3 Cystitis, Pyelonephritis, & Interstitial Cystitis

Question 1

_______ are more specific to pyelonephritis and _______ more specific to glomerulonephritis

Answer 1

WBC casts = pyelonephritis

RBC casts = GN

Question 2

Urine dipstick is most accurate in predicting a UTI when positive for …

Answer 2

Leukocyte esterase and/or nitrite in SYMPTOMATIC patients

BUT negative results do not reliably r/o UTI if symptomatic and positive results don’t necessarily support UTI in ASYMPTOMATIC patients

Question 3

What can cause false negative nitrite on urine dipstick?

Answer 3

Non-nitrate reducing organisms

Frequent urination/urine in bladder <4 hours

Question 4

What can cause false positive leukocyte esterase in urine dipstick?

Answer 4

Vaginal contamination

Trichomonas infection

Question 5

Among adults 20-50 yo, UTI’s are __________ in women

Answer 5

50x more common

Most commonly as cystitis or pyelonephritis

Question 6

In men aged 20-50 yo, most UTIs are…

Answer 6

Urethritis or prostatitis

Question 7

~95% of UTIs occur from …

Answer 7

Ascending bacterial infections

Escherichia coli accounts for 75-95% of cases

Question 8

Though most UTIs are caused by E.coli, other causative uropathogens can cause them in …

Answer 8

Immunocompromised or hospitalized patients

Staphylococcus saprophyticus
Enterococcus species
Proteus mirabilis
Klebsiella pneumoniae
Pseudomonas

Question 9

What are the risk factors for UTIs

Answer 9

Reduced urine flow (obstruction, inadequate fluid intake, neurogenic bladder)

Promotion of colonization (sexual activity, spermicide use, recent abx)

Fascilitated ascent (catheterization, urinary or fecal incontinence)

Question 10

Acute simple cystitis is is an acute UTI presumed to be …

Answer 10

Confined to the bladder in a non-pregnant individual

No s/s that suggest an upper urinary tract or systemic infection (no pyelonephritis)

Question 11

Acute UTI accompanied by SSx that suggest extension of infection beyond the bladder

Answer 11

Acute complicated UTI (ie pyelonephritis)

SSx include:
Fever (>99.9)
Chills, rigor, significant fatigue/malaise
Flank pain
CVA tenderness
Pelvic or perineal pain in men (if prostatitis)

Question 12

Special populations who may have acute simple cystitis but are at risk for a complicated UTI

Answer 12

Pregnant women
Men
Patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities

Question 13

Classic presentation of acute simple cystitis

Answer 13

Irritative voiding symptoms (Dysuria, Frequency, Urgency)

+/- Hematuria

+/- Suprapubic discomfort

Ask about LMP, sexual activity, Hx of STIs

Question 14

What ROS questions should you ask in cases of acute simple cystitis?

Answer 14

Fever, N/V, flank pain (should be no for simple cystitis)

Obstructive urinary symptoms (hesitancy, dribbling) esp in men

Penile discharge, vaginal pruritis or discharge, pelvic or perineal pain

Question 15

Atypical presentation of acute simple cystitis in the elderly

Answer 15

Urinary incontinence and confusion/change in mental status

Question 16

What should you do to rule out DDx in acute simple cystitis?

Answer 16

General assessment/vitals (should be stable)

Check for abdominal/suprapubic tenderness/CVAT (to rule out pyelonephritis)

Pelvic exam in women (looking for vaginal discharge, cervical motion tenderness)

Genital and rectal exam in men (looking for penile discharge/ulceration, testicular/scrotal pain, prostatic tenderness or enlargement)

Question 17

Acute Simple Cystitis DDx

Answer 17

Pyelonephritis 
Vaginitis, urethritis, prostatitis
STI
PID
Nephrolithiasis
Interstitial cystitis/bladder pain syndrome

Question 18

In addition to (+) leukocyte esterase and nitrites on dipstick, urine microscopy in someone with acute simple cystitis might reveal…

Answer 18

Pyuria (abnormal ≥ 10 leukocytes/µL - amount does not indicate severity of infection)

Bacteriuria

+/- hematuria

Question 19

When should you perform a urine culture

Answer 19

Atypical presentation/diagnostic uncertainty
Suspect complicated UTI
Symptoms that do not resolve or recur
Suspect antimicrobial resistance
Special populations (men, elderly, etc)

≥10^3 colony-forming units of a uropathogen is diagnostic

> 10^2 CFU/mL in women with typical symptoms of cystitis

Question 20

What can you use for SYMPTOMATIC treatment of acute simple cystitis?

