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CMS200 > week 14- UTI > Flashcards

week 14- UTI Flashcards

1
Q

dysuria

A

pain or burning with or after urination

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2
Q

if have dysuria probably have a

A

UTI

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3
Q

UTI- main cause?

A

Infection of the urinary tract is usually due to bacterial invasion of the structures involving the urinary tract (can be any of the structures between the urethra to renal pelvis)

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4
Q

SLIDE 5

A
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5
Q

Which of the following statements is true?
* Upper urinary tract infections are less common compared to lower urinary tract infections, but they tend to be more severe.
* Upper urinary tract infections are more common compared to lower urinary tract infections, but they tend to be less severe.
* Both upper and lower urinary tract infections are equally common, and the severity of infection varies.

A
  • Upper urinary tract infections are less common compared to lower urinary tract infections, but they tend to be more severe.
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6
Q

Which of the following infections is considered a lower urinary tract infection?
* Pyelonephritis
* Cystitis
* Urethritis
* Prostatitis

A
  • Cystitis
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7
Q

2 types of UTI

A

uncomplicated and complicated

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8
Q

what is an uncomplicated UTI

A

UTI in an individual with a normal urinary tract system

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9
Q

complicated UTI

A
  • UTI in patients with any of the following:
  • Male sex
  • Pregnancy
  • Functional or anatomic abnormality of the urinary tract (urinary tract obstruction, polycystic renal disease, nephrolithiasis, neurogenic bladder)
  • Diabetes mellitus
  • Immunosuppression
  • Indwelling urinary catheter
  • Recent urinary tract instrumentation
  • Systemic infection (such as bacteremia or sepsis)
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10
Q

who are uncomplicated UTIs most common in

A

most common in young, sexually active women

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11
Q

UTIs are how much more likely in women than men and what is the reason for this

A

UTIs are 4x more likely in women than men
* Proximity of urethral meatus to the rectum * Shorter urethral length

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12
Q

risk factors for men getting UTIs

A

homosexuality, lack of circumcision

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13
Q

risk factors for UTI

A
  • Female sex
  • Anatomical defects that lead to stasis, obstruction and urinary reflux
  • Sexual intercourse
  • Use of spermicides or a diaphragm
  • A new sexual partner in the past year or multiple sexual partners
  • Previous UTI
  • Urethral catheterization or other foreign body
  • Decreased resistance to microbial organisms
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14
Q

acute cystitis is an infection of what

A

bladder

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15
Q

what is the most common UTI

A

acute cystitis

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16
Q

how to diagnose acute cystitis

A

diagnosed when pyuria and bacteriuria are accompanied by urinary symptoms confined to the bladder

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17
Q

most common bacteria causing acute cystitis

A

E. coli

“KEEPS” pneumonic
* K = Klebsiella pneumoniae
* E = Escherichia coli (75–95%)
* E = Enterococcus faecalis
* P = Proteus mirabilis
* S = Staphylococcus saprophyticus, group B streptococcus

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18
Q

symptoms in acute cystitis

A
  • Dysuria
  • Suprapubic pain
  • Urinary frequency
  • Urinary urgency
  • Hematuria
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19
Q

what is there an absence of in acute cystitis

A

Absence of penile/vaginal discharge, costovertebral angle (CVA) tenderness, nausea, vomiting, fever

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20
Q

atypical presentation of acute cystitis in elderly

A
  • Delirium
  • Functional decline
  • Acute confusion
  • Lethargy
  • Generalized weakness
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21
Q

symptoms and signs that increase UTI in women

A
  • Dysuria (LR = 1.5)
  • Frequency of urination (LR = 1.8)
  • Hematuria (LR = 2.0)
  • Back pain (LR = 1.6)
  • Costovertebral angle tenderness (LR = 1.7)
  • Self-diagnosis in patients with recurrent UTI (LR = 4.0)
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22
Q

