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S ameer 2015 dysuria

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Approach to patient with dysuria.

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S ameer 2015 dysuria

  1. 1. Dysuria Sameer S. Sawaed
  2. 2. Definition: • The sensation of pain, burning or discomfort on urination.
  3. 3. Epidemiology • In adulthood, more common in women than men. • Approximately 25% of women report one episode of acute dysuria per year. • Most common in women 25-54 years of age and in those who are sexually active. • In men, dysuria becomes more prevalent with increasing age.
  4. 4. Etiology • Infectious: - Most common cause - Presents as; cystitis, urethritis, pyelonephritis, vaginitis or prostatitis • Non- infectious: - Hormonal conditions (hypoestrogenism), obstruction (BPH, urethral strictures), neoplasms, allergic reactions, chemicals, foreign body and trauma.
  5. 5. Differential Diagnosis of Dysuria • UTI • STD Chlamydia trachomatis , N. gonorrhea , and HSV all can cause urethritis and symptoms of LUTI. • Candidal infections • Urethral or bladder irritation. • Interstitial cystitis in young women. • Bladder tumors • Instrumentation • Trauma • BPH , prostatitis , epididymitis. • Renal stones, renal infarction papillary necrosis
  6. 6. Urinary Tract Infections • UTI is Any infection involving the urothelium, which includes urethral, bladder, prostate and kidney infections. • The term UTI and uncomplicated UTI are often used to refer to cystitis
  7. 7. Epidemiology • Urinary tract infection (UTI) is common in women, in whom it usually occurs in an anatomically normal urinary tract. • The incidence of UTI is 50 000 per million persons per year and accounts for 1–2% of patients in primary care.
  8. 8. • Recurrent infection causes considerable morbidity; if complicated, it can cause severe renal disease including end- stage renal failure. It is also a common source of life-threatening Gram- negative septicaemia.
  9. 9. Risk Factors Sexual intercourse Diaphragm contraceptive Vaginal spermicide Pregnancy Menopause Instrumentation Urinary tract obstruction DM Immunosuppression Malformation
  10. 10. Classification • Upper urinary tract Infections: - Pyelonephritis • Lower urinary tract infections - Cystitis (“traditional” UTI) - Urethritis (often sexually-transmitted) - Prostatitis
  11. 11. Presentation • Frequency, urgency, dysuria, hematuria, supra- pubic pain, grossly cloudy and malodorous urine  THINK OF CYSTITIS • High grade Fever, rigors (shaking chills), nausea, vomiting, diarrhea, loin pain  THINK OF ACUTE PYELONEPHRITIS • Flu like symptoms low backache, few urinary symptoms  THINK OF PROSTATITIS
  12. 12. Pathogenesis • Infection is most often due to bacteria from the patient’s own bowel flora transferred to the urinary tract via the ascending transurethral route • May be via the bloodstream, the lymphatics or by direct extension (e.g.from a vesicocolic fistula).
