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Surgery > UTI And Urological Malignancy > Flashcards

UTI And Urological Malignancy Flashcards

1
Q

Uncomplicated UTI

A

an infection in a healthy-patient with a structurally & functionally normal urinary tract (easily eradicated)

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2
Q

Complicated UTI

A

infection that is associated with factors that increase the chance of acquiring bacteria and decrease the efficacy of therapy.

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3
Q

Factors that suggest complicated UTI

A

1) Abnormal or anomalous GU tract
2) Children
3) Recent use of antibiotic
4) DM
5) Elderly
6) Male
7) Immunosuppression
8) Presence of Catheter
9) Week-long symptoms at presentation (7days)
10) Hospital-acquired
11) Recent Instrumentation
12) Pregnancy

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4
Q

Factors that increase the risk of infection of UTI:

A

• Advanced age
• Anatomic anomalies
• Poor nutritional status
• Smoking
• Chronic steroid use
• Immunodeficiency
• Chronic indwelling catheter
• Infected endogenous/exogenous material
• Distant coexistent infection
• Prolonged hospitalization
• Frequent sexual intercourse

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5
Q

Common urinary pathogens that cause UTI

A

• Community-acquired:
E.coli (85%)
Other gram negatives : Proteus, Klebsiella, Gram positives : E. faecalis, S. saprophyticus (usually females)
• Nosocomial infections:
E.coli (50%)
Klebsiella, Enterobacter, citrobacter, serrratia, Pseudomonas,
Providencia, E. faecalis, S. epidermidis (females)

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6
Q

Most common route of infection in the GU tract

A

Ascending route : most UTI are from ascent of bacteria through urethra . Adherence of pathogen to introital & urothelial mucosa plays a big role , most episodes of pyelonephritis are from ascent of bacteria from bladder

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7
Q

Cystitis presentation

A

LUTS;
dysuria, supra public pain, frequency, urgency, hematuria, foul-smelling
urine,
Usually no fever or chills

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8
Q

Clinical picture of pyelonephritis

A

➢ fever, chills, flank pain and irritative symptoms
➢ may be asymptomatic ( DM, elderly and SCI )
➢ may have GI symptoms of N/V, abdominal pain and diarrhea
➢ bacteriuria and pyuria with large amounts of WBC casts
➢ urine culture may be negative if ureter is obstructed or if infection is not in collecting system
➢ may present with sepsis

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9
Q

What is the most accurate way to obtain a urine sample free of contamination? ( in order )

A

1) Supra-pubic aspiration
2) Catheterized specimen
3) Voided specimen (MSU) } prep if uncircumcised or female

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10
Q

Findings indicative on microscopic urine analysis ?

A

➢ >3 WBC per HPF in male and >5 in female.
➢ Presence of leukocyte esterase .
➢ Microscopic hematuria found in 50% of UTI.
➢ Presence of nitrite has good specificity but low sensitivity.
➢ If squamous epithelial cells present on UA, consider contamination. ➢ Bacteriuria is found in >90% of infections.

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11
Q

Indication for imaging studies in patient with UTI:

A

In men
In compromise host
Febrile infection
Signs and symptoms of urinary tract obstruction
Failure to respond to antibiotics ( abscess)

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12
Q

Imaging technique

A

• X-ray KUB
• Ultrasound
• IVP
• CT scan
• Voiding Cystourethrogram ( VCUG )
• Radionuclide scan

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13
Q

Common Antibiotics used for UTI:

A

Trimethoprim/Sulfamethoxazole (Bactrim): (oral)
good except for enterococcus & Pseudomonas

Nitrofurantoin: ( Oral) good except for Pseudomonas & Proteus , high urine levels but poor tissue levels and good for prophylaxis regimes.

(Oral) Cephalosporins : safe in pregnancy ( IV if resistance)

Ampicillin/amoxicillin : high resistance rates

Aminoglycosides : good for iv pyelonephritis management

Fluoroquinolones : ideal for empiric treatment

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14
Q

Abx should be avoided during pregnancy?

A

Fluoroquinolones : cartilage damage

Tetracyclines :discoloured teeth and bone abnormalities

Chloramphenicol : grey baby syndrome ( hypotension, hypothermia and CV collapse)

Sulfa : kernicterus and hemolytic anemia

Aminoglycosides : deafness

Trimethoprim : structural defects ( folic acid antagonist)

Nitrofurantoin :hemolytic anemia

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15
Q

Safe drug in pregnancy with UTI?

A

Cephalosporin
Cefalaxin

Amoxicillin and ampicillin are part of the penicillin family of antibiotics. They’re first-choice antibiotics for UTIs during pregnancy. Amoxicillin is much more commonly used because many bacteria are resistant to ampicillin

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16
Q

Treatment of uncomplicated cystitis

A

3 days

Ciprofloxacin , Bactrim , Trimethoprim

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17
Q

If patient DM, > 65 yrs , >1 week symptoms or recent treated UTI

A

7 days

Bactrim or Ciprofloxacin

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18
Q

TTx of complicated cystits

A

10 - 14 days of

Ciprofloxacin ,Bactrim start oral

If the patient still febrile no improvement

N.B : IV Ciprofloxacin or Ampicillin + Gentamicin or Ceftriaxone if febrile

19
Q

Pyelonephritis treatment ( uncomplicated and no sepsis )

A

Urine culture
Imaging ( U/S or CT rule out stones or obstruction)
outpatient antibiotic for 10days (Ciprofloxacin / Bactrim )

if NO improvement, admit and review the culture ,start IV antibiotic

rule out obstruction or abscess

if improvement, culture after antibiotic

20
Q

Pylonepheritis treatment ( complicated or sepsis )