symptoms and signs that decrease probability of UTI

A
  • Patient complaint of vaginal discharge (LR = 0.3)
  • Vaginal discharge on examination (LR = 0.7)
  • Vaginal irritation (LR = 0.2)
  • Absence of dysuria (LR = 0.5)
  • Absence of back pain (LR = 0.8)
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23
Q

how helpful is one symptom in acute cystitis

A
  • Individual symptoms and signs will only modestly increase the post-test probability
  • No sign or symptom on its own is powerful enough to ‘rule in’ or ‘rule out’ the diagnosis of UTI
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24
Q

combining symptoms in acute cystitis; which 2 are most helpful

A
  • Dysuria and frequency without vaginal discharge or irritation yields a high likelihood of UTI (LR = 24.6)
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25
Q

what is the likelihood of a women having cystitis is have dysuria and frequency without vaginal discharge or irritation? what testing needs to be done?

A
  • A woman with dysuria and frequency but without vaginal discharge or irritation has a 90% likelihood of having cystitis, effectively ruling in the diagnosis based on history alone
  • Further testing is not required in women with classic uncomplicated cystitis – they can be treated without testing
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26
Q

further testing for acute cytitis

A
  • Urine dipstick test or urinalysis
  • Findings suggestive of cystitis:
  • Presence of leukocyte esterase
  • Presence of nitrites
  • White blood cells on urine microscopy (>5 per high powered field)
  • Hematuria demonstrated by presence of blood on dipstick or RBCs on microscopy
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27
Q

what does a rapid urine dipstick test measure

A
  • Leukocyte esterase
  • Nitrites
  • Urobilinogen
  • Protein
  • pH
  • Blood
  • Specific gravity * Ketones
  • Bilirubin * Glucose
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28
Q

what does a urinalysis measure

A
  • Leukocyte esterase
  • Nitrites
  • Urobilinogen
  • Protein
  • pH
  • Blood
  • Specific gravity * Ketones
  • Bilirubin * Glucose
  • Urinalysis consists of these chemical markers, a physical examination and evaluation through additional microscop
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29
Q

which chemical marker in an urinalysis has the highest LR+ for acute cystitis

A

leukocyte esterase

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30
Q

which 2/3 blood markers in urinalysis are most helpful for UTI diagnosis

A
  • Presence of nitrites (PV+ = 75% to 95%)
  • Presence of leukocytes (PV+ = 65% to 85%)
  • Presence of both nitrites and leukocytes (PV+ = 95%)
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31
Q

if leukocyte esterase and nitrites are negative then

A

If nitrite and leukocyte esterase tests are negative, the odds of a UTI decrease by 40% to 60%
* But false negative results are common – especially for nitrites
– WHY?

some bacteria dont produce nitrites

leukocyte count can be low or take antibiotics which reduce it

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32
Q

can you rule out cystitis if urinalysis is negative for nitrites and leukocyte esterase

A

Do not rule out cystitis by a urinalysis that is negative for both leukocyte esterase and nitrites in the presence of a convincing clinical presentation

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33
Q

notes of sample collection for urinalysis

A
  • Clean catch midstream urine sample should be used
  • Urine sample should be sent to the lab immediately or refrigerated
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34
Q

when to use a urine culture in acute cystitis

A
  • Unnecessary in uncomplicated cystitis and no history ofrecurrent infections or recent treatment failure
  • Used as a confirmatory test in setting of diagnostic uncertainty or the need to identify a specific bacterial pathogen and antimicrobial susceptibility (such as in recurrent cystitis)
  • Should be performed when:
  • Antimicrobial-resistance is suspected
  • Cystitis is suspected in men
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35
Q

who to use urine culture for in acute cystitis suspected

A
  • Should be performed when:
  • Antimicrobial-resistance is suspected
  • Cystitis is suspected in men
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36
Q

