UTI Flashcards
Urinary tract infections
- cystitis (acute uncomplicated, acute complicated, recurrent, interstitial cystitis)
- Acute pyelonephritis
- Acute prostatitis
- Epididymitis
- Urethritis (GC, NGU, Trichomoniasis)
Types of acute cystitis
o Uncomplicated
Healthy nonpregnant women
o Complicated Children Elderly Men Pregnancy Chronic medical conditions Recurrent UTI
UTI prevalence
o 50-60% of all women will experience a UTI o 10% post-menopausal women o 3% school-age girls o 1% school-age boys o <1% adult men have uncomplicated UTI
Pathophysiology of UTI
o Uropathogens from the fecal flora colonize the vaginal introitus
o Bacteria travel into the urethra and bladder and stimulate a host response
o May be facilitated by sexual intercourse
o Spermicides change the vaginal environment in favor of pathogens
Protective physiology against UTIs
o Micturition washes out most bacteria o Ureterovesical junctions close during micturition, preventing reflux of urine o Urine pH is bactericidal o Length of male urethra is prohibitive o Prostatic secretions are bactericidal
Risk factors for UTI
o Female sex o Sexual activity o Diabetes = more sugar in the urine which means that you're more likely for bacteria to grow o Neurogenic (atonic) bladder o Urinary obstruction (i.e. BPH) o Kidney stones change the pH of the urine - higher pH o Vesicoureteral reflux o Indwelling urinary catheters
Etiology of acute cystitis
o E. coli - 80-85%
o Staph saprophyticus 2nd most common
o Small number caused by Proteus, Klebsiella, enterococci, or other Gram negative bacteria
o Chlamydia may present as symptomatic UTI in some women
o Proteus is associated with kidney stones
Clinical presentation of acute cystitis
o Dysuria
o Urinary frequency and/or urgency
o Urinary incontinence
o Suprapubic pain or pressure
o Hematuria
o Elderly patients many times don’t present with classical symptoms like younger adults do
o Hematuria - always ask if thy are menstruating
o Because of the irritation of the bladder, they feel like they have to pee all of the time
o acute onset
Diagnosis of acute cystitis
o History, PE, Urinalysis
o PE
-Temp
-Abdominal exam
-CVA tenderness í leads you more to pyelonephritis
-GU/pelvic exam if symptoms
o You don't need to do a pelvic on everyone with a UTI
o Strawberry cervix = trichomonasUrinalysis for acute cystitis
o Midstream “clean catch” sample
o Leukocytes (pyuria), hematuria, nitrites
o Microscopic evaluation and culture usually not indicated
-Urine dipstick negative → Microscopic UA
-Casts indicate upper UTI
o UPT to rule out pregnancy
o Urine for GC/Chlamydia if suspected
o Nitrites are helpful because if you see them, then its probably E. coli
Treatment of uncomplicated acute cystitis
-Empiric treatment without microscopic UA or urine culture
-Nitrofurantoin; short course of SMP-TMX or a fluoroquinolone may be effective
-Depends on local resistance patterns and pt h/o recent abx use
-Pyridium 200mg po bid x 3 days prn dysuria
-Hydration; cranberry juice
-Can treat with Bactrim and sulfa
o All of these would be appropriate depending on your local resistance patterns
o SHORT COURSE - 3-5 days is usually enough for acute cystitis
treatment of complicated acute cystitis
o Complicated acute cystitis
-Fluoroquinolone PO x 7-10 days
-Ceftriaxone 1g IM or IV qd x 7-10 days
o If no clinical improvement in 48 hours:
-Urine culture
-Consider alternate diagnosis
-Imaging studies: US, CT to rule out urinary tract pathology
o Can’t give quinolone to pregnant women í have to give ceftriaxone
Follow up for acute cystitis
o Repeat urine culture not usually needed
o Follow up only if patient does not improve or worsens
o Society Guidelines
Recurrent cystitis
o Common among women
o Relapse vs Reinfection
-Relapse: same infecting strain; infection within 2 weeks of treatment
-Reinfection: same infecting strain >2 weeks after treatment; or a different strain
-Vast majority are reinfections
risk factors for recurrent cystitis
o Genetic component
-Nonsecretor, P1, and IL-8R phenotypes
-Mother with recurrent UTI
-Having first UTI before age 15 years
-If your mom and sisters and aunts get UTIs, you probably will too à there is a high probability you will too
o Frequent sexual intercourse
o Diaphragm-spermicide or condom with spermicide
o Urinary incontinence
o Cystocele
o Increased postvoid residual volume
-BPH
-Atonic bladder
o Vaginal/urethral atrophy
o Virulence determinants of uropathogens
