Week 5 Flashcards
6 host defenses against UTI?
- unobstructed urine flow
- specific urine characteristics such as osmolality, pH, etc
- emptying bladder promptly and efficiently
- chemo-attractant secretion with presence of bacteria
- specific serum and urinary antibodies
- flora in periurethral area of the prostate
how to do urine collection? follow up if repeat or recurrent UTI?
MSCC to decrease change of contamination from vaginal/perirectal area
if repeat or recurrent UTI repeat UA in 10-14 d then again in 4-6 wks
indications for further urological testing?
boys and men <50 yo
ssxs suggesting KD involvement
recurrent cystitis, esp in young girls
complicating factors such as diabetes, PG, hx of acute PN in last year, sxs lasting >7 d, recurrent >3x/yr, nosocomial infxn, sxs of renal failure, recent UT procedure, renal transplant, immunosuppression, prostatitis, infected urinary stone
MCC of urethritis in men? in the US? GCU MC in who?
STI - usu gonorrhea, followed by chlamydia, ureplasma, trichomonas
non-gonococcal urethritis is 2x as common as gonococcal-chlamdial urthritis in US
GCU is more common in homosexual males
Copius, purulent urethral discharge (yellow brown), dysuria, urethral itching More acute onset Prostate involved: freq, urg, noct Spread to vas def: epididymitis May be asymptomatic!
GCU
Dysuria, scant, white to clear watery urethral discharge,
dysuria, urethral itching
Less acute onset (longer incubation period)
NGU
Meatal edema, urethral tenderness
Gonococcal proctitis: rectal bleed
Periurethritis leading to urethral stenosis
Disseminated dz: arthritis, hepatitis, endocarditis,
GCU
Meatal edema and erythema
NGU
Urine NAAT PCR (sensitive but will not clarify antibiotic sensitivities, $)
DNA probe (not as sensitive)
Cultures of pharynx and rectum if indicated
Urethral smear: PMN’s, gram-negative diplococci
GCU
Urine NAAT PCR
Gram stain
DNA probe
NGU
DDX of GCU?
NGU, HSV
DDX of NGU?
GCU, HSV, trichomonas
if suspected or confirmed gonococcal urethritis what is the tx?
ceftriaxone (250 mg IM) PLUS azithromycin (1-2 g single dose) OR doxycycline 100 mg bid x 7 d
if suspected or confirmed chlamydia urethritis what is the tx?
azithromycin (1 gm) SD OR doxycycline 100 mg bid x 7d
adjunctive tx for GCU?
pelvic rest probiotics bromelain 300 mg TID ic to enhance tissue penetration vitamins C, A and zind echinacea, eleutherococcus urinary demulcent botanicals (marshmallow, zea mays) anti-inflam botanicals: boswellia alternating sitz or spray to pelvis counseling to avoid future infxn
what will happen if you don’t treat GCU in men?
can resolve w/o tx but can produce a high rate of asx carriage which may result in chronic infertility, chronic prostatitis, chronic epididymitis, recurrent acute infections
complications of NGU?
epididymitis, prostatitis, proctitis, Reactive arthritis (reactive arthritis triad: arthritis, uveitis, urethritis), lymphogranuloma venereum
MCC of acute urethritis in women? ssxs? UA results for chlamydia?
usu gonorrhea or chlamydia
ssxs: polyuria, frequency, urgency, lower abd pn, can accompany cervicitis
chlamydia may show pyuria
what medications to tx acute urethritis are C/I in PG?
fluroquinolones and tetracyclines as they are teratogenic!
DDX of acute urethritis in women?
detergents in bubble baths and some spermicides may cause non-bacterial urethritis (WBCs but no organisms seen on UA)
risks for developing chronic urethritis?
Spread from cervical or vaginal infx, STI (genital-genital, oral-genital), indwelling catheter,
Contaminated diapers, trauma (intercourse, childbirth)
ssxs of chronic urethritis?
Resembles symptoms of cystitis with longer duration
Dysuria, frequency, nocturia, urethral discomfort when walking
Meatal redness, hypersensitive meatus and urethra Usu but not always urethral d/c
DDX of chronic urethritis?
cystitis, psychological cause, interstitial cystitis
diagnosis of chronic urethritis? labs and instrumentation
initial UA may contain pus and bac
midstream sample - no pus
WBCs w/o bac suggests NGU (may be chlamydia)
may culture out strep faecalis, E. coli or ureaplasma
instrumentation: panendoscopy will show red and granular mucosa, mb inflam polyps in proximal urethra
tx and management of chronic urethritis?
