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Презентация на тему Urinary tract infectionsinterstitial cystitispyelonephritisnephrolithiasis

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Anatomy Review
Urinary Tract Infections Interstitial Cystitis Pyelonephritis NephrolithiasisMarch 3, 2016Philadelphia UniversityClinical MedicineAmanda L. Porter, PA-C Anatomy Review Acute CystitisInfection of the bladderAka: urinary tract infection (UTI) , bladder infectionE. Acute Cystitis– DefinitionsFirst infections: uncomplicated, typically young womenUnresolved: not sterilized during therapy Acute Cystitis– 	Complicated InfectionsMale: Rare, more common if uncircumcisedImplies underlying pathology: STI, Acute Cystitis– H&PHistoryDysuria, frequency, urgencySuprapubic discomfortHematuria (maybe)PEOften unremarkableMay have suprapubic tenderness on abdominal exam Acute Cystitis—Lab findingsUrinalysisDipstick used in office+ leukocytes+ nitrites (bacteria byproduct)+ bloodClean catch Acute Cystitis– Treatment Uncomplicated infectionsShort duration therapy usually adequate3-7 days Fluoroquinolones and Acute Cystitis– Treatment Complicated infectionsW/U to try to ID cause of persisting Acute Cystitis– Prevention In women with frequent UTIs, consider prevention prophylactic probiotic Acute Cystitis—Follow UpTest of CureRepeat UA C&S after completion of antibiotics it Acute Cystitis—Men Anatomical factorsMen do not have the tendency toward vaginal or Acute Cystitis– MenAcute prostatitisAcute epididymitisUrethritis (especially Gonorrhea or Chlamydia)PyelonephritisCatherization Interstitial Cystitis– Definition Pain with a full bladder that is relieved by Interstitial CystitisWomen > menAverage age of onset – 4050% experience remission without Interstitial Cystitis– H&P HistoryPain with bladder filling that is relieved with urinationUrgency, Interstitial Cystitis—Work-UpUA C&S to r/o infectionUrine cytology to evaluate for bladder carcinomaCT Interstitial Cystitis– Treatment Patient educationhttp://www.ichelp.orgLifestyle changesDietary changes to manage triggershttp://www.ichelp.org/Page.aspx?pid=389Fluid managementTimed voidingStress managementPelvic floor therapy Interstitial Cystitis—Treatment Pharmacologic TreatmentElmiron (pentosan polysulfate sodium)Only FDA approved IC treatmentThought to Interstitial Cystitis—Treatment Pharmacologic Treatment—off label medicationsHydroxyzineHistamine 1 blockerDrying effect makes if most Interstitial Cystitis—Treatment Non-pharmacological treatment optionsHydrodistentionStretching of the bladder to increase capacityOften done Nephrolithiasis (kidney stones)Lifetime prevalence in U.S. is 10%Men > women3:1 ratioChance of NephrolithiasisGeographic factorsMore common areas of high humidity and high temperatureMore common during Nephrolithiasis– Types of StonesCalcium oxalate Calcium phosphateStruvite—women with recurrent UTIs Uric acidCystine—may Nephrolithiasis- HistoryAcute onset of unilateral, colicky flank painMay radiate to labia/testeMay awaken Nephrolithiasis—Physical ExamGeneral: Pt may appear uncomfortable depending on pain severity. Pts many Nephrolithiasis—Lab FindingsUrinalysisMicroscopic or gross hematuriapH can be helpful in determining what type Nephrolithiasis—Imaging Spiral CT of abdomen and pelvisFirst line, gold standardNon-contrastWill show radiopaque NephrolithiasisKUBSpiral CT Scan Nephrolithiasis– TreatmentMedicationPain medication- narcotic/acetaminophen combination q 4-6 hoursAnti-inflammatories- ie: ibuprofen 600-800 mg Nephrolithiasis– TreatmentMost stones less than 5-6 mm will spontaneously resolve with medical Nephrolithiasis—Treatment Surgical intervention indicationsStones larger than 6mm Those that do not pass Nephrolithiasis—Surgical OptionsExtracorporeal shockwave lithotripsy Most common; least invasiveStone is broken for subsequent passage Nephrolithiasis—Surgical OptionsUreterscopySmall endoscope inserted from urethra through bladder to ureter for direct Nephrolithiasis—Surgical OptionsPercutaneous nephrolithotomyWire and tubing inserted into the kidney directly through the Acute PyelonephritisInfection of kidney parenchyma and renal pelvisMost commonly gram-negative bacteriaE. Coli, Acute Pyelonephritis—History Symptoms typically develop over a few hours or over the Acute Pyelonephritis– Physical ExamVital SignsFever, possible tachycardia, normotensiveGeneralIll appearing, uncomfortableAbdomenUnilateral CVA tenderness Acute Pyelonephritis—Lab W/UUrinalysisPyuria, bacteriuria, hematuriaUrine cultureGrows out causative agentCBCLeukocytosisBlood cultureMay be positive Acute Pyelonephritis– Treatment Uncomplicated infections; outpatient treatmentCiprofloxacin 750 mg bid for 14-21 Acute PyelonephritisFollow up urine cultures are necessary several weeks following treatment completionPrognosis
Слайды презентации

Слайд 2 Anatomy Review

Anatomy Review

Слайд 3 Acute Cystitis
Infection of the bladder
Aka: urinary tract infection

Acute CystitisInfection of the bladderAka: urinary tract infection (UTI) , bladder

(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:

Acute Cystitis– DefinitionsFirst infections: uncomplicated, typically young womenUnresolved: not sterilized during

