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123 Cards in this Set
- Front
- Back
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Define UTI
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It is a term applied to a variety of conditions ranging from asymptomatic bacteria in urine to severe kidney infection with resultant sepsis
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How common are UTI's?
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very common
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UTI's that are associated with conginital abnormalities such as vesicoureteral reflux or obstruction are common among what population?
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Age 5 and younger
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Who has a greater incidence of UTI's in the male population, circumsized or uncircumsized?
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Uncircumsized males
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UTI's that are associated with functional abnormalities such as dysfunctional voiding are common amound what population?
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Ages 6-15
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When does the incidence of UTI increase in young women?
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during adolescence
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What are the major risk factors for women 16-35 years of age?
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sex and diaphragm use
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Both men and women between the ages 36-65 have a significant incidence. What are the main causes in Men?
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prostetic hyperplasia/obstruction, catheterization, and surgery
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What about in women between 36-65?
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gynecologic surgery and bladder prolapse
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What is the risk factor for > 65 in both genders?
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Menopause, BPH leading to obstruction, fecal soiling of perinuem (incontinence), and chronic use of catheters
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In which populations are the morbidity and mortality the greatest from a UTI?
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<1 y/o and > 65yrs
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What are the four possible modes of bacterial entry into the Urinary Tract? Which is most common
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Acscending route (MC), Hematogenous spread, Lyphogenous spread, Direct extension
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Which route predisposes women more than men to UTI's?
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The Ascending route
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Can a pyelonephritis infection be due to ascending bacteria from all the way from the urethra?
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Yes, and it is common
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What is an essential host factor mechanism that prevents infection?
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Unobstructed urinary flow of acidic urine that subsequently washes out ascending bacteria.
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Besides the low pH, what other specific characteristics or urine are useful in inhibiting bacterial growth in the urinary tract?
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The Tamm-Horsfall glycoprotein (inhibits adherence to the UT lining), the urine osmolality, and the urea concentration
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How can compromise of urinary flow promote infection?
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Anything that causes an obstruction (including neurological dz, diabetes, and pregnancy), can cause stasis or urine reflux. Foreign bodies such as stents, catheters, stones) allow hiding places for bacteria
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What other host factors do we posses?
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Normal flora of periurethral area composed of organisms such as lactobacillus. They provide a defense against colonization of uropathogenic bacteria. In men the prostate secretes fluid that contains zinc which has prominent antimicrobial activity
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How is the defense mechanism of normal flora broken down?
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Anything that changes the ideal enviornment (pH level changes, estrogen, abx use).
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At least 80% of uncomplicated cystitis and pyelonephritis are caused by which pathogen?
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E. Coli
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Which serogroup does E. Coli belong to?
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O serogroup
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What are other less common uropathogens?
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Klebsiella, Proteus, and Enterobacter spp., as well as enterococci
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What two pathogens are normally associated with hospital aquired UTI's?
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Psuedomonas and Stapylococcus
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Which pathogens are there present, but do not generally cause infection in normal healthy individuals, but are seen as common urinary contaminants?
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Anaerobic bacteria, lactobacilli, corynebacteria, streptococci (excluding enterococci), and Staphylococcus epidermis
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Who normally gets acute cystitis men or women
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Ususally women
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What is the causitive agent, usually?
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E. Coli
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What is the normal route of infection?
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Ascending
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What are the presenting complaints of Acute Cystitis?
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FUN(+ or -)D (irritative voiding symptoms), may also c/o suprapubic discomfort
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How is Acute Cystitis diagnosed?
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A midstream urinalysis showing pyuria and bacteremia with varying degrees of hematuria
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How do you distinguish complicated from uncomplicated?
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Acute cystitis in an otherwise healthy non-pregnant female is non-comlicated; everyone else is complicated
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Should you admit all complicated UTI's?
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Not necessarily
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What is the tx for Acute Cystitis?
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Septra DS X 3days(which can be ineffective due to many resistant organisms, but yet is still commonly used), Nitrofurantoin - 5 days (which is only effective for lower GI infections), and Flouroquinolone
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Why is Nitrofurantoin only effective for lower GI tract infections?
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Because it is a bacteriostatic, by the the time the infection progresses to the kidneys, we need a bacteriocide.
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How will you determine whether or not Septra will work?
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check local lab/resistance rates
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What could you do for Acute Cystitis associated pain?
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Pyridium for two days (TID)/ Hot sitz bath
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What are the associated Side Effects of pyridium?
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discoloration of the urine, fabric, or contact lenses
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Why is it required that all men are worked up for Acute Cystitis?
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Because it is rare in men, and normally implicates pathology, and you must follow up (you cannot emperically treat)
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What are some of the causes of AC in men?
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Anatomic defects, Infected stones, Prostatitis, Chronic Urinary retention
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Who are candidates for AC prevention/prophylaxis?
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women who have more than three episodes per year.
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What must be done prior to prophylaxis?
