Urinary Tract Disorders


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Urinary Tract Disorders

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