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Peri-op > UTIs, Pyelonephritis and Hydronephrosis > Flashcards

UTIs, Pyelonephritis and Hydronephrosis Flashcards

1
Q

What are the classic symptoms of UTI?

A
  1. Dysuria (pain, stinging or burning when passing urine)
  2. Suprapubic pain or discomfort
  3. Frequency
  4. Urgency
  5. Incontinence
  6. Confusion is commonly the only symptom in older more frail patients

Note: these are lower UTI symptoms

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2
Q

What is cystitis?

A

Inflammation of the bladder, which can be due to infection (bacterial cystitis) or other causes

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3
Q

What is pyuria?

A

Presence of pus cells (neutrophil polymorphs) in significant quantities in urine

Represents an inflammatory response and is supportive evidence of the presence of a UTI

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4
Q

What is sterile pyuria?

A

The clinical scenario in which urine is negative on culture but significant numbers of pus cells are present

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5
Q

What is acute pyelonephritis?

A

Infetion of the upper urinary tract involving the kidneys

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6
Q

How does pyelonephritis present?

A
  1. Fever
  2. Loin, suprapubic or back pain (bilateral or unilateral)
  3. Looking and feeling generally unwell
  4. Vomiting
  5. Loss of appetite
  6. Haematuria
  7. Renal angle tenderness on examination
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7
Q

What is chronic pyelonephritis?

What causes it?

A

Pathological condition with renal scarring and potentially loss of renal function

Infection may be a contributory cause but the term does not necessarily imply ongoing infection

Other factors which may contribute include diabetes, vesicle-ureteric reflux and urinary obstruction

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8
Q

Are UTIs more common in men or women, why?

A

Women as the urethra is much shorter making it easy for bacteria to get into the bladder

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9
Q

Where is the main source of of bacteria for UTIs?

List 3 ways this may cause a UTI

A

Faeces

  1. Normal intestinal bacteria (ie. E. coli) can reach the urethral opening from the anus
  2. Sexual activity can spread bacteria around the perineum
  3. Incontinence or poor hygiene can also contribute to development of UTIs
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10
Q

What is a key source of UTIs in the hospital setting?

A

Catheters → ‘catheter-associated UTIs’

Tend to be more significant and difficult to treat

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11
Q

List 4 key symptoms which will differentiate between a lower UTI and pyelonephritis

A
  1. Fever
  2. Loin/back pain
  3. Nausea/vomiting
  4. Renal angle tenderness on examination
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12
Q

List 3 things which can be detected on dipstick testibg that may be associated with a UTI?

A
  1. Nitrites → gram (-) bacteria (ie. E. coli) break down nitrates in urine to nitrites
  2. Leukocytes → indicates infection or other cause of inflammation (leucocyte esterase is a marker of an inflammatory response)
  3. RBCs → haematuria, which is a common sign of infection

Presence of all 3 on a urine dip indicate a likley UTI

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13
Q

Compare microscopic vs macroscopic haematuria

A

Microscopic → blood is identified on a urine dipstick but not seen when looking at the sample

Macroscopic → blood is visible in the urine

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14
Q

What on the urine dip is the most indicative of a UTI?

A

Nitrites (better than leukocytes)

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15
Q

Interparate urine dipstick findings?

  1. (+) for Nitrites or Leukocytes and (+) for RBC
  2. (-) Nitrite, (+) for Leukocytes
  3. (+) for Nitrites
  4. (-) for Nitrites, Leukocytes and RBCs
A
  1. UTI is likely - requires treatment
  2. UTI is equally likely to other diagnoses - only treat as UTI if there is supporting clinical evidence
  3. It is worth treating as a UTI
  4. UTI less likely - do not treat as UTI
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16
Q

How do we determine the causitive organism in a suspected UTI?

Why is this important

A

A midstream urine (MSU) sample sent for microscopy, culture and sensitivity testing

Important to determine most effective antibiotic

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17
Q

Compare a uncomplicated vs complicated UTI

A

Uncomplicated → UTI caused by typical pathogens in people with a normal urinary tract and kidney function, and no predisposing co-morbidities

Complicated → UTI with an increased likelihood of complications ie. persistent infection, treatment failure and recurrent infection

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18
Q

When should an MSU be sent for culture?

A
  1. Pregnant
  2. > 65
  3. Recurrent UTIs
  4. Atypical symptoms
  5. Persistent symptoms or if treatment fails
  6. Catheterised or have recently been catheterised
  7. Have risk factors for resistant or complicated UTI
  8. Haematuria (visible or non-visible)
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19
Q

List 4 causitive organisms of a UTI and highlight the most common

A
  1. Escherichia coli (E. coli - gram (-) anaerobic, rod-shaped)
  2. Klebsiella pneumoniae
  3. Enterococcus
  4. Pseudomonas aeruginosa
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20
Q

Treatment for a lower UTI in non-pregnant women?

A

Trimethoprim or Nitrofurantoin for 3 days

21
Q

When to send a urine culture for a suspected UTI ina Non-pregnant woman?

A
  1. Aged > 65 years
  2. Visible or non-visible haematuria
22
Q

Management for a UTI in a pregnant women who is symptomatic

A
  1. Urine culture in all cases
  2. Antibiotic treatment
  • 1st-line: nitrofurantoin (should be avoided near term)
  • 2nd-line: amoxicillin or cefalexin
23
Q

Which 2 antibiotics MUST be avoided in pregnancy

Incl which trimester and why?

