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Disorders/Infectio
n
25-50% of women
15-40% of men
Juthani-Mehta et al., 2005
Nicolle, 2005
Advanced Age
Fecal incontinence/impaction
Incomplete bladder emptying or neurogenic bladder
Vaginal atrophy/estrogen deficiency
Pelvic prolapse/cystocele
Insufficient fluid intake/dehydration
Indwelling foley catheter or urinary catheterization or
instrumentation procedures
Etiology
Most common is Gram neg. bacteria
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,
acute sx female with sterile pyuria
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
Female
UTI 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
Urethritis
?
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, diarrhea, tachycardia, gen. muscle
tenderness
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
Diagnosis of UTI
History
Physical exam
Lab
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
?
Treatment
Uncomp. cystitis in pregnant patient
Asymptomatic
?
Bacteriuria
10 org/mL growth
5
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,Single
dose at symptom onset
Measures for prevention: voiding after
intercourse, good hydration, frequent and
complete voiding
Treatment of
Pyelonephritis -- Outpatient
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
?
Nephrolithiasis
Incidence = 2-3%
Morbidity
Obstruction pain
Chronic obstruction, may be asx loss of
renal function
Hematuria (rarely dangerous by itself)
Dangerous = obstruction + infection
Nephrolithiasis
?
Nephrolithiasis
Patient History
?
Nephrolithiasis
Patient History
Nephrolithiasis
Physical Exam
Nephrolithiasis
Workup
Urinalysis
uric acid,
Calcium, oxalate, uric acid in the 24 hour
urine
Nephrolithiasis
Workup
Nephrolithiasis
Treatment
If no obstruction or infection, stones < 56mm may likely pass
Restore fluid volume if dehyd.
Analgesics narcotics, nsaids
Antiemetics
Occasionally nifedipine to relax ureteral
smooth muscle and prednisone used
Urology consult
Nephrolithiasis
Treatment
?
Nephrolithiasis
Prophylaxis
?