Urinary Tract Disorders
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Urinary Tract Disorders

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Urinary Tract Disorders Urinary Tract Disorders Presentation Transcript

  • Urinary Tract Disorders
  • Objectives
    • Distinguish types of UTI, including bacteriuria, urethritis, cystitis, and pyelonephritis
    • Describe the pathophysiology related to UTI, such as organisms and host factors
    • Describe pathophys of common forms of nephrolithiasis, including risk factors for development of nephrolithiasis
    • Describe typical clinical presentations, and elicit a pertinent history, in a patient with UTI or nephrolithiasis
    • Describe the diagnostic methods and diagnostic criteria for the various types of UTI
    • Summarize the methods used for dx of nephrolithiasis
    • Describe modes of therapy for acute, chronic, and complicated UTI, including prophylaxis for recurrent infection
    • Summarize therapeutic options for nephrolithiasis, and strategies to prevent recurrence
  • Urinary Tract Infection
    • Lower
    • urethritis
    • cystitis
    • prostatitis
    • Upper
    • pyelonephritis
    • intrarenal and perinephric abscess
  • Also categorized into
    • Non-catheter associated (commum. acquired)
    • Catheter associated (hosp. acquired)
    • Any category may be sx or asx
  • Urinary Tract Infection
    • Pathogenic microorganisms in urine, urethra, bladder, kidney, prostate
    • Usually growth > 10 5 organisms per milliliter
    • From midstream “ clean catch” urine sample
    • If sx or from catheter specimen can be significant with 10 2 or 10 4 organisms per mL
  • Etiology
    • Most common is Gram neg. bacteria
      • E. coli = 80% of uncomp. acute UTI
      • Proteus – assoc. with stones
      • Klebsiella – assoc. with stones
      • Enterobacter
      • Serratia
      • Pseudomonas
  • Etiology
    • Gram pos. cocci
      • Staphylococcus saprophyticus 10-15 % acute sx UTI in young females
      • Enterococci – occas. in acute uncomp. cystitis
      • Staphylococcus aureus – assoc. with renal stones, instrumentation, increased susp. of bacteremic kidney infection
  • Etiology
    • Urethritis from chlamydia, gonorrhea, HSV – acute sx female with sterile pyuria
    • Ureaplasma urealyticum
    • Candida or other fungal species – commonly assoc. with cath. or DM
    • Mycobacteria
  • Pathogenesis
    • Usually ascent of bacteria from urethra to bladder to kidney
    • Vaginal introitus, distal urethra colonized by normal flora
    • Gram negative bacilli from bowel may colonize at introitus, periurethra
  • ? Predisposing conditions to UTI
    • Female
      • Short urethra, proximity to anus, termination beneath labia
      • Sexual activity
    • Pregnancy
      • 2-3% have UTI in preg, 20-30% with asx bacteriuria  may lead to pyelo
      • Increased risk of pyelo = decreased ureteral tone, decreased ureteral peristalsis, temp. incomp of vesicoureteral valves
  • ? Predisposing conditions
    • Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying)
    • Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, concomitant medical conditions such as DM
    • Vesicoureteral reflux
    • Bacterial virulence
    • Genetics
    • Change in urine nutrients, DM, gout
  • Urethritis ?
    • Acute dysuria, frequency
    • Often need to suspect sexually transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic pain, new sexual partner, cervicitis
  • Cystitis
    • Sx: frequency, dysuria, urgency, suprapubic pain
    • Cloudy, malodorous urine (nonspec.)
    • Leukocyte esterase positive = pyuria
    • Nitrite positive (but not always)
    • WBC (2-5 with sx) and bacteria on urine microscopy
  • Pyelonephritis
    • Fever
    • chills, N/V, diarrhea, tachycardia, gen. muscle tenderness
    • CVAT or tenderness with deep abdominal tenderness
    • Possibly signs of Gram neg. sepsis
  • ? Pyelonephritis
    • Leukocytosis
    • Pyuria with leukocyte casts, and bacteria and hematuria on microscopy
    • Complications: sepsis, papillary necrosis, ureteral obstruction, abscess, decreased renal function if scarring from chronic infection, in pregnancy – may increase incidence of preterm labor
  • Catheter-Associated ? Urinary Tract Infections
    • 10-15% of hosp. patients with indwelling catheter develop bacteriuria
    • Risk of infection is 3-5% per day of catheterization
    • UTI after one-time bladder cath approx. 2%
    • Gram neg. bacteremia most significant complication of cath-induced UTI
    • Greater antimicrobial resistance
  • Diagnosis of UTI
    • History
    • Physical exam
    • Lab
      • Urinalysis with micro = WBC, bacteria
      • Urine culture
      • Sensitivities of culture for tailored antibiotic therapy
      • May dx acute uncomp. cystitis based on hx, PE, and UA alone, no need for culture to treat
  • Diagnosis
    • Urinalysis
      • Leuk. Esterase pos. = pyuria
      • Nitrite pos. from urea prod. bact. (but not always)
      • Micro – WBC (even 2-5 in patient with sx)
      • Micro – Bacteria
  • Diagnosis
    • Urine culture
      • Once 10 5 colonies per mL considered standard for dx but misses up to 50%
      • Now, 10 2 to 10 4 accepted as significant if patient symptomatic
      • Needed in upper UTI, comp. UTI, and in failed treatment or reinfection
      • Sensitivities for better tailoring of tx
  • Treatment ?
    • Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx sufficient
      • Bactrim DS, Septra DS
      • Cipro or other FQ (avoid in preg.)
