Слайд 3
Acute Cystitis
Infection of the bladder
Aka: urinary tract infection
(UTI) , bladder infection
E. Coli most common pathogen
Enterococci also
normal pathogen
Women more common than men
6 million visits per year
1 in 5 women will be diagnosed with acute cystitis
Female pelvic anatomy allows for easy introduction of vaginal or rectal bacteria to the urethral meatus
Слайд 4
Acute Cystitis– Definitions
First infections: uncomplicated, typically young women
Unresolved:
not sterilized during therapy (may be secondary to bacterial
resistance, non-adherence, mixed infection, renal insufficiency)
Persistent: tract is sterilized but bacterial source persists (kidney stones, chronic pyelonephritis, prostatitis, fistulas)
Reinfection: new infection with new pathogen after successful treatment
Слайд 5
Acute Cystitis–
Complicated Infections
Male: Rare, more common if uncircumcised
Implies
underlying pathology: STI, infected stones, prostatitis, S/P catheterization, urinary
retention/BPH
Pregnancy: increased risk for progression, fetal injury
Immunocompromised: risk for progression
Underlying pathology: may need to treat longer and/or correct problem
Nosocomial: more complex pathogens, drug resistance
Слайд 6
Acute Cystitis– H&P
History
Dysuria, frequency, urgency
Suprapubic discomfort
Hematuria (maybe)
PE
Often unremarkable
May
have suprapubic tenderness on abdominal exam
Слайд 7
Acute Cystitis—Lab findings
Urinalysis
Dipstick used in office
+ leukocytes
+ nitrites
(bacteria byproduct)
+ blood
Clean catch method
Urine culture & sensitivity
ID’s
organism and appropriate treatment
Imaging—Not usually necessary for uncomplicated infections; may be needed if advanced infection or complicating factors
Слайд 8
Acute Cystitis– Treatment
Uncomplicated infections
Short duration therapy usually
adequate
3-7 days
Fluoroquinolones and nitrofurantoin are drugs of choice
Ciprofloxacin
250-500 mg bid x 3-5 days
Nitrofurantoin (Macrobid) 100 mg bid x 7 days
Trimethoprim-sulfamethoxazole (Bactrim)
160/800 mg 2 tablets x 1 dose
Seeing significant resistance to single dose option
Can be effective if used for 5-7 days
Phenazopyridine (Pyridium)
Bladder analgesic
200 mg tid x 2 days
Will turn urine orange
Can also stain contact lenses
Слайд 9
Acute Cystitis– Treatment
Complicated infections
W/U to try to
ID cause of persisting infection
Culture and sensitivity to r/o
resistance
CT scan or u/s to evaluate kidneys
Cystoscopy for persistent hematuria
May need longer course of treatment
Recurrent infections
In female patients who experience more than 3 episodes per year, consider using post-coital antibiotic use to prevent infection
Can use ciprofloxacin 250 mg or TMP-SMZ 160/800 mg after intercourse
Слайд 10
Acute Cystitis– Prevention
In women with frequent UTIs,
consider prevention prophylactic probiotic therapy with Lactobacillus
NAPRUTI study
252 women
Half treated with BID TMP-SMZ, half given BID lactobacillus
Abx group reduced infection rate from 7 per year to 2.9 and lactobacillus group reduced infection rate from 6.8 per year to 3.3
Lactobacillus group was not determined to be “non-inferior” but antibiotic resistance was completely absent from that group
Слайд 11
Acute Cystitis—Follow Up
Test of Cure
Repeat UA C&S after
completion of antibiotics it ensure that infection has been
completely cleared
Слайд 12
Acute Cystitis—Men
Anatomical factors
Men do not have the
tendency toward vaginal or rectal bacterial seeding to the
urethra that is possible in females
Longer urethra means that ascending bacteria are often flushed by urination before reaching the bladder
Urinary tract infections in men are always considered “complicated”
Irritative voiding and bacteriuria in males should prompt w/u for underlying problem
Слайд 13
Acute Cystitis– Men
Acute prostatitis
Acute epididymitis
Urethritis (especially Gonorrhea or
Chlamydia)
Pyelonephritis
Catherization
Слайд 14
Interstitial Cystitis– Definition
Pain with a full bladder
that is relieved by emptying; often associated with urgency
and frequency
Society for Urodynamics and Female Urology definition
An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks’ duration, in the absence of infection or other identifiable causes.