A

blood & urine cultures

imaging

IV antibiotic (Ciprofloxacin or ampicillin + gentamicin or ceftriaxone) 7 days

if NO improvement rule out abscess or persistent obstruction and re-culture

once afebrile, oral antibiotic for 10-14 days (Cipro / Bactrim / Keflex)
culture after antibiotic therapy (at 2weeks then again at 4-6 weeks)

21
Q

Prostatitis presentation

A

LUTS
➢ Pain ( genital, Supra-pubic, perineal, low back)
➢ Painful ejaculation
➢ Erectile dysfunction
➢ Tender, worm and boggy Prostate ( acute bacterial prostatitis )
➢ Fever
➢ May have sepsis

22
Q

Prostatis workup

A

CBC
➢ Urinalysis ➢Urine culture and blood culture if needed
➢ Test using prostate massage (avoid during acute bacterial prostatitis)

23
Q

Classification of prostatis catogry 1

A

Acute bacterial prostatitis

24
Q

Category I: (acute bacterial prostatitis)

A

➢Purulent prostatic fluid (VB3)

➢Cultured bacteria

➢Acute onset of pain (perineal, supra-pubic, genital or low back)

➢LUTS

➢Systemic febrile illness ( can have septicemia )

➢Most common organism E.coli

25
Q

Category II : ( chronic bacterial prostatitis

A

➢Purulent prostatic fluid (VB3) ➢Cultured bacteria ➢NO systemic signs ➢Recurrent UTI is common
➢ May be asymptomatic between acute episodes or may present with
long history of chronic pelvic pain syndrome ( CPPS ) ➢LUTS

26
Q

Category III of prostatis

A

( chronic GU PAIN with absence of bacteria in prostate )

27
Q

• Category III : (chronic GU PAIN with absence of bacteria in prostate)

A

➢WBCs in VB3 urine
➢Pain is predominant symptom (perineal,Supra-pubic,genital or low
back)
➢Pain during or after ejaculation is prominent ➢LUTS ➢ No cultured bacteria

28
Q

Category IV of prostatis

A

(asymptomatic inflammatory prostatitis)

29
Q

Category IV : (asymptomatic inflammatory prostatitis)

A

➢No WBC or bacteria in VB3
➢No Symptoms
➢Diagnosed on biopsy or prostate surgery as inflammatory prostatic
gland.

30
Q

Management of Acute Bacterial Prostatitis

A

Avoid prostate massage, aggressive digital rectal examination and urethral instrumentation

In case of urinary retention , place suprapubic catheter

Oral Ciprofloxacine for 4-6 weeks

If febrile , admit the patient and give IV Ciprofloxacine or ampicillin with gentamicin

If persistent fever Consider pelvic CT scan to rule out prostate abscess

31
Q

If persistent fever in acute bacterial prostatis consider ?

A

CT scan to out prostate abscess

32
Q

Fournier’s Gangrane

A

Necrotizing fasciitis of the genitalia & perineum

33
Q

Fournier’s gangrane spread along …. Of scroutm & … of perineum & …. Of anterior abdominal wall

A

dartos fascia of scrotum

Colles’ fascia of
perineum

Scarpa’s fascia of anterior abdominal wall

34
Q

Risk factors for Fournier’s gangrene

A

• DM • Surgery in local area • Alcohol abuse • Traumatic catheterization (urine extravasation) • Malnutrition • Old age • Paraphimosis • Obesity • Immunosuppression (eg HIV)

35
Q

Presentation for Fournier’s gangrene

A

Usually starts with local cellulitis that spreads deeper. • Pain, fever, and systemic toxicity (mental status changes, tachypnea,
tachycardia).
• Most commonly mixed bacterial growth ( E coli most common single
pathogen).
• mortality rate is 20-30 %

36
Q

Management of Fournier’s gangrene

A

• ABC.

• IV fluids

• Routine blood work.

• Culture of urine, blood, and site of infection

• Broad spectrum Antibiotic ( ampicillin + ceftriaxone + flagyl ).

• Immediate surgical debridement:
- all necrotic skin, fascia, fat must be excised & wound left ope
- repeat debridement in 24-48hrs and PRN
- place testicles in thigh pouch or wrap in moist NS-soaked gauze

37
Q

In Fournier’s gangrene if urethral trauma or extravastion suspected ?

A

Supra pubic catheter tube

38
Q

if colonic or rectal communication in Fournier’s gangrene ?

A

Colostomy

39
Q

Priapsim definition?

A

Prolonged penile erection > 4 hours with or without sexual stimulation or excitement.

Involves corpus cavernosum (rarely can involve corpus spongiosum).

40
Q

Classification of priapism

A

Ischemic ( veno-occlusion )

Non-ischemic (unregulated blood inflow)

Recurrent “stuttering”

41
Q

Ischemic ( veno - occlusive) priapism

A

Vascular stasis with decreased venous outflow due to mechanical factors
(eg sickle cell), local viscosity changes, and increased local Coagulability.

Low-flow priapism

Presents WITH PAIN and rigid corpora cavernosa

ABG of cavernous bodies show hypoxia, hypercapnia, and acidosis.

42
Q

Non ischemic ( unregulated blood inflow ) priapsim

A

Traumatic disruption of penile vasculature with fistula formation .

High-flow priapism

Presents WITHOUT PAIN and corpora cavernosa are not usually fully rigid
ABG of cavernous bodies does not reveal hypoxia or acidosis

43
Q

Management of ischemic priapism

A

Aspiration +/- irrigation and simultaneous treatment of underlying cause (eg sickle cell).

Intracavernous injection of α-adrenergic agonist (Phenylephrine).

Distal shunting.

Proximal shunting

Penile prosthesis

44
Q

Management of non ischemic priapism

A

✓ Observation.
✓Arteriography and selective arterial embolization.
✓Surgical ligation.

Surgery (14 decks)

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