  13. 13. Causative Agents • Escherichia coli and other ‘coliforms’ – 80% • Proteus mirabilis • Klebsiella aerogenes • Enterococcus faecalis • Staphylococcus saprophyticus or epidermidis – 5-15%
  14. 14. Lower Urinary Tract Infection Cystitis Uncomplicated (Simple) cystitis In healthy woman, with no signs of systemic disease Complicated cystitis In men, or woman with co-morbid medical problems. Recurrent cystitis
  15. 15. Uncomplicated (simple) Cystitis • Definition Healthy adult woman (over age 12) Non-pregnant Rarely in men. • Signs and symptoms Dysuria Frequency , urgency or both No fever, nausea, vomiting, flank pain and no vaginal discharge • Diagnosis Dipstick urinalysis positive for nitrites or leukocyte esterase. (no culture or lab tests needed) • Prognosis : Treatment is usually successful. Symptoms of a bladder infection usually disappear within 24 - 48 hours after treatment
  16. 16. Risk Factors and Treatment • Major risk factor for uncomplicated simple cystitis is sexual activity. Treatment: • Sulfamethoxazole-trimethoprim • Amoxicillin • Nitrofurantoin • Ampicillin • Ciprofloxacin • Levofloxacin
  17. 17. Complicated Cystitis • Females with comorbid medical conditions • All male patients • Indwelling foley catheters • Urosepsis/hospitalization
  18. 18. Diagnosis • CBC + blood culture . • Urine dipstick : pyuria on microscopic examination urine WBC positive for nitrites or leukocyte esterase. • Middle stream urine culture: bacterial account > 10^5/ml • The following tests may be done to help rule out problems in the urinary system that might lead to infection or make a UTI harder to treat:  CT scan of the abdomen  Intravenous pyelogram (IVP)  Kidney scan  Kidney ultrasound  Voiding cystourethrogram
  19. 19. Risk Factors and Treatment Risk factors: • Blockages in the urinary tract: Kidney stones or an enlarged prostate can trap urine in the bladder and increase the risk of urinary tract infection. • Urinary tract abnormalities: that don't allow urine to leave the body or cause urine to back up in the urethra • Catheter to urinate: • Diabetes • Advanced age Treatment • Fluoroquinolone (or other broad spectrum antibiotic) • 7-14 days of treatment (depending on severity) • May treat even longer (2-4 weeks) in males with UTI
  20. 20. Recurrent Cystitis • Recurrent cystitis is usually defined as three episodes of urinary tract infection in previous 12 months or two episodes in previous six months. • It’s common in young, healthy women . One study show that 27% of women developed a second infection within six months of the first attack.
  21. 21. Evaluation and Treatment • May consider urologic work-up to evaluate for anatomical abnormality. • Postcoital antibiotics (taken within two hours of intercourse) reduce the rate of clinical recurrence of cystitis as effectively as continuous treatment. • Self-administered trimethoprim/sulfa-methoxazole or continuous prophylaxis are effective in preventing recurrence of cystitis in 95% of the cases • Cranberry products (juice or capsules) seem to significantly reduce the recurrence of symptomatic cystitis.
  22. 22. Prostatitis Diagnosis: • Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain,cloudy urine) • The finding of an edematous and tender prostate on physical examination • Increased PSA • Urinalysis, urine culture
  23. 23. Risk Factors and Treatment • Being a young or middle-aged man • Having a past episode of prostatitis • Cystitis or urethritis • Having a pelvic trauma, such as injury from cycling or horseback riding • Not drinking enough fluids (dehydration) • Using a urinary catheter • Having unprotected sexual intercourse • Having HIV/AIDS • Being under psychological stress Treatment: • Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic • 4-6 weeks of treatment
  24. 24. Complications of Prostatitis • Bacterial infection of the blood (bacteremia) • Epididymitis • Prostatic abscess • Abnormalities in semen and infertility (this can occur with chronic prostatitis).
  25. 25. Urethritis Urethritis is swelling and irritation (inflammation) of the urethra. Urethritis may be caused by bacteria or a virus. The same bacteria that cause urinary tract infections (E. coli) and some sexually transmitted diseases (chlamydia, gonorrhea) can lead to urethritis. Viral causes of urethritis include herpes simplex virus and cytomegalovirus. Other causes include: Injury Sensitivity to the chemicals used in spermicides or contraceptive jellies,creams, or foams Risks for urethritis include: • Being a female in the reproductive years • Being male, ages 20 - 35 • Having many sexual partners • High-risk sexual behavior (such as anal sex without a condom) • History of sexually transmitted diseases
  26. 26. Presentation Symptoms • In men:  Blood in the urine or semen  Burning pain while urinating (dysuria)  Discharge from penis  Fever (rare)  Frequent or urgent urination  Pain with intercourse or ejaculation • In women:  Abdominal pain  Burning pain while urinating  Fever and chills  Frequent or urgent urination
  27. 27. Treatment Treatment (Chlamydia): Azithromycin – Doxycycline – x 7 days (Neisseria gonorrhea): • Ceftriaxone • Levofloxacin • Ofloxacin – • Spectinomycin
  28. 28. Pyelonephritis Infection of the pelvis of kidney • Symptoms of acute pyelonephritis : short duration; hours to days It can cause high fever, pain on passing urine, and abdominal pain that radiates along the flank towards the back. There is often associated vomiting. • Physical examination may reveal fever and tenderness at the costovertebral angle on the affected side.