Diagnosis of exclusion—R/O infection, radiation cystitis, chemical cystitis, STIs, gynecological problems (vaginitis, PID, endometriosis, etc)
Слайд 15
Interstitial Cystitis
Women > men
Average age of onset –
40
50% experience remission without treatment
Average duration of symptoms –
8 months
Associated with bladder problems in childhood, severe allergies, irritable bowel disease, irritable bowel syndrome
Etiology—not clear
Increased epithelial permeability, sensory nervous system abnormalities, autoimmunity
Слайд 16
Interstitial Cystitis– H&P
History
Pain with bladder filling that
is relieved with urination
Urgency, Frequency, Nocturia
Inquire about pelvic radiation
or cyclophosphamide exposure to r/o radiation and chemical cystitis
Physical exam
Often normal
Examination should include evaluation for genital herpes and vaginitis
Слайд 17
Interstitial Cystitis—Work-Up
UA C&S to r/o infection
Urine cytology to
evaluate for bladder carcinoma
CT or MRI of abdomen and
pelvis to r/o pelvic mass or proximal inflammatory process (ie: diverticulitis)
Urodynamic testing to assess bladder sensation and compliance
Cystoscopy to r/o carcinoma
Слайд 18
Interstitial Cystitis– Treatment
Patient education
http://www.ichelp.org
Lifestyle changes
Dietary changes to
manage triggers
http://www.ichelp.org/Page.aspx?pid=389
Fluid management
Timed voiding
Stress management
Pelvic floor therapy
Слайд 19
Interstitial Cystitis—Treatment
Pharmacologic Treatment
Elmiron (pentosan polysulfate sodium)
Only FDA
approved IC treatment
Thought to provide protective lining to the
bladder preventing potentially irritating solutes in the urine from reaching the bladder wall
100 mg tid
May take 4-6 months for effect to be seen
Side affects: Rare and mild
Nausea, abdominal pain, alopecia (reversible with discontinuation), HA, rash and dizziness
Слайд 20
Interstitial Cystitis—Treatment
Pharmacologic Treatment—off label medications
Hydroxyzine
Histamine 1 blocker
Drying
effect makes if most effective for urgency and frequency
symptoms
Amitriptyline
Tricyclic antidepressant
Exhibits analgesic effect in various pain syndromes
Anticholinergic effect can aid in decreasing urgency and frequency
Gabapentin (Neurontin)
Seizure medication with some analgesic properties
SSRIs
Various antidepressants in this category have been used
Good option in patients with comorbid depression/anxiety
Слайд 21
Interstitial Cystitis—Treatment
Non-pharmacological treatment options
Hydrodistention
Stretching of the bladder
to increase capacity
Often done during cystoscopy as part if
diagnostic w/u
Can be repeated if efficacious
Intravesicular therapy
Medication instilled directly to the bladder via urinary catheter
TENS therapy
Electrical stimulation of nerves innervating the bladder
Слайд 22
Nephrolithiasis (kidney stones)
Lifetime prevalence in U.S. is 10%
Men
> women
3:1 ratio
Chance of white male experiencing a kidney
stone by age 70 is 1 in 8
First episode usually age 30-40s
$2.1 billion per year
Слайд 23
Nephrolithiasis
Geographic factors
More common areas of high humidity and
high temperature
More common during summer months
Dietary factors
High salt/ low
water intake
High protein intake
Genetics
Cystinuria
Distal renal tubular acidosis
Слайд 24
Nephrolithiasis– Types of Stones
Calcium oxalate
Calcium phosphate
Struvite—women with
recurrent UTIs
Uric acid
Cystine—may be genetic; difficult to treat
Most
common (85%)
Слайд 25
Nephrolithiasis- History
Acute onset of unilateral, colicky flank pain
May
radiate to labia/teste
May awaken pt from sleep
May have nausea
and vomiting
Possible urinary changes (urgency, frequency)
Stone size does not correlate to severity of symptoms
Слайд 26
Nephrolithiasis—Physical Exam
General: Pt may appear uncomfortable depending on
pain severity. Pts many times are constantly moving trying
to find comfortable position