Prevention strategies for recurrent cystitis
o Postcoital voiding
o Discontinue spermicide use
o Increased fluid intake (to increase micturition)
o Cranberry juice (unsweetened)
o Treatment of underlying issues (incontinence, atrophic vaginitis, etc)
Treatment of recurrent cystitis
o Antimicrobial prophylaxis
-Two or more symptomatic UTI within 6 months
-Three or more symptomatic UTI within 12 months
o Women are over 85% accurate in their own diagnosis of UTI
o Post-menopausal women
-Vaginal estrogen cream normalizes vaginal flora and can reduce recurrent UTI
o Lactobacilli
-Maintain low pH
-Produce bactericidal chemicals (H2O2)
Antimicrobial prophylaxis for recurrent cystitis
o Varying recommendations for length of prophylaxis
-6-12 months → increased rate of recurrence
->2 years
o Side effects of prophylaxis
-GI disturbance
-Oral and/or vaginal candidiasis
Urology referral qualifications
o Recurrent UTI if suspect urogenital abnormality or complicated patients
o Persistent hematuria despite treatment
o Complicated UTI in males
Diagnostic studies
o CT scan Abdomen & Pelvis o Abdominal US - bladder pathology o Renal US - nephrolithiasis or obstruction o Cystoscopy o Voiding cystourethrogram o Urine cytology
interstitial cystitis
o Syndrome of chronic or recurring bladder discomfort and/or pelvic pain in absence of other etiology
o Affects tissues of the lower urinary tract, pathology poorly understood
o Symptoms include urinary urgency, frequency, dysuria, nocturia, pubic/pelvic pain/pressure
Epidemiology of interstitial cystitis
o Common but prevalence not clear, probably 3%-6% women in USA
-Women 5x more likely than men
o Usually diagnosed in 4th decade of life
o Associated with other chronic pain syndromes
-Fibromyalgia, Irritable bowel syndrome, Vulvodynia
-Vulvodynia, fibromyalgia, IBS
vulvodynia
vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.
fibromyalgia
common cause of chronic musculoskeletal pain. It is one of a group of soft tissue pain disorders that affect muscles and soft tissues, such as tendons and ligaments. None of these conditions is associated with tissue inflammation and the etiology of the pain is not known.
IBS
Irritable bowel syndrome (IBS) is a gastrointestinal syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. It is the most commonly diagnosed gastrointestinal condition.
Interstitial cystitis pathophysiology theory - abnormal permeability
o Disruption in the urothelium and dysfunction of defense mechanisms
o Toxic compounds in urine (K+) penetrate protective layer of urothelium → activation of nerves and muscle tissue in the bladder
o Urothelial abnormalities in patients with IC/BPS include: altered bladder epithelial expression of HLA Class I and II antigens, decreased expression of uroplakin and chondroitin sulfate, altered cytokeratin profile, and altered integrity of the GAG layer. A defect in Tamm-Horsfall protein has been found in some patients. In addition, the expression of interleukin-6 and P2X3 ATP receptors is increased, and activation of the NFkB gene is enhanced.
o The GAG layer of the bladder normally coats the urothelial surface and renders it impermeable to solutes
o Antiproliferative factor (APF) may also have a pathogenetic role in the generation of IC/BPS symptoms
interstitial cystitis pathophysiology theory - neurologic upregulation
o Activation of sensory nerves in the bladder
o Neural activation may result from
-Peripheral nerve stimulation
-Injury from potassium
-Nerve regeneration
-Central activation of the sacral reflex arc
o Central sensitization and increased activation of bladder sensory neurons during normal bladder filling may result in bladder pain. Similar alterations in neural pathways may be responsible for the suprapubic tenderness that is present in IC/BPS patients.
interstitial cystitis pathophysiology theory - mast cells and other mediators
o Mechanism and role not well understood
o Mast cell degranulation may cause symptoms
o Mast cells may be a response to the causative agent, contributing to the disease
o Other cell mediators present in IC may have roles as well
clinical presentation of interstitial cystitis
o Urinary urgency, frequency, bladder and/or pelvic pain most frequent symptoms
-Discomfort worsens with bladder filling, relieved with bladder emptying
o Insidious onset with gradual progression
-Usually 6 weeks to months or longer for diagnosis
-May be acute pain episodes or “flares”
o Symptoms may wax and wane
