week 14- UTI Flashcards
dysuria
pain or burning with or after urination
if have dysuria probably have a
UTI
UTI- main cause?
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)
SLIDE 5
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.
- Upper urinary tract infections are less common compared to lower urinary tract infections, but they tend to be more severe.
Which of the following infections is considered a lower urinary tract infection?
* Pyelonephritis
* Cystitis
* Urethritis
* Prostatitis
- Cystitis
2 types of UTI
uncomplicated and complicated
what is an uncomplicated UTI
UTI in an individual with a normal urinary tract system
complicated UTI
- 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)
who are uncomplicated UTIs most common in
most common in young, sexually active women
UTIs are how much more likely in women than men and what is the reason for this
UTIs are 4x more likely in women than men
* Proximity of urethral meatus to the rectum * Shorter urethral length
risk factors for men getting UTIs
homosexuality, lack of circumcision
risk factors for UTI
- 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
acute cystitis is an infection of what
bladder
what is the most common UTI
acute cystitis
how to diagnose acute cystitis
diagnosed when pyuria and bacteriuria are accompanied by urinary symptoms confined to the bladder
most common bacteria causing acute cystitis
E. coli
“KEEPS” pneumonic
* K = Klebsiella pneumoniae
* E = Escherichia coli (75–95%)
* E = Enterococcus faecalis
* P = Proteus mirabilis
* S = Staphylococcus saprophyticus, group B streptococcus
symptoms in acute cystitis
- Dysuria
- Suprapubic pain
- Urinary frequency
- Urinary urgency
- Hematuria
what is there an absence of in acute cystitis
Absence of penile/vaginal discharge, costovertebral angle (CVA) tenderness, nausea, vomiting, fever
atypical presentation of acute cystitis in elderly
- Delirium
- Functional decline
- Acute confusion
- Lethargy
- Generalized weakness
symptoms and signs that increase UTI in women
- 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)
symptoms and signs that decrease probability of UTI
- 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)
how helpful is one symptom in acute cystitis
- 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
combining symptoms in acute cystitis; which 2 are most helpful
- Dysuria and frequency without vaginal discharge or irritation yields a high likelihood of UTI (LR = 24.6)
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 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
further testing for acute cytitis
- 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
what does a rapid urine dipstick test measure
- Leukocyte esterase
- Nitrites
- Urobilinogen
- Protein
- pH
- Blood
- Specific gravity * Ketones
- Bilirubin * Glucose
what does a urinalysis measure
- 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
which chemical marker in an urinalysis has the highest LR+ for acute cystitis
leukocyte esterase
which 2/3 blood markers in urinalysis are most helpful for UTI diagnosis
- Presence of nitrites (PV+ = 75% to 95%)
- Presence of leukocytes (PV+ = 65% to 85%)
- Presence of both nitrites and leukocytes (PV+ = 95%)
if leukocyte esterase and nitrites are negative then
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
can you rule out cystitis if urinalysis is negative for nitrites and leukocyte esterase
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
notes of sample collection for urinalysis
- Clean catch midstream urine sample should be used
- Urine sample should be sent to the lab immediately or refrigerated
when to use a urine culture in acute cystitis
- 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
who to use urine culture for in acute cystitis suspected
- Should be performed when:
- Antimicrobial-resistance is suspected
- Cystitis is suspected in men
urine culture is used to
find the causative organism in the case of an infection
how to do urine culture
- 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
how many CFU for a urine culture to be positive
- A positive urine culture is defined as >
105 colony-forming units (CFU) of bacteria per milliliter
how to manage uncomplicated vs complicated acute cystitis
- Uncomplicated: antibiotics for 1-5 days
- Complicated: longer duration of antibiotics (7-14 days)
how long does symptom relief occur within after treating acute cystitis
36 hours
how common is UTI recurrence
- UTI recurrence in ~25% of women within 6 months
other complications in acute cystitis
- Other complications are relatively rare:
- Antibiotic resistant organisms
- Pyelonephritis
- Acute renal failure
- Renal or perinephric abscess
- Sepsis
- Chronic prostatitis
what is asymptomatic bacteriuria
- Presence of bacteria in the urine (at a concentration of ≥105 cfu/mL) in the absence of symptoms of infection
who is asymptomatic bacteruiria common in
- 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
asymptomatic bacteriuria (ASB) and pregnancy
- 2-15% of pregnant women have ASB
- May increase risk of preterm birth
- ~20-40% will develop pyelonephritis if untreated
what will baby develop if dont treat asymptomatic bacteriuria in pregnancy
pyelonephritis
should you screen for asymptomatic bacteriuria?