Abdominal: Dramatic costovertebral angle tenderness; abdominal tenderness, peritoneal signs absent—key in distinguishing from acute abdomen
Слайд 27
Nephrolithiasis—Lab Findings
Urinalysis
Microscopic or gross hematuria
pH can be helpful
in determining what type of stone
Normal pH is
5.85
Less than 5.5 suggests uric acid or cystine which will not show up on regular x-ray
Over 7.2 suggests struvite stone which should show up on x-ray
Слайд 28
Nephrolithiasis—Imaging
Spiral CT of abdomen and pelvis
First line,
gold standard
Non-contrast
Will show radiopaque and radiolucent stones
KUB w/ renal
u/s
Kidney, ureter bladder
Plain film x-ray plus ultrasound
Will show most stones
Слайд 29
Nephrolithiasis
KUB
Spiral CT Scan
Слайд 30
Nephrolithiasis– Treatment
Medication
Pain medication- narcotic/acetaminophen combination q 4-6 hours
Anti-inflammatories-
ie: ibuprofen 600-800 mg q 8 hour
Medical expulsion therapy—relaxes
ureter to ease stone passage
Nifedipine XR 30 QD
Tamsulosin 0.4 mg QD
Anti-emetics if needed
Слайд 31
Nephrolithiasis– Treatment
Most stones less than 5-6 mm will
spontaneously resolve with medical management
Double fluid intake
Sleep stone-side
down
Observation x 6 weeks
Stone capture
Urine should be strained to catch stone for evaluation if possible
F/U lab work up
Check serum calcium, phosphate, uric acid, and electrolytes
Слайд 32
Nephrolithiasis—Treatment
Surgical intervention indications
Stones larger than 6mm
Those
that do not pass and continue to cause pain
after 6 weeks
Obvious obstruction
Severe pain unresponsive to analgesics
Nausea and vomiting requiring IV fluids
Слайд 33
Nephrolithiasis—Surgical Options
Extracorporeal shockwave lithotripsy
Most common; least invasive
Stone
is broken for subsequent passage
Слайд 34
Nephrolithiasis—Surgical Options
Ureterscopy
Small endoscope inserted from urethra through bladder
to ureter for direct visualization of the stone
Basket extraction
or direct fragmentation can be performed via the endoscope
Слайд 35
Nephrolithiasis—Surgical Options
Percutaneous nephrolithotomy
Wire and tubing inserted into the
kidney directly through the flank
Useful for removing large stone
from the kidney and proximal ureter
Слайд 36
Acute Pyelonephritis
Infection of kidney parenchyma and renal pelvis
Most
commonly gram-negative bacteria
E. Coli, Proteus, Klebsiella, Enterobacter, Pseudomonas
Usually ascend
from lower urinary tract
Слайд 37
Acute Pyelonephritis—History
Symptoms typically develop over a few
hours or over the day
May or may not have
symptoms of urinary tract infection: urinary urgency, frequency, dysuria
Possible gross hematuria
Unilateral (less likely, bilateral) flank pain
Fever
Anorexia
Nausea
Vomiting
Слайд 38
Acute Pyelonephritis– Physical Exam
Vital Signs
Fever, possible tachycardia, normotensive
General
Ill
appearing, uncomfortable
Abdomen
Unilateral CVA tenderness over involved kidney
BS normoactive
Mild to
moderate suprapubic tenderness
Слайд 39
Acute Pyelonephritis—Lab W/U
Urinalysis
Pyuria, bacteriuria, hematuria
Urine culture
Grows out causative
agent
CBC
Leukocytosis
Blood culture
May be positive depending on agent and severity
Слайд 40
Acute Pyelonephritis– Treatment
Uncomplicated infections; outpatient treatment
Ciprofloxacin 750
mg bid for 14-21 days
TMP-SMZ 160-800 bid for 14-21
days
Nitrofurantoin 100 mg bid for 14-21 days
Severe or complicated infections; inpatient tx
Ampicillin 1 g q 6 hours + gentamicin 1 mg/kg q 8 hours IV until C&S back then tailor tx according to sensitivity
Treat with IV abx until afebrile for 24 hours then change to oral abx to complete 21 day course
Слайд 41
Acute Pyelonephritis
Follow up urine cultures are necessary several
weeks following treatment completion
Prognosis is good if diagnosis is
made and treatment initiated promptly however late diagnosis or inadequate treatment can lead to sepsis, renal scarring, chronic pyelonephritis, or abscess formation