Culture-specific antibiotic if organism found
Probiotics
Gradual urethral dilatations up to 36F in adults
Consider regular, local application of an antiseptic (e.g. hexachlorophene,) to the introitus to reduce bacteria counts of the perineum, vagina, and vulva
Botanicals: demulcents, urinary antiseptics
RFs for cystitis?
change in flora, decrease in urine flow, damage to mucous membranes, change in pH prior abx use anal intercourse infrequent urination prostate of KD dz PG spermicides tampon use blood group A or AB non=-secretor fecal or urinary incontinence external contamination vaginal douching poor hygiene DM instrumentation
ssxs of cystitis?
Classic symptoms: dysuria (pn/burning), frequency, urgency, suprapubic pn
RARELY back pain or fever
Urethral discharge may be present but little tenderness on palpation.
Pt may void in unusual positions, (HP repertory) or not want to void due to pain.
Kids may have non-specific sx
4 potential pathogenic mechs of cystitis?
- ascending from periurethral area
- hematogenous spread of infection to the KD in immunocomp pts
- lymphatogenous spread through rectal, colonic, peri-uterine lympahtics
- direct extension and spread from neighborhing organisms
virulence factors of E. coli? make up what %age of cystitis causes?
adherence properties; resist bacteriocidal activity, produce hemolysin (initiates tissue invasion), express K capsular antigen (protects from phagocytosis)
2 types of pili (fimbriae)
80% of cystitis cases are dt E. coli
cystitis causative factor MC in kids? most commonly cause nosocomial infxns? MCC UTIs in young women, negative nitrites? can cause urethritis, prostatis, epididymitis, mimic cystitis, routine culture (=) since IC bac?
MC in kids: klebsiella, enterobacter
nosocomial infxns: pseudomonas, staph
UTIs in young women, negative nitrites: staphylococcus sap
urethritis, prostatitis, epididymitis: chlamydia
DDX for dysuria, urgency, frequency?
vulvovaginitis, STI causing urethritis or pyuria, IC HSV, trauma cystitis, eosinophilic cystitis
DDX hematuria?
neoplasia or nephrolithiaisis, psychological dysfunction (eg psychogenic purpura/hematuria) PID, Pyelonephritis
in kids, fever can cause what UA finding? in FUO need to r/o what?
fever can cause pyuria
need to r/o URI then UTI
dx for cystitis?
UA shows pyuria, bacteriuria, hematuria (gross or microscopic), pos LE, protein trace or +1, nitrite usu (+) unless amicrobic, NO CASTS
tx and management of cystitis based on what?
based on complication of case, sensitivity from C and S, age, sex, concomitants, vitality
abx options in uncomplicated cystitis in women?
nitrofuratoin: 100mg twice a day for 5 days
OR TMP-SMX: one double strength (160/800mg) twice a day for 3 days
OR fosfomycin 3 g sachet SD
abx options in complicated cystitis in women?
ciprofloxacin: 500mg po twice a day for 5-14 days OR
evofloxacin: 750 mg po daily for 5-14 days
Parenteral treatment may be needed if cannot tolerate oral meds
abx options for men with complicated and uncomplicated cystitis?
complicated: paernteral tx mb needed
uncomplicated: TMP-SMX: one double strength (160/800mg) twice/d x 7 days
naturopathic tx options for cystitis? lifestyle recommendations? supplements? hygiene? sexual? botanicals?
avoid sugar, EtOH, caffeine, aspartame, tobacco, bananas, avocados, figs, yogurt, chocolate
clarify and avoid allergens
flush organisms by drinking filtered water (8 oz) q 20 min for 2-3 q then every hour
cranberry juice
supplements: vit c, a, e, D-mannose
hygiene: white cotton underwear, change daily, use mild detergents, avoid tampons, use non-deodorized sanitary pads, wipe front to back, avoid bubble baths, shower after swimming, avoid tight paints
sexual: avoid BCPs, spermicidal creams, leaving diaphragm inserted, check latex allergy, avoid vaginal intercourse after anal w/o changing condom, use adequate vaginal lubrication
botanicals: berberis, uva ursi, apis, pulsatilla, buchu, cantharis, capsicum, solidago, taraxacum, zea mays
HP to consider for cystitis?