urine culture is used to

A

find the causative organism in the case of an infection

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37
Q

how to do urine culture

A
  • Takes about 24-48 hours to complete
  • Use clean catch urine sample, then grow on a medium for incubation period, then identify the possible involved organisms and identify possible sensitivities to treatment
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38
Q

how many CFU for a urine culture to be positive

A
  • A positive urine culture is defined as >
    105 colony-forming units (CFU) of bacteria per milliliter
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39
Q

how to manage uncomplicated vs complicated acute cystitis

A
  • Uncomplicated: antibiotics for 1-5 days
  • Complicated: longer duration of antibiotics (7-14 days)
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40
Q

how long does symptom relief occur within after treating acute cystitis

A

36 hours

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41
Q

how common is UTI recurrence

A
  • UTI recurrence in ~25% of women within 6 months
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42
Q

other complications in acute cystitis

A
  • Other complications are relatively rare:
  • Antibiotic resistant organisms
  • Pyelonephritis
  • Acute renal failure
  • Renal or perinephric abscess
  • Sepsis
  • Chronic prostatitis
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43
Q

what is asymptomatic bacteriuria

A
  • Presence of bacteria in the urine (at a concentration of ≥105 cfu/mL) in the absence of symptoms of infection
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44
Q

who is asymptomatic bacteruiria common in

A
  • More common in women; increases with age
  • 5-20% in women aged 65-90; 45% in women older than 90 years
  • 5% in men younger than 80 years; 20% in men older than 80 years
45
Q

asymptomatic bacteriuria (ASB) and pregnancy

A
  • 2-15% of pregnant women have ASB
  • May increase risk of preterm birth
  • ~20-40% will develop pyelonephritis if untreated
46
Q

what will baby develop if dont treat asymptomatic bacteriuria in pregnancy

A

pyelonephritis

47
Q

should you screen for asymptomatic bacteriuria?

A

Asymptomatic bacteriuria is common but should not be screened for or treated except in pregnancy (at week 12-16) or shortly before invasive urologic procedure such as transurethral resection of the prostate

48
Q

recurrent cystitis is defined by how many episodes

A
  • 2 episodes of acute cystitis within the last 6 months, or
  • 3 episodes of acute cystitis within the last year
49
Q

risk factors for recurrent cystitis

A
  • Sexually active women with higher frequency of intercourse
  • Spermicide use, especially if used with a diaphragm
  • Atrophic vaginitis
  • Anatomical or functional defects of the urinary tract
  • Cystoceles and pelvic organ prolapse
  • Inadequate fluid intake
  • Incomplete bladder emptying
  • Inadequate/suboptimal personal hygiene
50
Q

what test to use to differentiate between recurrent and relpasing infections

A
  • Urine culture and sensitivity to differentiate between recurrent infections from relapsing infections
51
Q

in women and in men what tests for recurrent cystitis

A
  • Pelvic exam in women to assess for cystoceles, vaginitis, vaginal atrophy, pelvic organ prolapse
  • Rectal exam in men to assess for prostatitis
52
Q

when is imaging and cystoscopy needed in recurrent cystitis

A
  • Imaging and cystoscopy generally not required
  • Indications for abdominal and pelvic CT scan or renal ultrasonography:
  • Relapsing infections
  • Persistent hematuria after treatment
  • History of stone passage
  • Repeated isolation of Proteus from the urine (associated with renal stones)
  • Indications for cystoscopy:
  • Evaluation of incomplete bladder emptying
  • Possible bladder calculi
53
Q

patient education in managing recurrent cystitis

A
  • Personal hygiene: wiping front to back, avoid baths
  • Avoid long intervals between urinations
  • Increase fluid intake if inadequate
54
Q

how to manage recurrent cystitis

A

*patient education
* Antimicrobial prophylaxis (continuous or postcoital) may reduce the risk of recurrence by 95% for women with 3 or more infections in a year
* Vaginal estrogen if due to atrophic vaginitis in peri-/post- menopausal women