Answer 20

OTC Phenazopyridine (Pyridium) 200mg TID prn (urinary analgesic)

Question 21

What are the precautions for Pyridium?

Answer 21

LIMITED TO TWO-DAY COURSE to make sure you’re not just masking Sx

Turns body secretions red/orange - don’t wear contacts as it will stain them

Caution if CR<50 or declined kidney function

Question 22

Abx therapy for acute simple cystitis in non-pregnant individuals

Answer 22

Primary:
• Nitrofurantoin (Macrobid) 100 mg PO BID x 5 days
• Bactrim 160/800 mg PO BID x 3 days (avoid if ≥20% local Ecoli are resistant)
• Fosfomycin (Monurol) 3 GBM PO single dose

Alternatives (if allergy, drug runs, resistance)
• Beta-lactate (Augmenting, Cefdinir)
• Fluoroquinolones (Cipro, Levaquin)

Question 23

When would you avoid Nitrofurantoin & Fosfomycin?

Answer 23

If early pyelonephritis due to low renal concentrations (won’t adequately penetrate the kidney)

Question 24

How do you treat acute simple cystitis in pregnant women?

Answer 24

Augmentin, Cephalexin, Cefpodoxime, Fosfomycin are all options

Nitrofurantoin/Bactrim - use/avoidance based on trimester (CONSULT OB)

AVOID FLUOROQUINOLONES

Question 25

How do you treat acute simple cystitis in Men

Answer 25

Same primary therapies (macrobid, bactrim) but for longer duration (7 days) Also, make sure you r/o underlying prostatitis

Question 26

How to treat acute simple cystitis in patients with comorbidities, immunocompromised conditions, or underlying urologic abnormalities

Answer 26

Primary therapies (macrobid, bactrim) but for longer duration (1-2 weeks) Low threshold to manage as complicated UTI

Question 27

Important patient education points for acute simple cystitis

Answer 27

``` Increase fluid intake Void when you feel the urgency Proper hygiene Postcoital voiding COMPLETE course of abx - should expect relief in 48 hours ER precautions (signs of pyelonephritis) ```

Question 28

Are follow up urine cultures required for acute simple cystitis

Answer 28

Not needed in simple cases except pregnant women or those whose symptoms don’t resolve on abx

Question 29

Clinical presentation of acute pyelonephritis

Answer 29

``` Lower UTI symptoms (frequency, urgency, dysuria) FLANK PAIN Constitutional symptoms GI symptoms (N/V) FEVER CVA tenderness ```

Question 30

DDx for acute pyelonephritis

Answer 30

``` Cholecystitis Pancreatitis Diverticulitis Appendicitis Renal pathology Nephrolithiasis PID Ectopic pregnancy Acute epididymitis Acute prostatitis Lower lobe pneumonia ```

Question 31

What diagnostics should you do when suspecting acute pyelonephritis?

Answer 31

``` UA (all) Urine culture and sensitivity (ALL - unlike acute cystitis) +/- GC/Chlamydia +/- Labs (CBC/CMP) +/- Imaging ```

Question 32

What will the UA/culture show in acute pyelonephritis?

Answer 32

``` (+) LE (+) Nitrites Pyuria (≥10 leukocytes/µl) Bacteriuria +/- Hematuria WBC casts***** Urine culture positive with ≥10^5 CFU/mL ```

Question 33

CBC/CMP not necessary in pyelonephritis unless patient is hospitalized but if you do it, you’ll find...

Answer 33

Leukocytosis with left shift Look at CMP to assess renal function, hydration, electrolytes

Question 34

Imaging is not typically indicated in pyelonephritis unless...

Answer 34

Severely ill Persistent symptoms despite 48-72 hours of abx Suspicion for obstruction Recurrent symptoms within a few weeks of treatment CT A/P (w/ and w/o contrast) image of choice - caution if risk of contrast neuropathy Renal U/S and MRI also used

Question 35

What is the treatment of choice for outpatient management of mild-moderate acute pyelonephritis?

Answer 35

Fluoroquinolones • Ciprofloxacin 500 mg PO BID x 5-7 days • Ciprofloxacin extended release 1000 mg PO qd x 5-7 days • Levofloxacin 750 mg PO qd x 5-7 days If local FLQ resistance, initial IV or IM dose of Ceftriaxone (Rocephin) 1g, followed by above regimen If uropathogen known to be susceptible to Bactrim, then 160/800 mg PO BID x 7-10 days

Question 36

What must the patient education include for mild-moderate outpatient management of acute pyelonephritis?

Answer 36

Analgesic/antipyretic Phenazopyridine x 2 days for dysuria ER precautions MUST FOLLOWUP IN 24-48 HOURS!!!! Follow up urine cultures not needed except in pregnant women or those who’s symptoms don’t resolve

Question 37

Indications for hospitalization for acute pyelonephritis

Answer 37

Critically ill/hemodynamically instability Persistently high fever (>103) Persistent pain/marked debility Suspected or documented urinary tract obstruction Metabolic derangement (renal dysfunction) Unable to take liquids by mouth Concerns about compliance with followup instructions

Question 38

How do you treat complicated/severe acute pyelonephritis (inpatient management)?

Answer 38