A

Trimethoprim in 1st trimester → teratogenic (but should be avoided entirely)

Nitrofurantoin in 3rd trimester → risk of neonatal haemolysis

24
Q

Management of asymptomatic bacteriuria in pregnant women?

A
  1. Urine culture routinely at the first antenatal visit
  2. Immediate antibiotic prescription of either nitrofurantoin (avoid near term), amoxicillin or cefalexin - 7-day course
  3. further urine culture as a test of cure
25
Q

What is the rationale of treating asymptomatic bacteriuria?

A

Significant risk of progression to acute pyelonephritis

26
Q

Management of a UTI in Men?

A
  1. Immediate antibiotic prescription for 7 days
  2. Abx: 1st line is Trimethoprim or nitrofurantoin (unless prostatitis suspected)
27
Q

Does a male with a UTI require refferal to urology?

A

Not routinely required for men who have had one uncomplicated lower UTI

28
Q

Management of a UTI in Catherised patients

A

If symptomatic, should be treated with a 7-day antibiotic course

29
Q

Management for a patient with signs of acute pyelonephritis?

A
  1. hospital admission should be considered
  2. local Abx guidelines - BNF recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
30
Q

What may recurrent UTIs in men indicate?

A

May be presenting feature of Prostatitis, infection of the prostate and may be acute or chronic

31
Q

What is Pyelonephritis?

A

Inflammation of the kidney resulting from bacterial infection

Affects the renal pelvis and parenchyma

32
Q

List 4 risk factors for Pyelonephritis

A
  1. Female sex
  2. Structural urological abnormalities
  3. Vesico-ureteric reflux
  4. Diabetes
33
Q

What is the most common bacterial cause of Pyelonephirits?

A

E. coli (gram-negative, anaerobic, rod-shaped)

Others incl: Klebsiella, Enterococcus, Candida albicans

34
Q

TRIAD of Pyelonephritis?

A
  1. Fever
  2. Loin or back pain (bilateral or unilateral)
  3. Nausea / vomiting

+/- Systemic illness, loss of appetite, haematuria, renal angle tenderness

35
Q

Investigations for pyelonephritis?

A
  1. Urine dipstick (nitrites, leukocytes and blood)
  2. MSU for microscopy, culture and sensitivit
  3. Blood tests (raised inflammatory markers )
  4. USS or CT scan to excl stones or abscesses
36
Q

Management of pyelonephritis?

A
  1. If septic, refer to hospital
  2. If not, 7-10 days antibiotic treatment in community
37
Q

First line antibiotics for pyelonephritis?

A
  1. Cefalexin
  2. Co-amoxiclav (if culture results available)
  3. Trimethoprim (if culture results available)
  4. Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
38
Q

Management of pyelonephritis with sepsis for patients admitted to hospital?

A

Sepsis six

GIVE:

  • Oxygen (maintain 94-98% or 88-92% in COPD)
  • Empirical broad-spectrum IV antibiotics
  • IV fluids

TAKE

  • Blood lactate level
  • Blood cultures
  • Urine output
39
Q

List 2 things to consider if a patient has significant symptoms or does not respond well to treatments?

A
  1. Renal abscess
  2. Kidney stone obstructing ureter
40
Q

What is chronic pyelonephritis?

A

Recurrent episodes of infection in the kidneys

Leads to scarring of the renal parenchyma, leading to CKD which can progress to end-stage renal failure

41
Q

How is damage in recurrent/chronic pyelonephritis assessed?

A

Dimercaptosuccinic acid (DMSA) scans

Involves injecting radiolabeled DMSA and gamma cameras. DMSA builds up in healthy kidney tissue, areas that do not take up the DMSA indicate damage

42
Q

What is Hydronephrosis

A

Swelling of the renal pelvis and calyces in the kidney.

Occurs due to obstruction of the urinary tract, leading to back-pressure into the kidney

43
Q

What is Idiopathic hydronephrosis?

How is it treated?

A

Narrowing at the PUJ (where the renal pelvis becomes the ureter) which may be congenital or develop later

Treated with an surgery (pyeloplasty)

44
Q

List 4 causes of unilateral hydronephrosis

(PACT)

A
  • Pelvic-ureteric obstruction (congenital or acquired)
  • Aberrant renal vessels
  • Calculi
  • Tumours of renal pelvis
45
Q

List 4 causes of bilateral hydronephrosis

(SUPER)

A
  • Stenosis of the urethra
  • Urethral valve
  • Prostatic enlargement
  • Extensive bladder tumour
  • Retro-peritoneal fibrosis
46
Q

First line investigation for suspected hydronephrosis

A

Ultrasound

47
Q

Investigation for suspected renal colic causing hydronephrosis

A

if suspect renal colic: CT KUB

48
Q

Management of hydronephrosis

A
  • Remove the obstruction and drainage of urine
  • Acute upper urinary tract obstruction: nephrostomy tube
  • Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
49
Q

What is seen on the CT below?

A

Massive hydronephrosis and a small calculus in the left kidney

A single large calculus is present distally in the left ureter with accompanying hydroureter

Peri-op (22 decks)

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