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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

A

3 days

25
Q

3rd line acute uncomplicated cystitis in women

A

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
Q

1st line: acute COMPLICATED cystitis in nonpreg women

A

FLUOROQUINOLONES (Cipro 5-14 d or Levo 3 d)

*if po is untolerated then treat parenterally

27
Q

Tx for men with acute uncomplicated cystitis

A

Bactrim of FQ

28
Q

Tx for Pregnant women with acute cystitis

A

Nitrofurantoin or Amoxicillin-clavulanate (augmentin)

*no FQ bc worry about cartilage development in fetus

29
Q

What education should you provide a pt with acute cystitis?

A 
push fluids
void when feel urge
void before/after sex
complete antibiotic
watch for signs of pyelonephritis
30
Q

Is acute pyelonephritis dangerous? Why or why not?

A

Yes,, potentially organ and/or life threatening.

Can lead to renal abscess, sepsis, shock and or acute renal failure

31
Q

what is septic shock

A

sepsis induced hypotension that doesn’t respond to fluid.. can go into renal failure

32
Q

What clinical and lab findings are consistent in pt with acute pyelonephritis

A

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
Q

What are UA findings in pt with acute Pyelonephritis

A

UA:
+pyuria >10
+/- hematuria
WBC casts (char. of pyelo but not always seen)

Urine culture: + = colony count >10,000

34
Q

CBC findings in acute pyelonephrits

A

leukocytosis with left shift (neutrophils ^)

35
Q

why order BMP for acute pyelonephritis

A

assess renal function (BUN, Cr)

36
Q

Acute uncomplicated pyelonephritis.. do you image?

A

imaging not typically indicated in uncomplicated pyelonephritis unless lack of improvement or recurrence

37
Q

acute complicated pyelonephritis.. image?

A

Yes if appear ill
- CT with contrast is image of choice!!! but caution bc contrast nephropathy

  • renal US and MRI also used
38
Q

Ddx acute pyelonephritis

A
  • 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
Q

1st line tx: acute mild to mod pyelonephritis

A

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
Q

when and why must you F/u in pt with mild to mod acute pyelonephritis

A

F/u in 24-48 hr! must check susceptibility studies, alter accordingly, make sure no abscess or sepsis!

41
Q

When should you admit a pt with acute pyelonephritis

A

comorbid conditions, hemodynamically unstable, Male, metabolic derangement, pregnant, severe flank or abdominal pain, appears toxic, unable to take liquids, high fever, pt unreliable

42
Q

How does the AUA define interstitial cystitis/ Bladder Pain Syndrome?

A

“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
Q

Etiology of interstitial cystitis/painful bladder syndrome (IC/PBS)

A

W>M
common in 4th decade or later
often coexists with other chronic pain conditions ie fibromyalgia, IBS, vulvodynia

44
Q

why should we be sympathetic towards IC/PBS pt

A

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
Q

what causes IC/PBS

A

etiology and pathology unclear..

likely a combo of bladder urothelial injury,mast cell activation, chornic inflammatory changes, leukocytosis, firbosis, hypersensitivity

46
Q

what is the most important central finding in IC/PBS

A

ALTERED UROTHELIUM
GAG layer commonly damaged: impedes urothelial growth –> chronic inflammation/injury –> mast cell activation –> inflammation –> sensory innervation –> pain and voiding dysfunction

47
Q

what is the pathophysiology behind IC/PBS

A

K leaks through permeable bladder tissue and depolarizes nerves –> tissue injury
as condition progresses, fibrosis can occur
glomerulations common (petechiae, small hemorrhages)

48
Q

what percent of IC/PBS pt are ulcerative

A

only 10% are the ulcerative type (hunners ulcers)

49
Q

how does a pt with IC/BPS present to the office

A

highly variable

  • suprapubic/bladder pain (pressure/discomfort)
  • often worse with bladder filling, relieved with voiding
  • pressure, heaviness, discomfort, painful intercourse
50
Q

what information should you get from a pt suspicious of IC/PBS

A 
clinical, careful hx
>6wk sx
location, severity, character pain
PMH: prior recurrent UTI, pelvic trauma/surg
why increased urinary frequency?
#voids/d
51
Q

what PE elements should be included in pt with IC/PBS

A

abd exam, bimanual pelvic exam, DRE in males

*may note variable tenderness +/- pelvic floor spasm

52
Q

how do you diagnose IC/PBS

A

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
Q

when should you get cystoscopy

A

indicated if in doubt

*if hematuria

54
Q

should you try the K+ sensitivity test on IC/PBS pt

A

not recommended, this is painful

55
Q

how should you approach treating a pt with IC/PBS

A

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
Q

1st line tx for pt with IC/PBS

A
  • lifestyle changes - avoid citrus, acidic/spicy foods, caffeine, EtOH, carbonation
  • behavior modification: bladder retraining
  • low impact exercise
  • psychotherapy or IC/PBS support groups
57
Q

2nd line tx IC/PBS

A

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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