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
recurrent cystitis is defined by how many episodes
- 2 episodes of acute cystitis within the last 6 months, or
- 3 episodes of acute cystitis within the last year
risk factors for recurrent cystitis
- 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
what test to use to differentiate between recurrent and relpasing infections
- Urine culture and sensitivity to differentiate between recurrent infections from relapsing infections
in women and in men what tests for recurrent cystitis
- Pelvic exam in women to assess for cystoceles, vaginitis, vaginal atrophy, pelvic organ prolapse
- Rectal exam in men to assess for prostatitis
when is imaging and cystoscopy needed in recurrent cystitis
- 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
patient education in managing recurrent cystitis
- Personal hygiene: wiping front to back, avoid baths
- Avoid long intervals between urinations
- Increase fluid intake if inadequate
how to manage recurrent cystitis
*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
acute pyelonephritis is an infection of
the parenchyma of the kidney
how serious is acute pyelonephritis
> 250,000 cases/year; 200,000 need hospitalization
what is usually the cause of acute pyelonephritis
- 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
KEEPS organisms causing acute cystitis and acute pyelonephritis and acute bacterial prostatitis
- K = Klebsiella pneumoniae
- E = Escherichia coli (75–95%)
- E = Enterococcus faecalis
- P = Proteus mirabilis
- S = Staphylococcus saprophyticus, group B streptococcus
risk factors of pyelonephritis
- UTI (cystitis)
- Structural/anatomical problem of urinary track which causes blockage or reflux
- Pregnancy
- Diabetes
signs and symptoms in pyelonephritis
- 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)
symptoms of pyelonephritis in elderly and kids
- Confusion in elderly
- Feeding difficulty in infants
- Children less than 2 may just have high fever
in urinalysis or urine dipstick test for pyelonephritis what is seen
- White blood cell casts seen on urine microscopy
is urine culture negative or positive in pyelonephritis
positive in 90% of patients
blood culture for pyelonephritis
CBC with differential
other further testing for pyelonephritis
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
antibiotic therapy for pyeloneprhtisi
- 7-10 days for uncomplicated pyelonephritis * 14 days for complicated pyelonephritis
long term consequences in pyelonephritis? life threatening?
- 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
indication for hospital admission for pyelonephritis
- Unstable vital signs
- Inability to tolerate oral medications
- Concern for nonadherence
- Pregnancy
- Immunocompromised state
- Concern for urinary tract obstruction or nephrolithiasis
infectious urethritis is inflammation in
- Infection-induced inflammation of the urethra
what is infectious urethritis usually caused by
sexually transmitted infection
high incidence rates in age for infectious urethritis
20-24 yrs old
who is infectious urethritis more common in (gender)
- More common in homosexual males than heterosexual males and females in general
80% of the time the STI that causes infectious urethritis is
neisseria gonorrhoeae
STI causes of infectious urethritis
- 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)
STI of genitourinary tract manifests how in men vs women
STIs of the genitourinary tract manifest as urethritis in men and cervicitis in women
symptoms of cervicitis from STIs in women
- Dysuria
- Cervical discharge
- Dyspareunia
- Spontaneous or postcoital vaginal bleeding
symptoms of urethritis from STIs in men
- Dysuria
- Urethral pruritus
- Urethral discharge
- Dyspareunia
- Abdominal pain
- Testicular pain
further testing for urethritis/cervicitis from STIs
- 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
management of urethritis/cervicitis from STIs
- Antibiotic therapy
- Abstain from intercourse
- Sexual partners should be evaluated and treated
urethriritis caused by reiter’s syndrome is aka
reactive arthritis
risk factors for Urethritis caused by Reiter’s Syndrome
aka reactive arthritis
- Most common in men aged 20-50, HLAB27 gene, HIV/AIDS or immunocompromised
signs and symptoms for Urethritis caused by Reiter’s Syndrome aka reactive arthritis
- 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)
what is Urethritis caused by Reiter’s Syndrome from?
- 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
who is acute bacterial prostatitis most common in
- 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
what is acute bacterial prostatitis usually caused by
ascending urethral infection or intraprostatic reflux
which bacterial in acute bacterial prostatitis
- KEEPS, 80% E. Coli
- Suspect N. Gonorrhea in sexually active men <35 years of age
how do bacterial get into the prostate in acute bacterial prostatitis
- Rectal bacteria can cause direct/lymphatic spread
- Bacteria introduced with recent cystoscopy, post prostatic biopsy, catheterization
- Will often also see benign prostatic hyperplasia
acute bacterial prostatitis signs and symptoms
- 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
further testing in acute bacterial prostatitis
- 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
management of acute bacterial prostatitis
- 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
chronic bacterial prostatis is
- Recurrent exacerbations of acute bacterial prostatitis
- Relapsing UTI with same pathogen – more difficult to treat * Tends to develop more slowly
what exam may be normal in chronic bacterial prostatitis
digital rectal exam
signs and symptoms in chronic bacterial prostatitis
- 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
testing for chronic bacterial prostatitis
- Urine culture and sensitivity: 4 specimens
- EPS and VB3 must exceed VB1 and VB2 by 10x
management for chronic bacterial prostatitis
- Long course of antibiotics (3-4 months) * Even if urine culture is negative
dermatological causes of dysuria
- Irritant/contact dermatitis, lichen sclerosus, lichen planus, psoriasis, Stevens-Johnson syndrome, Behcet syndrome
infectious causes of dysuria
- Cystitis, urethritis, pyelonephritis, STIs, perineal inflammation
- In males: prostatitis, epididymitis, orchitis
- In females: vulvovaginitis, cervicitis
non-infectious causes of dysuria
- Foreign body (stones, stents, catheters), urethritis (as the result of reactive arthritis/Reiter’s syndrome), drug side effects/radiation induced
3 inflammatory causes of dysuria
- dermatologic
- infectious
- non-infectious
5 non-inflammatory causes of dysuria
- anatomic
- endocrine
- idiopathic
- neoplastic
- psyhcogenic
anatomic causes of dysuria
- Urethral stricture, urinary diverticulum
- In males: benign prostatic hyperplasia
endocrine causes of dysuria
In females: atrophic vaginitis (hypoestrogenism), endometriosis
idiopathic causes of dysuria
Chronic bladder pain syndrome/interstitial cystitis
neoplastic causes of dysuria
- Kidney, bladder, prostate, penile or vulvovaginal cancers
psychogenic causes of dyrusia
Anxiety/stress, depression and somatization disorders
history questions for dysuria
- 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
dysuria physical exams
- 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
further testing for dysuria
- 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