cantharis, sarsaparilla, apis, merc cor, staphy, benzoic acid, pulsatilla, causticum, cannibis sat, arsenicum, equisetum, lycopodium, med, staph, nux v., sepia
how to alter urine pH to tx or prevent cystitis?
acidify urine via unsweetened cranberry, blueberry juice/capsules
alkalinize urine via K, Na citrate, citrus juice
what hormone can you use for postmenopausal women to prevent and tx cystitis?
estriol cream 0.5 mg IV qd
what can cause unresolved cystitis?
Bacterial resistance, mixed infx, non-compliance with antibiotic course, Staghorn calculi, papillary necrosis
what can cause reinfection (UTI, cystitis)?
New infx with new pathogens, typically by the fecal-perineal-urethra route after 3 to 4 weeks from the previous infection.
what can cause bacterial persistence?
sequestration of bacteria in protected site
Due to: infected stones, chronic bacterial prostatitis, utereral duplication, foreign body, urethral diverticula, infected urachal cysts, perivesical abscess with fistula to bladder, biofilm development
DDX of cystitis?
Eosinophilic cystitis (rare) (from food allergens, drugs): see eosinophils in filtrate
RFs of pyelonephritis? ssxs? PE?
RFs: Unsafe sex practices, DM, urinary tract abnormalities, nephrolithiasis, catheter, BPH
ssxs: preceding LUT infx, fever/chills, anorexia, N&V, dysuria, polyuria, myalgia, flank pain
PE: Appear ill/toxic, temp 101-104°F, tachycardic, pos CVA tenderness, abdominal guarding
DX of PN? CBC, UA, microscopy, C and S?
CBC: Elevated WBC with left shift
UA: Dipstick: pos LE, nitrites, Protein is usu negative; presence is ominous sign suggesting nephron destruction
Microscopic: Many WBCs and WBC casts
Glitter cells=PMN’s with cytoplasmic granules in state of Brownian motion
Hematuria, bacteriuria, may see bacterial casts
Urine culture and sensitivity: >100,000 cfu/ml
when would you order imaging with suspected PN?
poorly responding to treatment; boys, older men (also check prostate); diabetics; history of stones; history of previous urologic surgery; immunosuppressed; previous episodes of PN
DDX of PN?
PID (+CMT); Nephrolithiasis (blood, no fever, inc pain); appendicitis (+McBurney’s, +psoas); Acute GN (RBC casts, protein); Perinephritic abscess (mass); endometriosis (cyclic nature); acute abdomen (peritonitis, +rebound tenderness)
tx and management of PN with abx? if stable, minimal illness and well hydrated? if sick? consider hospitalization when?
appropriate abx based on C and S
stable, minimal illness, well hydrated: cipro 500 mg BID x 7 d
levofloxacin 750 mg qd x 5 d
TMP/sulfa 160/80 mg one double strength bid
sick pts: hospitalization, IV fluids, IV abx
consider hospitalization if toxic, DM, immunocompromised, suspected bacteremia, persistent N/V, suspected obstruction, PG
other supportive measurements for cystitis tx?
increase fluids bed rest probiotics w/after abx uva ursi, aconite, galium vit c, a, zinc renafood, renatropin physical med: diathermy over KD COP over KD oregano EO single drop anti-inflams, digestive enzymes may see specific indications for ribes nigram, juniperis prevent recurrence by addressing risks
f/u of cystitis? what do you need to measure/monitor?
if no improvement in 48-72 hrs mb urinary stasis dt obstruction of ureter - monitor BUN/Cr for KD fxn
CT or US for further assessment
may need to continue to tx for 3-4 wks
if persistent or recurrent sxs then repeat cultures
prognosis of cystitis?
usu heal w/o problems or seqeulae in uncomplicated cases
complications: renal abscess requiring drainage
acute PN may lead to tubular necrosis, glomerular infection, papillary necrosis, acute renal failure, sepsis with shock and possibly death
acute PN can be a source for sepsis
DDX of cystitis?