  29. 29. • Most cases of "community-acquired" pyelonephritis are due to bowel organisms that enter the urinary tract. • Common organisms are E. coli (70–80%) and Enterococcus faecalis. • Hospital-acquired infections may be due to coliform bacteria and enterococci, as well as other organisms uncommon in the community (e.g. Pseudomonas aeruginosa and various species of Klebsiella). • Most cases of pyelonephritis start off as lower urinary tract infections, mainly cystitis and prostatitis.
  30. 30. Diagnosis • Symptoms + U/A (+ve Nitrite and WBCs) are sufficient to diagnose and are an indication for empirical treatment, • CBC shows neutrophilia • Urine culture and antibiotic sensitivity are useful to establish a formal diagonsis • KUB if suspected stone • Where available, a noncontrast CT scan is the diagnostic modality of choice in the radiographic evaluation of suspected nephrolithiasis • Treatment: 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone Hospitalization and IV antibiotics if patient unable to take oral medication
  31. 31. Complications: • Perinephric/Renal abscess: suspect in patient who is not improving on antibiotic therapy. • Renal failure • Sepsis
  32. 32. UTI – Diagnostic Evaluation URINE-ANALYSIS • Dipstick (leukocyte esterase, nitrites, protein) • Microscopy (WBCs, RBCs, bacteria, crystals & casts) URINE-CULTURE • MSU >105 CFU/ml • Catheterization > 102 – 104 CFU/ml • Supra-pubic aspiration > any growth is +ve BLOOD TESTS • CBC, ESR, CRP, blood culture IMAGING • US, IVU or cystoscopy
  33. 33. Habits that might prevent UTI • Maintain good hydration (especially with cranberry juice). • Wipe urethra from front to back to avoid contamination of the urethra with feces from the rectum. • Avoid feminine hygiene sprays and scented douches. • Empty bladder immediately before intercourse.
  34. 34. Urine Analysis
  35. 35. Types of Sample Collection There are 3 ways to obtain a urine specimen: • Spontaneous voiding • Urethral catheterization • Suprapubic bladder aspiration
  36. 36. Spontaneous Voiding • A clean catch - midstream urine sample is collected after cleaning the external urethral meatus with soap & water, this avoids contamination of urine by contents of urethra or vagina and therefore its constituents are more likely to reflect kidney origin.
  37. 37. Urethral Catheterization • The healthcare provider inserts a foley catheter into the bladder through the urethra to collect the urine specimen. • Required only in special situations (comatose patients). • Has the danger of introducing microorganisms from urethra and perineum and causing urinary tract infection.
  38. 38. Suprapubic Bladder Aspiration • This method is used when a bedridden patient cannot be catheterized or a sterile specimen is required. The urine specimen is collected by needle aspiration through the abdominal wall into the bladder.