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Any previous infection must be eradicated. A negative urine culture must be obtained 1-2 weeks after tx.
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Before actually prescribing the med, what should you be sure that you have talked with her about?
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Contraception, hygiene, hydration, postcoidal voiding habits, cranberry juice, and any prior treatment (failures)
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With regard to prophylaxis due to sexual intercourse, what should you instruct the patient on?
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Frequency. If she is not having sex often, then daily prophylaxis is not required. If she is having sex quite frequently, then she may consider the daily dose
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What are the prophylactic treatments of AC?
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The same as the UTI treatment, but a lower dose. Septra 40-200mg instead of 200mg daily. And Nitrofurantoin 50-100mg
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What do you do about AC treatment failures?
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They require further urological work-up (cystoscopy/CT/US/IVP)
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What is the clinical definition of infertility?
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Failure to conceive after one year of unprotected intercourse. (Due to many couples being so anxious to conceive sooner, an evaluation may be warranted after only 6 months of trying)
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What percentage of married couples does infertility affect?
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15-20% of married couples
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In the case of male vs. female or combined factors, which factor makes up the majority of cases of infertility?
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It's equal across the board. 1/3 female factors, 1/3 male factors, and 1/3 combined
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What is the critical step in evaluating cases of infertility?
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That both partners are evaluated SIMULTANEOUSLY
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Will all causes be determined?
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50% of causes will not ever be determined
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What are the cornerstones of laboratory investigations after the H & P?
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Endocrine profiles and detailed semen analysis
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What is the definition of Oligospermia?
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presence of <20million sperm/ml in the ejaculate
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What is the definition of Azospermia?
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Complete absence of sperm (as in the case of cystic fibrosis)
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In the work up, why is it important to review the pt's history and events for the past three months?
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Because spermatogenesis takes approximately 74 days
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What type of questions might you ask, pertaining to the hx for the past three months?
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Have you soaked in a hot tub? Do you use legal or illegal drugs or alcohol? Have you had cases of Torsion, Cryptorchidism, trauma, groin surgery? Mumps, epididymitis, excessive heat, chemotherapy? Have there been any varicoceles, Hypospadias?
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What other questions should you inquire about concerning the pt's history?
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"Sexual habits, previous fertility (with different parnters), previous infertility work-ups, the age of his partner (>35yrs?), Endocrine disorders, other dz's (renal failure, cirrhosis, sickle cell, cystic fibrosis, ADPKD, Klinefelter's), poor dietary intake, the use of Home products such as a ""Fertell"" (a home fertility kit that checks motility)"
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What should be performed in the physical exam?
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Full inspection of the penis and scrotum. Check for varicocele while standing/valsalva. The vas deferens, epididymis, and the prostrate should be palpated. Check for signs of Hypogandism
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What are signs of hypogonadism?
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Underdeveloped sex characteristics, diminished male hair pattern distribution, Eunichoid skeletal proportions, gynecomastia
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Why is it important to measure the size of the scrotal contents?
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Can detect atrophy due to a history of viral orchitis
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How long after specimen collection can semen be analyzed?
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within 1 hour
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What is the normal size of an adult testis?
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4.5 x 2.5 cm
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When should semen be collected?
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after 72 hours of abstinence, but less than 7 days
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What should the patient avoid in preparation for a specimen collection?
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gonadotoxins such as alcohol
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What is the normal sperm concentration?
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> 20 million sperm/ ml
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What is the normal volume of an ejaculate?
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> or = 2ml
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What is the normal motility percentage of sperm?
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50% motile cells
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What is the normal morphology percentage?
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Only 15% normal morphology
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What of all these factors is the best predictor of fertility?
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Normal morphology of 15%
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When is endocrine evaluation warranted?
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if sperm counts are low or if there is a clinical basis for suspecting an endocrine disorder
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When is Genetic evaluation warranted?
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After the urology referral and is as needed (PRN)
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What labs should you order if the pts sperm count is zero?
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Serum FSH, semen fructose, and a testicular biopsy
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What is the next step after an abnormal sperm count is detected?
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Repeat the semen analysis in **60 days** (also, inquire about pt's history again… he may have omitted telling you some things)
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If after the repeat semen analysis you get a normal sperm count, what is the next step?
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Repeat again if normal (because infertility still exists- you should always have at least two separate samples). (If abnormal, then collect the serum LH, FSH, testosterone, and prolactin)
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"What is the next step after a ""repeat"" abnormal sperm count?"
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Collect the serum LH, FSH, testosterone and prolactin
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What should you do if there is a low ejaculate volume (less than 2ml)?
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Collect a post ejaculate urinalysis…
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What should you also do if the low ejaculate volume is azoospermic?
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Consider a post ejaculate urinalysis fructose level (a special test not performed in primary care)
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What are some other considerations if the patient has a low volume?
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Non-compliance (MC reason- maybe the patient didn't get it all in the cup). Or maybe the patient has retrograde ejaculate (it didn't all come out). This is why you would collect a post-ejaculate urinalysis
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What type of imaging can you get to document a varicocele?