emphysematous PN
acute focal or multifocal bac nephritis
pyonephrosis
xanthogranulomatous PN
acute necrotizing infxn caused by gas producing uropathogens, often in DM pts, common triad is fever, vomiting, flank pn, seen on plain film, excretory urography, tx w/hydration, IV abx, mb surgery
emphysematous pyelonephritis
more severe than PN, seen in DM, sepsis common, dx w/U/S and CT, tx with abx, hydration
acute focal or multifocal bacterial nephritis
infected hydronephrosis leading to suppurative destruction of renal parenchyma, pt very ill w/fever, chills, flank pn, mb no bacteriuria w/obstruction, dx w/U/S or CT, tx with drainage and abx
pyonephrosis
accumulation of lipid laden macrophages often from nephrolithiasis, obstruction or proteus or E. coli infxn, recurrent UTIs, flank pn, fever, wt loss, large, non-functioning KD seen on CT, ab surgery (often nephrectomy)
xanthogranulomatous PN
B/L pyogenic KD infxn or congenital reflux nephropathy leading to parenchymal scarring and atrophy of the calyces, over 20+ years
chronic pyelonephritis
RFs of chronic pyelonephritis?
elderly DM chronic urolithiasis low water intake/infrequent urination urine reflux sedentary lifestyle BPH w/obstruction chronic analgesic use recurrent bacterial UTI
ssxs: usu asx, found incidentally w/imaging; with progression seen HTN, renal failure develops; oliguria late stage, nonspecific except as renal failure develops
chronic PN
how to dx chronic PN?
UA: bacteriuria and pyuria if active infxn, minimal proteinuria until glomerular involvement
dec SG and urine osmolality mb 1st clues
late see granular, waxy, broad casts
what will chronic PN look like on KUB? on IVU, CT or U/S? voiding cystogram?
KUB: small KDs, irregular outline
IVU, CT, U/S: small atrophic, scarred KDs, impaired excretion of contrast material and possibly stones and dilated ureters
voiding cystogram: to R/O vesicoureteral reflux
DDX of chronic PN?
KD fibrosis, bladder CA, RCC, BPH, chronic prostatitis, prostate CA, nephrolithiasis
management and tx options for chronic PN?
optimize health! (limited tx options if late dz as renal damage can be irreversible) eliminate current UTI probiotics immune support correct structural problems proteolytic enzymes anti-inflams antioxs constitutional hydro renal protective R/O DM, cystic dz, analgesic use
RFs for renal abscess? when to consider?
RFs: previous hx of calculi, neurogenic bladder, vesicoureteral reflux, DM, PCKDs
consider renal abscess if acute renal infxn does not improve after 5 days of treatment!
ssxs of renal abscess?
similar to acute PN
fever, chills, flank pn, N/V, malaise, CVA, abd tenderness
dx of renal abscess?
CBC shows leukocytosis w/L shift
blood cultures (+)
UA shows pyuria, bacteriuria, moderate proteinuria
CT is crucial to make dx! better than U/S
DDX of renal abscess?
acute PN with papillary necrosis
emphysematous PN
RCC
management and tx options of renal abscess?
abx therapy
referral if not better in 48 hrs - order perQ aspiration under CT or U/S guidance
open surgical drainage - last resort
possible complication of renal abscess? what is it? ssxs?
perinephric adn paranephric abscess - purulent material ruptures to surrounding area
ssxs: fever >5 d, chills, fever, abd pn, dysuria, symptoms >4 d, tender, palpable abd mass, flank pn w/skin erythema, abscess seen on renal U/S
tx is the same as for a renal abscess
RFs for nephrolithiasis?
males btw 30-50 yo SES (+) FHx chronic diarrhea females post-meno obesity chemotherapy sedentary occupation crystalluria hot climate meds: diuretics, antacids, anti-HTN diet: high fat, animal proteins, fructose, Na, oxalates, coffee, EtOH, low fiber, low fluid intake
factors that contribute to stone formation?
calcium (aim to decrease calcium in urine)
oxalate (high dietary intake can precipitate stones)
phosphate
uric acid
magnesium
inhibitors of stones?
sodium
citrate
magnesium
sulfate
5 different types of stones and the MC type?