55
Q

acute pyelonephritis is an infection of

A

the parenchyma of the kidney

56
Q

how serious is acute pyelonephritis

A

> 250,000 cases/year; 200,000 need hospitalization

57
Q

what is usually the cause of acute pyelonephritis

A
  • Usually ascending from lower UTI
  • Bacterial causes are same as those that cause cystitis – remember the KEEPS organisms (i.e. e coli)
  • Can also be caused hematogenous spread and “seeding” of usually gram-positive cocci
58
Q

KEEPS organisms causing acute cystitis and acute pyelonephritis and acute bacterial prostatitis

A
  • K = Klebsiella pneumoniae
  • E = Escherichia coli (75–95%)
  • E = Enterococcus faecalis
  • P = Proteus mirabilis
  • S = Staphylococcus saprophyticus, group B streptococcus
59
Q

risk factors of pyelonephritis

A
  • UTI (cystitis)
  • Structural/anatomical problem of urinary track which causes blockage or reflux
  • Pregnancy
  • Diabetes
60
Q

signs and symptoms in pyelonephritis

A
  • Rapid onset (hours to days)
  • Similar symptoms of cystitis: dysuria, frequency, urgency, hematuria

Plus:
* Fever
* Chills
* Malaise
* Nausea or vomiting
* Flank or back pain
* Costovertebral angle tenderness (LR+ 1.1-2.5, LR- 0.78-0.96)

61
Q

symptoms of pyelonephritis in elderly and kids

A
  • Confusion in elderly
  • Feeding difficulty in infants
  • Children less than 2 may just have high fever
62
Q

in urinalysis or urine dipstick test for pyelonephritis what is seen

A
  • White blood cell casts seen on urine microscopy
63
Q

is urine culture negative or positive in pyelonephritis

A

positive in 90% of patients

64
Q

blood culture for pyelonephritis

A

CBC with differential

65
Q

other further testing for pyelonephritis

A

Indications for further investigations with imaging – abdominal/pelvic CT scan or ultrasound:
* Symptoms not resolving within 48-72 hours of treatment
* History of urinary tract abnormality
* Suspected nephrolithiasis or obstruction
* Diagnosis is uncertain

66
Q

antibiotic therapy for pyeloneprhtisi

A
  • 7-10 days for uncomplicated pyelonephritis * 14 days for complicated pyelonephritis
67
Q

long term consequences in pyelonephritis? life threatening?

A
  • Most do not have long-term consequences with adequate treatment
  • Can be potentially life-threating in some and can cause permanent scarring of kidneys (predispose to chronic kidney disease, hypertension, renal failure) or sepsis
68
Q

indication for hospital admission for pyelonephritis

A
  • Unstable vital signs
  • Inability to tolerate oral medications
  • Concern for nonadherence
  • Pregnancy
  • Immunocompromised state
  • Concern for urinary tract obstruction or nephrolithiasis
69
Q

infectious urethritis is inflammation in

A
  • Infection-induced inflammation of the urethra
70
Q

what is infectious urethritis usually caused by

A

sexually transmitted infection

71
Q

high incidence rates in age for infectious urethritis

A

20-24 yrs old

72
Q

who is infectious urethritis more common in (gender)

A
  • More common in homosexual males than heterosexual males and females in general
73
Q

80% of the time the STI that causes infectious urethritis is

A

neisseria gonorrhoeae

74
Q

STI causes of infectious urethritis

A
  • Neisseria gonorrhoeae (80%)→gonococcal urethritis
    non-gonococcal urethritis:
  • Chlamydia trachomatis (10-40%)
  • Less common causes: Mycoplasma genitalium (15- 25%), Trichomonas, herpes simplex virus, adenovirus
  • Enteric bacteria are an uncommon cause (anal intercourse is a risk factor)
75
Q

STI of genitourinary tract manifests how in men vs women

A

STIs of the genitourinary tract manifest as urethritis in men and cervicitis in women

