UTI And Urological Malignancy Flashcards
Uncomplicated UTI
an infection in a healthy-patient with a structurally & functionally normal urinary tract (easily eradicated)
Complicated UTI
infection that is associated with factors that increase the chance of acquiring bacteria and decrease the efficacy of therapy.
Factors that suggest complicated UTI
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
Factors that increase the risk of infection of UTI:
• 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
Common urinary pathogens that cause UTI
• 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)
Most common route of infection in the GU tract
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
Cystitis presentation
LUTS;
dysuria, supra public pain, frequency, urgency, hematuria, foul-smelling
urine,
Usually no fever or chills
Clinical picture of pyelonephritis
➢ 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
What is the most accurate way to obtain a urine sample free of contamination? ( in order )
1) Supra-pubic aspiration
2) Catheterized specimen
3) Voided specimen (MSU) } prep if uncircumcised or female
Findings indicative on microscopic urine analysis ?
➢ >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.
Indication for imaging studies in patient with UTI:
In men
In compromise host
Febrile infection
Signs and symptoms of urinary tract obstruction
Failure to respond to antibiotics ( abscess)
Imaging technique
• X-ray KUB
• Ultrasound
• IVP
• CT scan
• Voiding Cystourethrogram ( VCUG )
• Radionuclide scan
Common Antibiotics used for UTI:
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
Abx should be avoided during pregnancy?
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
Safe drug in pregnancy with UTI?
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
Treatment of uncomplicated cystitis
3 days
Ciprofloxacin , Bactrim , Trimethoprim
If patient DM, > 65 yrs , >1 week symptoms or recent treated UTI
7 days
Bactrim or Ciprofloxacin
TTx of complicated cystits
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
Pyelonephritis treatment ( uncomplicated and no sepsis )
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
Pylonepheritis treatment ( complicated or sepsis )
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)
Prostatitis presentation
LUTS
➢ Pain ( genital, Supra-pubic, perineal, low back)
➢ Painful ejaculation
➢ Erectile dysfunction
➢ Tender, worm and boggy Prostate ( acute bacterial prostatitis )
➢ Fever
➢ May have sepsis
Prostatis workup
CBC
➢ Urinalysis ➢Urine culture and blood culture if needed
➢ Test using prostate massage (avoid during acute bacterial prostatitis)
Classification of prostatis catogry 1
Acute bacterial prostatitis
Category I: (acute bacterial prostatitis)
➢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
Category II : ( chronic bacterial prostatitis
➢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
Category III of prostatis
( chronic GU PAIN with absence of bacteria in prostate )
• Category III : (chronic GU PAIN with absence of bacteria in prostate)
➢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
Category IV of prostatis
(asymptomatic inflammatory prostatitis)
Category IV : (asymptomatic inflammatory prostatitis)
➢No WBC or bacteria in VB3
➢No Symptoms
➢Diagnosed on biopsy or prostate surgery as inflammatory prostatic
gland.
Management of Acute Bacterial Prostatitis
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
If persistent fever in acute bacterial prostatis consider ?
CT scan to out prostate abscess
Fournier’s Gangrane
Necrotizing fasciitis of the genitalia & perineum
Fournier’s gangrane spread along …. Of scroutm & … of perineum & …. Of anterior abdominal wall
dartos fascia of scrotum
Colles’ fascia of
perineum
Scarpa’s fascia of anterior abdominal wall
Risk factors for Fournier’s gangrene
• DM • Surgery in local area • Alcohol abuse • Traumatic catheterization (urine extravasation) • Malnutrition • Old age • Paraphimosis • Obesity • Immunosuppression (eg HIV)
Presentation for Fournier’s gangrene
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 %
Management of Fournier’s gangrene
• 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
In Fournier’s gangrene if urethral trauma or extravastion suspected ?
Supra pubic catheter tube
if colonic or rectal communication in Fournier’s gangrene ?
Colostomy
Priapsim definition?
Prolonged penile erection > 4 hours with or without sexual stimulation or excitement.
Involves corpus cavernosum (rarely can involve corpus spongiosum).
Classification of priapism
Ischemic ( veno-occlusion )
Non-ischemic (unregulated blood inflow)
Recurrent “stuttering”
Ischemic ( veno - occlusive) priapism
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.
Non ischemic ( unregulated blood inflow ) priapsim
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
Management of ischemic priapism
Aspiration +/- irrigation and simultaneous treatment of underlying cause (eg sickle cell).
Intracavernous injection of α-adrenergic agonist (Phenylephrine).
Distal shunting.
Proximal shunting
Penile prosthesis
Management of non ischemic priapism
✓ Observation.
✓Arteriography and selective arterial embolization.
✓Surgical ligation.