  39. 39. Urine Analysis  MARCOSCOPIC EXAMINATION OF THE URINE 1. Color 2. Clarity 3. odor  Chemical examination using dipsticks 1. Proteinuria 2. Glycosuria 3. Hematuria 4. Ketones 5. Nitrites 6. Leukocyte esterase test 7. Specific gravity 8. Osmolality 9. pH  MICROSCOPIC EXAMINATION OF URINE: 1. Red Blood Cells 2. White Blood Cells 3. Epithelial Cells 4. Casts 5. Crystals 6. Bacteria 7. Yeast
  40. 40. Diseases Identified with a Urine Test Strip • Diseases of the kidneys and the urinary tract • Carbohydrate metabolism disorders (diabetes mellitus) • Liver diseases and haemolytic disorders
  41. 41. Diseases of the kidneys and the urinary tract Screening parameters: UTI • Leukocytes • Nitrite • pH • Specific gravity Glomerular/ Tubular diseases • Protein • Blood
  42. 42. Leukocyte esterase and Nitrite test Leukocyte esterase  Used to detect leucocytes in the urine  The test is positive if there are more than 5 leucocytes/hpf.  A negative leukocyte esterase test means that an infection is unlikely and that, without additional evidence of urinary tract infection, microscopic exam and/or urine culture need not be done to rule out significant bacteriuria. Nitrite test  Normal urine does not contain nitrites. Urine nitrite test is used for screening for bacteria  A positive test indicates presence of more than 10 organisms/ml..
  43. 43. pH • A more acidic pH may be the result of fever, phenylketonuria or metabolic acidosis. • Alkaline urine may occur in urinary tract infections, metabolic or respiratory alkalosis. • pH of normal urine is between 4.5 and 7.8, but usually it ranges between 5.0 and 6.0, due to obligatory excretion of acid produced every day. • Very alkaline urine is suggestive of infection with a urea splitting organism. Prolonged storage can lead to overgrowth of urea splitting organism and falsely cause high urine pH. Rarely alkaline pH may be due to metabolic alkalosis or acidification defect. • Low urine pH (<5.0) is most commonly due to metabolic acidosis. Acid urine may also be associated with ingestion of large amounts of meat.
  44. 44. Specific Gravity • Specific gravity determines the ability of the kidney to concentrate or dilute urine. • Specific gravity –depends on both the weight and the number of particles in solution The normal range is between 1.005 and 1.035.. • Osmolality is dependent only on the number of particles Osmolality of urine is between 40 to 1200mosm/kg. • Specific gravity is a convenient and easily measured indicator of urine osmolality • To determine specific gravity, urine should be collected after a period of water deprivation such as an early morning sample before ingestion of any fluid.
  45. 45. Specific Gravity • Increased: Volume depletion, congestive heart failure (CHF), adrenal insufficiency, diabetes mellitus, inappropriate antidiuretic hormone (ADH), increased proteins (nephrosis) • If markedly increased (1.040–1.050), suspect artifact or excretion of radiographic contrast media. • Decreased: Diabetes insipidus, pyelonephritis, glomerulonephritis, water load with normal renal function
  46. 46. Protein • Most healthy individuals excrete between 30-130 mg/day of protein in urine. • More than 150 mg/day is defined as Proteinuria. • Trace proteinuria = 10mg/dl 1+ proteinuria = 30mg/dl 2+ proteinuria =100mg/dl 3+ proteinuria =300mg/dl 4+ proteinuria = 1gm/ dl
  47. 47. Protein • The urine dipstick is most sensitive to albumin and is often insensitive to other proteins. Hence, this may give a false negative result with immunoglobulin light chains (Bence- Jones protein) or microalbuminuria. • False positive may occur if there is delay in reading the strip.
  48. 48. Protein • Indication by dipstick of persistent proteinuria should be quantified by 24-hr urine studies: • Positive: Pyelonephritis, glomerulonephritis, Kimmelstiel-Wilson syndrome (diabetes), nephrotic syndrome, myeloma, postural causes, preeclampsia, inflammation, and malignancies of the lower tract, functional causes (fever, stress, heavy exercise), malignant hypertension, congestive heart failure
  49. 49. Proteinuria can be: • Transient – occurs commonly especially in children and usually resolves within a few days often associated with fever, exercise or stress. In older patients may be due to CHF. • Intermittent – frequently associated with postural changes. Commonly occurs in upright position in young adults and rarely exceeds 1g/day. Resolves spontaneously in about half of patients and not associated with disease. If normal renal function evaluate no further. • Persistent – usually due to glomerular cause with >2g protein/day of which major component is albumin. Some may also coexist with haematuria.