76
Q

symptoms of cervicitis from STIs in women

A
  • Dysuria
  • Cervical discharge
  • Dyspareunia
  • Spontaneous or postcoital vaginal bleeding
77
Q

symptoms of urethritis from STIs in men

A
  • Dysuria
  • Urethral pruritus
  • Urethral discharge
  • Dyspareunia
  • Abdominal pain
  • Testicular pain
78
Q

further testing for urethritis/cervicitis from STIs

A
  • Gram stain of discharge or urine culture
  • Urethral culture
  • Microscopy of discharge showing > 5 WBCs per oil immersion field (sensitivity 26%, specificity 95%, LR+ 2.7)
  • Urinalysis
  • Positive leukocyte esterase on first-void urine
  • Microscopy of first-void urine showing > 10 WBCs per high power field
  • PCR testing for gonorrhea and chlamydia
  • Urine sample preferred for males (sensitivity 90-100%, specificity 97- 100%)
  • Vaginal, cervical and urine testing considered equivalent for women
79
Q

management of urethritis/cervicitis from STIs

A
  • Antibiotic therapy
  • Abstain from intercourse
  • Sexual partners should be evaluated and treated
80
Q

urethriritis caused by reiter’s syndrome is aka

A

reactive arthritis

81
Q

risk factors for Urethritis caused by Reiter’s Syndrome
aka reactive arthritis

A
  • Most common in men aged 20-50, HLAB27 gene, HIV/AIDS or immunocompromised
82
Q

signs and symptoms for Urethritis caused by Reiter’s Syndrome aka reactive arthritis

A
  • Pain/swelling in joints (esp. knees and ankles) and heels, persistent low back pain, burning sensation/rash on feet, eye redness/irritation (uveitis/conjunctivitis), and burning with urination (urethritis/cervicitis)
83
Q

what is Urethritis caused by Reiter’s Syndrome from?

A
  • Autoimmune condition which is a painful form of inflammatory arthritis
  • Etiology – set off by a preceding infection (usually C. Trachomatis, or Salmonella/Shigella/Yersinia/Campylobacter)
  • Usually these preceding infections occur in the genitals or in the bowel
84
Q

who is acute bacterial prostatitis most common in

A
  • Most common urologic diagnosis in men <50 years of age
  • ~10% of all prostatitis diagnoses
  • Incidence peaks between ages 20-40 and in men >70
85
Q

what is acute bacterial prostatitis usually caused by

A

ascending urethral infection or intraprostatic reflux

86
Q

which bacterial in acute bacterial prostatitis

A
  • KEEPS, 80% E. Coli
  • Suspect N. Gonorrhea in sexually active men <35 years of age
87
Q

how do bacterial get into the prostate in acute bacterial prostatitis

A
  • Rectal bacteria can cause direct/lymphatic spread
  • Bacteria introduced with recent cystoscopy, post prostatic biopsy, catheterization
  • Will often also see benign prostatic hyperplasia
88
Q

acute bacterial prostatitis signs and symptoms

A
  • Acute onset
  • Systemic symptoms: fever, chills, malaise, vomiting
  • Rectal, low back and/or perineal pain
  • Dysuria, urinary frequency, urgency
  • Hematuria
  • May also see: painful ejaculation, hematospermia, painful defecation
89
Q

further testing in acute bacterial prostatitis

A
  • Digital rectal exam – gently
  • Urinalysis
  • Urine culture and sensitivity: 4 specimens *
    1) VB1: initial (urethra)
  • 2) VB2: midstream (bladder)
  • 3) EPS: not usually performed
  • 4) VB3: post-massage / DRE
  • Serum PSA
  • CT or transrectal ultrasound only if necessary
90
Q

management of acute bacterial prostatitis

A
  • Supportive therapies
  • Antipyretics, analgesics, stool softeners
  • Antibiotics
  • 4-6 weeks to prevent complications
  • Based on most likely suspected organism, adjusted after return of culture and sensitivity results
  • Treat for gonorrhea and chlamydia if under 35 years of age
  • Hospital admission if:
  • Sepsis, urinary retention, immunodeficiency
91
Q