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A scrotal US
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What type of imaging can you get to document flow in intratesticular arteries?
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A color doppler study
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What type of imaging is required for a suspected ductal obstruction?
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Vasography - This is the gold standard for diagnosing pelvic, inguinal, scrotal, and vasal obstruction
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Which test is in the process of replacing Vasography?
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A transrectal ultrasound (TRUS)
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Specialty testing of infertility include the following…
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"Testis biopsy, percutaneous FNA ""mapping"" (instructor said not to worry about these tests)"
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How do you treat infertility?
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ID and treat underlying cause (if you can), make sure partner is being worked up simultaneously, and tx PRN, Pt ed regarding timing of sex, avoid all lubricants (spermacidal or not), D/C toxic meds, D/C toxic exposure (may be occupational), avoid hot tubs, Referral for assisted reproductive techniques (ART), lastly... Adoption
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"In regard to ""avoiding all lubricants"", there is one exception that is ""ACOG approved"". What is it?"
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ConceiveEase is okay to use
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Interstitial Cystitis is primarily a dz among whom?
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Middle-aged women
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What is IC characterized by?
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Fibrosis of vesical wall, with consequent loss of bladder capacity (the chronic plaque build up causes signs similar to UTI's)
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How is interstitial Cystitis diagnosed?
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It's a diagnosis of exclusion. U need a negative urinalysis, culture, and cytology
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How long does interstitial Cystitis take to resolve?
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In 50% of the cases, it my resolve in about 8 months. (Etiology is unkown)
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How is this patient's pain relieved?
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By urinating
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What are the presenting sxs of IC?
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Urgency, frequency, and nocturia
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Why is Cytology performed?
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To rule out malignancy
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What does Urinalysis and culture exclude?
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Infection
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Will anything show up on microscopy with Interstial Cystitis?
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microscopic hematuria
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What is the cure for interstitial Cystitis?
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No cure
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What can the patient do on her own to help relieve some of the symptoms of IC.
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Practice going to the bathroom around the clock, whether she has to or not. This will relieve the pain caused by the fibrosed walls when the bladder spontaneously fills.
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What can you do for the patient's pain?
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consider a referral to a Pain Clinic
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What drug therapies are available for this pt?
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Amitriptyline, Dimethyl sulfoxide (DMSO), Steroids
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What procedural therapies are available?
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Hydrodistention (diagnostic and therapeutic), Intravesical lidocaine, Vesical lavage with silver nitrate, and surgery
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What is the approximate amount of fluid that a person with IC can hold?
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Probably less than 200cc's.
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What is Acute Pyelonephritis?
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An inflammatory dz that involves the parenchyma and renal pelvis
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What is the most common infectious agent?
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E. Coli
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What is the most common mode of infection?
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It normally ascends from the lower Urinary tract
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What are the symtomes associated with Acute pyelonephritis?
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Flank pain, Fever/chills, irritative voiding, N&V, possibly diarrhea
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What are some PE findings?
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Fever, tachycardia, CVA tenderness
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What will the urinalysis show?
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White cell casts, pyuria, bacteriuria, and varying degrees of hematuria
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What will the urine culture show?
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The offending agent
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What will the CBC show?
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leukocytosis
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Is imaging required?
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Not always
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If imaging is taken, what will it show?
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in complicated cases, it may show hydronephrosis from stones or obstructions
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What are the complications of AP?
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Sepsis with shock can occur
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What are the complications for a diabetic with AP?
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life threatening emphysematous pyelonephritis, resulting from gas-producing organisms
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If untreated or inadequately treated, what can AP lead to?
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Abscess formation
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Who gets admitted?
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Diabetics; pregnant ppl; pts with obstructive uropathies, renal failure pts; pts with multi-resistant drug pathogens
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Who is treated as an outpatient?
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compliant, nonpregnant, or patients with uncomplicated or mild dz
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When should the outpatient follow up after treatment?
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TWO days
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What is the first-line drug therapy for Acute pyelonephritis?
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Levaquin 750mg everyday for 5-7 days, or Cipro 500mg for 7 days.
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What are the alternates?
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Septra and Augmentin for 14 days (BID)
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What is the one drug that is not meant for upper UTI's?
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Nitro
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For severe cases, such as those who are admitted, what is the drug therapy?
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Start with IV form of Levaquin, Ceftriaxone, or Amp&Gent then switch to an oral form of the same meds
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When is the appropriate time to switch from IV to Oral?
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When the patient is fever free for 24 hours
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How long should the total treatment last in these severe cases?
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minimum course is 14 days
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How long may these fevers persist?
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up to 72 hours
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When a patient doesn't respond to therapy, and the fever persists longer than 72 hours, what is the next course of action?
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Imaging work up with US or CT to exclude complicating factors such as abscess or obstructions. A documented follow-up urine culture is also mandatory at this point
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