  50. 50. Blood - Hematuria RBC: The exact definition of microscopic hematuria is debated, but is generally defined as >3 RBC/HPF (40×).
  51. 51. Blood • Positive test indicates either haematuria, haemoblobinuria or myoglobinuria • False positive readings most often due to contamination with menstrual blood, vulvar pruritis.
  52. 52. Hematuria vs. Hemoglobinuria and Myoglobinuria • absence of RBC's on the microscopic examination Hemoglobin vs. Myoglobin • Hemoglobin usually is bound and is too large to pass through the glomerular filter. If the renal threshold is exceeded, the hemoglobin can pass into the urine. Myoglobin on the other hand, is not bound and freely passes through the glomerular filter. • Free hemoglobin may be present from trauma, from a transfusion reaction, or from lysis of RBCs (RBCs will lyse if the pH is <5 or >8). • There may be myoglobin present because of a crush injury, burn, or tissue ischemia.
  53. 53. Carbohydrate metabolism disorders • Glucose - Identified ay Glycosuria • Ketones - Identified as Ketonuria
  54. 54. Glycosuria • Glycosuria (excess sugar in urine) generally means diabetes mellitus.. • Blood sugar above renal threshold (10mmol/l or 180mg/dl) will appear in urine . • Dipstick will detect glucose in the urine in the range of 50 mg/dl to 1000 mg/dl. • This is specific to glucose and no other sugar such as galactose and fructose.
  55. 55. Ketonuria • acetone, aceotacetic acid, beta-hydroxybutyric acid • Glomeruli freely filter ketones and the tubules then resorb them completely. If the tubular resorptive capacity is saturated, then the ketones are incompletely resorbed, resulting in ketonuria. • Ketonuria does not signify renal disease, but rather excessive lipid or defective carbohydrate metabolism. • Dipstick tests are semiquantitative and only detect acetone and acetoacetic acid. Reagent strips contain nitroprusside that does not react with beta-hydroxybutyric acid. • Ketonuria may be caused by starvation, insulinoma, diabetic ketoacidosis, persistent hypoglycemia, high fat low carbohydrate diets, and glycogen storage disease.
  56. 56. Diabetic ketoacidosis • Ketonuria most commonly it is a sign of impaired insulin function (uncontrolled diabetes mellitus) • The finding of ketones in the urine may signal an urgent medical situation, as these compounds raise the acidity of the blood (metabolic ketoacidosis) can cause coma and even death if untreated.
  57. 57. Liver diseases and haemolytic disorders • Urobilinogen - Identified as Urobilinogenuria • Bilirubin - Identified as Bilirubinuria
  58. 58. Conjugated bilirubin vs. Unconjugated bilirubin • Urine normally contains no bilirubin and only very little urobilinogen. • Urobilinogen its concentration in urine is usually <1mg/dl • Unconjugated bilirubin is water insoluble and bound to albumin  does not appear in urine • conjugated bilirubin is water solubleappear in urine.
  59. 59. Bilirubin and Urobilinogen - Dipstick It is very sensitive and detects as little as 0.05 mg/dl of bilirubin resulting in color change to pink. - false negative results are obtained if urine is tested after prolonged exposure, since bilirubin degenerates with exposure to light. - False positive results are obtained if there is contamination with stool or if the temperature of the reagent strip is elevated.
  60. 60. Bilirubin and Urobilinogen • Low Urobilinogen+Low Bilirubin = Congenital enzymatic defect/ drugs that acidify urine, such as ammonium chloride or ascorbic acid. • Low Urobilinogen+High bilirubin = biliary obstruction • High Urobilinogen+High bilirubin = Hemolytic Anemia
  61. 61. Thank You! 

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