nonpreg women
FLUOROQUINOLONES (Cipro 5-14 d or Levo 3 d) *if po is untolerated then treat parenterally
27
Tx for men with acute uncomplicated cystitis
Bactrim of FQ
28
Tx for Pregnant women with acute cystitis
Nitrofurantoin or Amoxicillin-clavulanate (augmentin) *no FQ bc worry about cartilage development in fetus
29
What education should you provide a pt with acute cystitis?
``` push fluids void when feel urge void before/after sex complete antibiotic watch for signs of pyelonephritis ```
30
Is acute pyelonephritis dangerous? Why or why not?
Yes,, potentially organ and/or life threatening. | Can lead to renal abscess, sepsis, shock and or acute renal failure
31
what is septic shock
sepsis induced hypotension that doesn't respond to fluid.. can go into renal failure
32
What clinical and lab findings are consistent in pt with acute pyelonephritis
H&P: Lower UTI sx (freq, urge, dysuria), Upper UTI sx (flank pain), Constitutional sx (fever, chills malaise) GI (N/V, anorexia, abdominal pain, possible suprapubic tenderness)
33
What are UA findings in pt with acute Pyelonephritis
UA: +pyuria >10 +/- hematuria WBC casts (char. of pyelo but not always seen) Urine culture: + = colony count >10,000
34
CBC findings in acute pyelonephrits
leukocytosis with left shift (neutrophils ^)
35
why order BMP for acute pyelonephritis
assess renal function (BUN, Cr)
36
Acute uncomplicated pyelonephritis.. do you image?
imaging not typically indicated in uncomplicated pyelonephritis unless lack of improvement or recurrence
37
acute complicated pyelonephritis.. image?
Yes if appear ill - CT with contrast is image of choice!!! but caution bc contrast nephropathy * renal US and MRI also used
38
Ddx acute pyelonephritis
- appendicitis (but usually RLQ) - Diverticulitis (but usually LLQ) - Cholecystitis (usually RUQ) - Lower lobe pneumonia - PID * also include nephrolithiasis but these stones are usually more painful
39
1st line tx: acute mild to mod pyelonephritis
FQ (Cipro x7d or Levo x5d) * if local FQ resistance in E.coli is >10% then give the FQ+ Rocephin 1g * must followup in 24-48 hr to check susceptibility studes, make sure no abscess/sepsis
40
when and why must you F/u in pt with mild to mod acute pyelonephritis
F/u in 24-48 hr! must check susceptibility studies, alter accordingly, make sure no abscess or sepsis!
41
When should you admit a pt with acute pyelonephritis
comorbid conditions, hemodynamically unstable, Male, metabolic derangement, pregnant, severe flank or abdominal pain, appears toxic, unable to take liquids, high fever, pt unreliable
42
How does the AUA define interstitial cystitis/ Bladder Pain Syndrome?
"an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower UTI sx of more than 6 wk duration in the absence of infection or other identifiable causes"
43
Etiology of interstitial cystitis/painful bladder syndrome (IC/PBS)
W>M common in 4th decade or later often coexists with other chronic pain conditions ie fibromyalgia, IBS, vulvodynia
44
why should we be sympathetic towards IC/PBS pt
often have sx 5-7 yr before dx * impacts psychosocial functioning and quality of life (QOL) - sexual dysfunction, depression * some studies equate IC/PBS to RA and endstage renal disease in QOL
45
what causes IC/PBS
etiology and pathology unclear.. likely a combo of bladder urothelial injury,mast cell activation, chornic inflammatory changes, leukocytosis, firbosis, hypersensitivity
46
what is the most important central finding in IC/PBS
ALTERED UROTHELIUM GAG layer commonly damaged: impedes urothelial growth --> chronic inflammation/injury --> mast cell activation --> inflammation --> sensory innervation --> pain and voiding dysfunction
47
what is the pathophysiology behind IC/PBS
K leaks through permeable bladder tissue and depolarizes nerves --> tissue injury as condition progresses, fibrosis can occur glomerulations common (petechiae, small hemorrhages)
48
what percent of IC/PBS pt are ulcerative
only 10% are the ulcerative type (hunners ulcers)
49
how does a pt with IC/BPS present to the office
highly variable * suprapubic/bladder pain (pressure/discomfort) - often worse with bladder filling, relieved with voiding * pressure, heaviness, discomfort, painful intercourse
50
what information should you get from a pt suspicious of IC/PBS
``` clinical, careful hx >6wk sx location, severity, character pain PMH: prior recurrent UTI, pelvic trauma/surg why increased urinary frequency? #voids/d ```
51
what PE elements should be included in pt with IC/PBS
abd exam, bimanual pelvic exam, DRE in males *may note variable tenderness +/- pelvic floor spasm
52
how do you diagnose IC/PBS
Dx of exclusion: UA with microscopy and urine culture** to exclude infection and hematuria... if blood then cytology and cystoscopy *get cytology if hx of smoking *get culture if chlamydia risk *potential post void residual urine volume to r/o bladder outlet obstruction or neuro disorder
53
when should you get cystoscopy
indicated if in doubt | *if hematuria
54
should you try the K+ sensitivity test on IC/PBS pt
not recommended, this is painful
55
how should you approach treating a pt with IC/PBS
establish baseline sx: 1. voiding log 2. O'leary-Sant Sx and problem questionnaire 3. Pelvic pain and urgency/frequency (PUF) questionnaire * help determine tx response
56
1st line tx for pt with IC/PBS
* lifestyle changes - avoid citrus, acidic/spicy foods, caffeine, EtOH, carbonation * behavior modification: bladder retraining * low impact exercise * psychotherapy or IC/PBS support groups
57
2nd line tx IC/PBS
Oral meds: - TCA (amitriptyline) (not FDA approved but works faste) - Elmiron (only FDA approved tx for IC/BPS but may take 3-6 months to work) - antihistamines (mast cell activation) ie Hydroxyzine, Cimetidine

Clinical Medicine II (8 decks)

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