``` Acceptable IV abx regimens: • Fluoroquinolone • Extended-spectrum cephalosporin • Extended-spectrum penicillin • Carbapenem (Vabomere) • Aminoglycosides (Zemdri) ``` Supportive care - analgesics/antipyretic, anti-emetic, IVF

Question 39

What are the possible complications of acute pyelonephritis?

Answer 39

Sepsis with shock Renal failure Scarring or chronic pyelonephritis (if coexistence kidney disease) Renal abscess formation FOLLOWUP IN 24-48 HOURS

Question 40

An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower UT symptoms of more than six weeks duration in the absence of infection or other identifiable causes

Answer 40

Interstitial cystitis aka Bladder pain syndrome Aka painful bladder syndrome

Question 41

What does a typical interstitial cystitis patient look like?

Answer 41

Woman in fourth decade or later, often with coexisting chronic pain condition (ie Fibromyalgia, IBS) It’s a clinical diagnosis of exclusion - patients experience symptoms for an avg of 5-7 years before receiving a correct dx

Question 42

What is the pathophysiology of interstitial cystitis?

Answer 42

Altered urothelium Likely a multifactorial involving varying components of: • Disruption of the glycosaminoglycan (GAG) layer • Bladder urothelial injury • Secretion of proinflammatory substances, mast cell activation, fibrosis • Neural hypersensitivity • Neuropathic pain and voiding dysfunction

Question 43

Clinical presentation of interstitial cystitis

Answer 43

Suprapubic/bladder pain (pressure, discomfort), often worse with bladder filling, relieved with voiding +/- urinary urgency, frequency, nocturia +/- pain in pelvis, perineum, urethra, lower ABD, lower back +/-dyspareunia, vaginal burning Men: pelvic pain with concomitant sexual dysfunction

Question 44

Physical exam in interstitial cystitis should include...

Answer 44

ABD exam Bimanual pelvic exam in women Rectal exam in males May note variable tenderness, +/- pelvic floor muscle spasm

Question 45

What are the two big “DONT MISS” DDx for interstitial cystitis?

Answer 45

Urinary and genital tract cancer Acute cystitis, vaginitis, urethritis, prostatitis

Question 46

How do you diagnosis interstitial cystitis?

Answer 46

UA with microscopy and urine culture - unremarkable/negative (done to r/o infection and hematuria) If (+) hematuria —> urine cytology and cystoscopy to r/o cancer, esp if smoker Urine cytology if (+) smoking history STI testing in patients at risk +/- postvoid residual urine volume - r/o bladder outlet obstruction or neuro disorder +/- cystoscopy —> if in doubt

Question 47

If you do a cystoscopy on a patient with suspected interstitial cystitis, what would support your diagnosis?

Answer 47

Altered urothelium - glomerulations and HUNNER LESIONS

Question 48

What is the first line treatment for interstitial cystitis?

Answer 48

Self-care and behavioral modifications Diet - consider avoiding citrus fruits, acidic/spicy foods, caffeine, EtOH, carbonated beverages Bladder retraining Low-impact exercise Psychotherapy or IC support groups Urinary analgesics (pyridium) short term 2 day use for flares

Question 49

Second-line treatment for interstitial cystitis?

Answer 49

Oral meds: • Tricyclic antidepressant (Amitriptyline) • Pentosan Polysulfate (Elmiron) - may take 3-6 months to respond • Antihistamines (Hydroxyzine) restores GAG layer to reduce inflammation Intravesical meds: • Lidocaine Pelvic Physical Therapy

Question 50

What are the more advanced treatments for interstitial cystitis?

Answer 50

(All by urology, not by us) Cystoscopy with short-duration, low pressure bladder hydrodistension Intravesical instillation of glycosaminoglycans Intravesical Dimethyl sulfoxide (DMSO) Intradetrusor botulinum toxin Sacral neuromodulation Cyclosporine Surgery (urinary diversion)

Question 51

Indications for referral in interstitial cystitis

Answer 51

Hematuria Complex symptoms Incomplete bladder emptying A neurologic disorder that affects bladder function Prior pelvic radiation Prior pelvic surgery Have not responded to initial tx with oral meds