calcium oxalate (MC stone type) struvite calcium phosphate uric acid cystine
low water intake, hyperoxaluria, hypercalciuria, hyperuricosuria, hypocitriuria, hyperPTH
radiopaque <1 cm, white on KUB
calcium oxalate
GU tract colonization by urea-splitting organisms
radiopaque, often staghorn
struvite (magnesium ammonia phosphate)
hyperPTH, renal tubular acidosis
radiopaque
calcium phosphate
hyeruricosuria
radiolucent (black)
uric acid
cystinuria, radiopaque
cystine (rare)
DDX of nephrolithiasis?
appendicitis, diverticular dz, PUD, ovarian torsion/rupture, ectopic PG, PID, bowel obstruction, biliary stones, RAS, abd aortic aneurysm, PN, UTI, phleboliths, cholelithiasis, calcified nodes, foreign body ***also consider narcotic-seeking individuals
ssxs of nephrolithiasis?
pain hematuria, pyuria developing infxn (PN) N/V increased thirst, increased urinary frequency oliguria if stone blocks ureter abd pn, low back pn restlessness
labs with nephrolithiasis?
proteinuria (will rise w/infxn, obstruction, development of RF)
hematuria, pyuria
pH will vary depending on stone type
BUN and Cr to assess renal fxn
Specific gravity
strain urine for stone sediment so as to identify
what do you need to measure for chronic stone formers?
24 hour urine to look at calcium, oxalate, citrate, uric acid, creatinine, total volume, pH, urea, nitrogen and sodium
special situation which can precipitate stones?
PG dysmorphia (spinal cord injury, cerebral palsy, spina bifida) obesity medullary sponge KD renal tubular acidosis TCC or SCC in upper urinary tract pediatric RFs caliceal diverticular renal malformations
indications to refer a pt w/nephrolithiasis to a urologist?
stone > 5 mm sxs of obstruction or KD damage anuria staghorn calculus cystine stone persistent vomiting pn unresponsive to oral analgesics
treatment and management strategy with nephrolithiasis?
most will pass on own w/in 48 hrs initial KUB to locate and measure stone increase fluid intake magnesium citrate deal with any infection NSAIDs or opioids for pn relief herbs for pain relief, increasing diuresis, antimicrobial, alkalinize or acidify urine HPs homeopathy (vinegar packs) IV magnesium, pyridoxine in lactated ringer's dissolution agents
how to prevent recurrence of nephrolithiasis?
increase fluids!
stone analysis, 24 hr urine collection
Na and Calcium restricted diet for few days
oral meds to alkalinize (K citrate, sodium, potassium bicarb), acidify (prunes, plums, vit C, orange juice) urine
gastrointestinal absorption inhibitors
hibiscus or hydrangea for uricosuric effect and prevent recurrence
increase fiber, decrease refined sugar, decrease high oxalate foods, animal products, increase fruits and vegetables
specific nutrients which can be helpful in preventing recurrent nephrolithiasis?
vitamin B6 folic acid glutamic acid vitamin K taurine glycosaminoglycans NAC lactobacillus EPA
causes voiding dysfunction (urethral stricture, BPH, bladder neck contracture, flaccid or spastic neurogenic bladder) or foreign body (catheter), stagnant urine precipitates stones
irritative voiding, intermittent urinary stream, UTIs, hematuria, pelvic pn
U/S is diagnostic
most stones can be crushed and removed by cystoscope
bladder stone
usu sm and numerous, composed of calcium phosphate, dx: radiograph or transrectal U/S
prostatic stones
smooth, hard, rare, mb assoc w/hemospermia, PE reveals hard stony gland w/crunching when multiple stones are present
seminal vesicle stones
usu from bladder, most pass spontaneously, caused by urinary stasis, urethral diverticulum, near urethral strictures or at sites of previous surgery
in men prostatic or bulbar regions, solitary
in women, rare, most assoc w/urethral diverticular
ssxs: similar to bladder stones, pn mb severe in men, radiating to the tip of the penis
dx w/palpation, f/o w/radiography
urethral stones
develop secondary to a severe obstructive phimosis or poor hygiene w/inspissated smegma
dx via palpation
tx underlying cause w/a dorsal preputial slit or circumcision
prepucal stones