chronic bacterial prostatis is

A
  • Recurrent exacerbations of acute bacterial prostatitis
  • Relapsing UTI with same pathogen – more difficult to treat * Tends to develop more slowly
92
Q

what exam may be normal in chronic bacterial prostatitis

A

digital rectal exam

93
Q

signs and symptoms in chronic bacterial prostatitis

A
  • Genitourinary pain, lower abdominal and lower back pain
  • Irritative and/or obstructive lower urinary tract symptoms
  • Frequency, urgency, dysuria, retention, hesitancy, weak/interrupted stream
  • Fever/chills uncommon
  • May also see ejaculatory pain, sexual dysfunction, hematospermia
94
Q

testing for chronic bacterial prostatitis

A
  • Urine culture and sensitivity: 4 specimens
  • EPS and VB3 must exceed VB1 and VB2 by 10x
95
Q

management for chronic bacterial prostatitis

A
  • Long course of antibiotics (3-4 months) * Even if urine culture is negative
96
Q

dermatological causes of dysuria

A
  • Irritant/contact dermatitis, lichen sclerosus, lichen planus, psoriasis, Stevens-Johnson syndrome, Behcet syndrome
97
Q

infectious causes of dysuria

A
  • Cystitis, urethritis, pyelonephritis, STIs, perineal inflammation
  • In males: prostatitis, epididymitis, orchitis
  • In females: vulvovaginitis, cervicitis
98
Q

non-infectious causes of dysuria

A
  • Foreign body (stones, stents, catheters), urethritis (as the result of reactive arthritis/Reiter’s syndrome), drug side effects/radiation induced
99
Q

3 inflammatory causes of dysuria

A
  1. dermatologic
  2. infectious
  3. non-infectious
100
Q

5 non-inflammatory causes of dysuria

A
  1. anatomic
  2. endocrine
  3. idiopathic
  4. neoplastic
  5. psyhcogenic
101
Q

anatomic causes of dysuria

A
  • Urethral stricture, urinary diverticulum
  • In males: benign prostatic hyperplasia
102
Q

endocrine causes of dysuria

A

In females: atrophic vaginitis (hypoestrogenism), endometriosis

103
Q

idiopathic causes of dysuria

A

Chronic bladder pain syndrome/interstitial cystitis

104
Q

neoplastic causes of dysuria

A
  • Kidney, bladder, prostate, penile or vulvovaginal cancers
105
Q

psychogenic causes of dyrusia

A

Anxiety/stress, depression and somatization disorders

106
Q

history questions for dysuria

A
  • Timing, persistence, severity, duration, and exact location of pain
  • Frequency, urgency, incontinence, hematuria, malodorous urine, nocturia
  • Presence of flank pain, nausea, fever, systemic symptoms
  • History of dysuria, UTIs, STIs, recent sexual activity
  • Medication use, family history, procedural history
  • Vaginal discharge, vaginal irritation, most recent menstrual period, type of contraception used
107
Q

dysuria physical exams

A
  • Vital signs
  • Evaluation for costovertebral angle tenderness
  • Recall the LR- is 0.9 – What does this mean?
  • Palpation for abdominal masses or tenderness
  • Inspection for dermatologic conditions
  • Inspection for acute joint effusions
  • Inspection for infectious or atrophic vaginitis and STIs in women and prostatitis and STIs in men
108
Q

further testing for dysuria

A
  • May not be required (e.g., in a woman presenting with uncomplicated UTI) – can treat empirically
  • Urinalysis and urine dipstick test
  • Other tests may be considered in some cases:
  • Urine culture and sensitivity
  • Abdominal/pelvic imaging: CT, ultrasonography * STI testing
109
Q
A

CMS200 (22 decks)

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