      • Nitrofurantoin (7 days)
      • Augmentin
      • Bladder analgesis, Pyridium
  • Treatment
    • Uncomp. cystitis in pregnant patient
      • Requires longer tx of 7-14 days
      • Cephalosporin, nitrofurantoin, augmentin, sulfonamides (do not use near term, inc. kernicterus)
  • Asymptomatic ? Bacteriuria
      • 10 5 org/mL growth
      • Empiric treatment of all asymptomatic bacteriuria (ASB) in pregnancy. Screening at first visit.
      • ASB if untreated = inc. PTD and LBW, 20-30% develop pyelo.
      • Do TOC in 2 weeks and each trimester.
      • Screen Sickle cell trait each trimester. Twofold inc. risk of ASB
  • Asymptomatic Bacteriuria
    • Treatment failures: repeat tx based on sensitivities for 1 week, then prophylactic therapy for remainder of pregnancy
    • Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMX
  • Treatment Recurrent uncomp. UTI
    • 3 or more episodes in one year, 2 in 6 months
    • Bactrim DS ( or septra DS) QD for 3-6 months once infection eradicated, self-admin. Single dose at symptom onset or one DS tab post-coitus
    • Measures for prevention: voiding after intercourse, good hydration, frequent and complete voiding
  • Treatment of Pyelonephritis -- Outpatient
    • Uncomp. Nonpreg pyelo
    • Primary – any FQ x 7 days, cipro
    • Alt. -- Augmentin, TMP/SMX, or oral CSP for 14 days
  • Treatment of Pyelonephritis – Inpatient ?
    • Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO meds
    • Use FQ or amp/gent or ceftriaxone or piperacillin
    • If no improvement on IV, consider imaging studies to look for abscess or obstruction
    • All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediately
  • Treatment of Complicated UTI
    • Catheter related
    • Amp/gent or Zosyn or ticaricillin/clav or imipenem or meropenem x 2-3 weeks
    • Switch to PO FQ or TMP/SMX when possible
    • Rule out obstruction
    • Watch out for enterococci and pseudomonas
  • Nephrolithiasis ?
    • Supersat. of urine by stone forming constituents
    • Crystals of foreign bodies act as nidi
    • Freq. stone types: Calcium (most common), struvite, oxalate, uric acid, staghorn
    • Risk factors: metabolic disturbances, previous UTI, gout, genetic
  • Nephrolithiasis
    • Incidence = 2-3%
    • Morbidity
      • Obstruction  pain
      • Chronic obstruction, may be asx  loss of renal function
      • Hematuria (rarely dangerous by itself)
      • Dangerous combo = obstruction + infection
  • Nephrolithiasis ?
    • More prev. in Asians and whites
    • Males > females, 3:1
    • Struvite stones – from infection, increased in females
    • Ages 20-49
    • Recurrent
    • Uncommon after 50 y.o.
  • Nephrolithiasis Patient History ?
    • Often dramatic pain, poss. infection, hematuria
    • Even nonobst. May cause sx
    • Bladder irritating sx
    • Renal colic because of stone in ureter
      • Severe, undulating cramps because of ureter peristalsis, sever pain, N/V
      • Pain may migrate
  • Nephrolithiasis Patient History
    • Duration, char, location of pain
    • Hx of stones?
    • UTI?
    • Loss of renal function?
    • FHx of stones
    • Solitary/ transplanted kidney
  • Nephrolithiasis Physical Exam
    • Dramatic CVAT, may migrate as stone moves
    • Usu. Lacking peritoneal signs
    • Calculus often in area of maximum discomfort
  • Nephrolithiasis Workup
    • Urinalysis
      • Evid. Of hematuria and infection
      • 24-hour urinalysis helpful in identifying cause
    • CMP, uric acid, CBC
    • Calcium, oxalate, uric acid in the 24 hour urine
  • Nephrolithiasis Workup
    • Plain abd film (KUB)
    • Renal USG
    • IVP
    • Helical CT without contrast (stone protocol)
  • Nephrolithiasis Treatment
    • If no obstruction or infection, stones < 5-6mm may likely pass
    • Restore fluid volume if dehyd.
    • Analgesics – narcotics, nsaids
    • Antiemetics
    • Occasionally nifedipine (CCB) to relax ureteral smooth muscle and prednisone used
    • Urology consult
  • Nephrolithiasis Treatment ?
    • Surgical intervention (call urology)
      • Extracorporeal shock-wave lithotrypsy (not in pregnancy)
      • Ureteral stent
      • Percutaneous nephrostomy
      • Ureteroscopy
      • Indications = pain, infection, obstruction
      • Contraindications = active untx infection, uncorrected bleeding diathesis,
      • pregnancy (relative)
  • Nephrolithiasis Prophylaxis ?
    • Increase fluid intake (2 liters per day of UOP)
    • 24 hour urine, eval calcium, oxalate, uric acid to determine dietary prevention
    • metabolic tests to determine cause (Ex: hyperparathyroidism)
    • Decrease salt intake
  • References
    • Braunwald et al. (2002) Harrison’s Principals of Internal Medicine (15 th edition). New York: McGraw-Hill.
    • Ling F., & Duff, P. () Obstetrics and Gynecology, Principles for Practice. 2001. New York: McGraw-Hill.
    • www.emedicine.com
    • ACOG Practice Bulletin, Clinical Mgmt Guidelines (No 23, Jan 2001). Antibiotic Prophylaxis for Gyn Procedures
    • Brankowski et al. The Johns Hopkins Manual of Obstetrics and Gynecology. 2002. Philadelphia: LWW
    • The Sanford Guide to Antibiotic Therapy