Transcript Urinary Tract Disorders

Urinary Tract
Disorders
May 12, 2005
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 > 105 organisms per milliliter
 From midstream “ clean catch” urine sample
 If sx or from catheter specimen can be
significant with 102 or 104 organisms per mL
Etiology
 Most common is Gram neg. bacteria
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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
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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 105 colonies per mL considered
standard for dx but misses up to 50%
 Now, 102 to 104 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
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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
 105 org/mL growth
 Empiric treatment of all asymptomatic
bacteriuria (ASB) in pregnancy. Screening
at first visit.
 ASB if untreated = inc. PTD and LBW, 2030% 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 postcoitus
 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
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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
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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 (15th 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