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

Acute Cystitis– 	Complicated InfectionsMale: Rare, more common if uncircumcisedImplies underlying pathology:

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

Acute Cystitis– H&PHistoryDysuria, frequency, urgencySuprapubic discomfortHematuria (maybe)PEOften unremarkableMay have suprapubic tenderness on abdominal exam

have suprapubic tenderness on abdominal exam


Слайд 7 Acute Cystitis—Lab findings
Urinalysis
Dipstick used in office
+ leukocytes
+ nitrites

Acute Cystitis—Lab findingsUrinalysisDipstick used in office+ leukocytes+ nitrites (bacteria byproduct)+ bloodClean

(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

Acute Cystitis– Treatment Uncomplicated infectionsShort duration therapy usually adequate3-7 days Fluoroquinolones

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

Acute Cystitis– Treatment Complicated infectionsW/U to try to ID cause of

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,

Acute Cystitis– Prevention In women with frequent UTIs, consider prevention prophylactic

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

Acute Cystitis—Follow UpTest of CureRepeat UA C&S after completion of antibiotics

completion of antibiotics it ensure that infection has been

completely cleared

Слайд 12 Acute Cystitis—Men
Anatomical factors
Men do not have the

Acute Cystitis—Men Anatomical factorsMen do not have the tendency toward vaginal

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

Acute Cystitis– MenAcute prostatitisAcute epididymitisUrethritis (especially Gonorrhea or Chlamydia)PyelonephritisCatherization

Chlamydia)
Pyelonephritis
Catherization


Слайд 14 Interstitial Cystitis– Definition
Pain with a full bladder

Interstitial Cystitis– Definition Pain with a full bladder that is relieved

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 –

Interstitial CystitisWomen > menAverage age of onset – 4050% experience remission

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

Interstitial Cystitis– H&P HistoryPain with bladder filling that is relieved with

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

Interstitial Cystitis—Work-UpUA C&S to r/o infectionUrine cytology to evaluate for bladder

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

Interstitial Cystitis– Treatment Patient educationhttp://www.ichelp.orgLifestyle changesDietary changes to manage triggershttp://www.ichelp.org/Page.aspx?pid=389Fluid managementTimed voidingStress managementPelvic floor therapy

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

Interstitial Cystitis—Treatment Pharmacologic TreatmentElmiron (pentosan polysulfate sodium)Only FDA approved IC treatmentThought

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

Interstitial Cystitis—Treatment Pharmacologic Treatment—off label medicationsHydroxyzineHistamine 1 blockerDrying effect makes if

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

Interstitial Cystitis—Treatment Non-pharmacological treatment optionsHydrodistentionStretching of the bladder to increase capacityOften

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

Nephrolithiasis (kidney stones)Lifetime prevalence in U.S. is 10%Men > women3:1 ratioChance

> 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

NephrolithiasisGeographic factorsMore common areas of high humidity and high temperatureMore common

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

Nephrolithiasis– Types of StonesCalcium oxalate Calcium phosphateStruvite—women with recurrent UTIs Uric

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

Nephrolithiasis- HistoryAcute onset of unilateral, colicky flank painMay radiate to labia/testeMay

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

Nephrolithiasis—Physical ExamGeneral: Pt may appear uncomfortable depending on pain severity. Pts

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

Nephrolithiasis—Lab FindingsUrinalysisMicroscopic or gross hematuriapH can be helpful in determining what

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,

Nephrolithiasis—Imaging Spiral CT of abdomen and pelvisFirst line, gold standardNon-contrastWill show

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

NephrolithiasisKUBSpiral CT Scan

Слайд 30 Nephrolithiasis– Treatment
Medication
Pain medication- narcotic/acetaminophen combination q 4-6 hours
Anti-inflammatories-

Nephrolithiasis– TreatmentMedicationPain medication- narcotic/acetaminophen combination q 4-6 hoursAnti-inflammatories- ie: ibuprofen 600-800

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

Nephrolithiasis– TreatmentMost stones less than 5-6 mm will spontaneously resolve with

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

Nephrolithiasis—Treatment Surgical intervention indicationsStones larger than 6mm Those that do not

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

Nephrolithiasis—Surgical OptionsExtracorporeal shockwave lithotripsy Most common; least invasiveStone is broken for subsequent passage

is broken for subsequent passage


Слайд 34 Nephrolithiasis—Surgical Options
Ureterscopy
Small endoscope inserted from urethra through bladder

Nephrolithiasis—Surgical OptionsUreterscopySmall endoscope inserted from urethra through bladder to ureter for

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

Nephrolithiasis—Surgical OptionsPercutaneous nephrolithotomyWire and tubing inserted into the kidney directly through

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

Acute PyelonephritisInfection of kidney parenchyma and renal pelvisMost commonly gram-negative bacteriaE.

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

Acute Pyelonephritis—History Symptoms typically develop over a few hours or over

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

Acute Pyelonephritis– Physical ExamVital SignsFever, possible tachycardia, normotensiveGeneralIll appearing, uncomfortableAbdomenUnilateral CVA

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

Acute Pyelonephritis—Lab W/UUrinalysisPyuria, bacteriuria, hematuriaUrine cultureGrows out causative agentCBCLeukocytosisBlood cultureMay be

agent
CBC
Leukocytosis
Blood culture
May be positive depending on agent and severity


Слайд 40 Acute Pyelonephritis– Treatment
Uncomplicated infections; outpatient treatment
Ciprofloxacin 750

Acute Pyelonephritis– Treatment Uncomplicated infections; outpatient treatmentCiprofloxacin 750 mg bid for

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

Acute PyelonephritisFollow up urine cultures are necessary several weeks following treatment

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

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