CLMD - UTI, pyelo, sepsis, changes in outflow/obstruction

Question 1

Risk factors for UTIs in women

Answer 1

Use of spermicide with diaphragm for contraception

Frequent sexual intercourse

Anatomic factors affecting bladder emptying: cystoceles, urinary incontinence, residual urine

Tissue effect of post-menopausal estrogen depletion

Diabetes

Question 2

Risk factors for UTIs in males

Answer 2

Prostatic hypertrophy

Non-circumcised

Question 3

DDX for dysuria in a female

Answer 3

Cystitis
Cervicitis (Chlamydia, Neisseria)
Vaginitis (candida, trichomonas)
Urethritis (herpetic)
Interstitial cystitis
Non-infectious vaginal or vulvar irritation

Question 4

When is asymptomatic bacteriuria worrisome and needing further workup and potential tx?

Answer 4

In a pregnant pt — untreated asymptomatic bacteriuria in pregnant pts more likely to result in symptomatic pyelonephritis which is also more likely to develop sepsis

Question 5

Prostatitis can be chronic in prostatic hypertrophy; prolonged abx course may be necessary x ___ weeks

Answer 5

4-6

Question 6

Pyelonephritis results in bacteremia in 20-30% of cases. Hematogenous spread is rare, but more likely with what 3 organisms?

Answer 6

Candida
Salmonella
Staph aureus

Question 7

3 major complications of pyelonephritis

Answer 7

Papillary necrosis
Emphysematous pyelonephritis
Xanthogranulomatous pyelonephritis

Question 8

Besides pyelonephritis, what other conditions may lead to papillary necrosis?

Answer 8

Obstruction
Diabetes
Sickle cell
Analgesic nephropathy

Question 9

Emphysematous pyelonephritis is production of gas in nephric and perinephric areas. It occurs almost exclusively in pts with _____

Answer 9

Diabetes

Question 10

______ pyelonephritis develops in cases of chronic obstruction or chronic infection and causes suppurative destruction of renal tissue and may lead to abscess formation

Answer 10

Xanthogranulomatous

Question 11

Differentiate sepsis (septicemia) from septic shock

Answer 11

Sepsis = suspected or documented infection and acute increase in organ failure; dysregulated host response to infection leading to hypofunction of uninfected organs

Septic shock — progressive organ dysfunction leading to marked increase in mortality (subset of sepsis); vasopressor therapy needed to maintain MAP at 65+ mmHg, serum lactate greater than 2 mmol/L (18mg/dL) = AKA hypotension that cannot be reversed with infusion of fluids

Question 12

Important considerations in tx of sepsis/septic shock

Answer 12

Volume resuscitation with IV fluids

Cultures — blood, urine, CSF, etc

Initiate abx for most likely cause (generally broad spectrum)

Pressor agents: NE, vasopressin, etc. for severe cases

Correct acid/base imbalance — fluids, oxygenation, monitor electrolytes

Question 13

Preventative strategies for recurrent UTI

Answer 13

Consider PRN antibiotic therapeutic regimens — continuous, post-coital, or patient-initiated

Empty bladder as soon as reasonable after intercourse

Wipe front to back after toileting

Showers instead of tub baths

Lactobacillus probiotics

Cranberry products

Vitamin C

Increased fluid intake

Question 14

3 phases of unilateral ureteral obstruction effects on renal function

Answer 14

1. Urine backflow — increases intraluminal hydrostatic pressure; a simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR. Activation of RAAS leads to second phase
2. [6+ hours] Decrease glomerular blood flow d/t afferent arteriole vasoconstriction
3. Decreased luminal hydrostatic pressure AND renal blood flow baseline

[note that persistent obstruction >24 hours can cause a 50% drop in GFR]

Question 15

2 phases of bilateral ureteral obstruction in renal injury

Answer 15

1. Urine backflow — increases intraluminal hydrostatic pressure. Simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR. RAAS is activated which leads to second phase
2. [6+ hours] Decrease glomerular blood flow due to afferent arteriole vasoconstriction; this persistent efferent and (partial) afferent arteriole vasoconstriction maintains GFR

[note that ANP may play a role in maintaining GFR/arteriole function]

Question 16

Changes in Na+ regulation with unilateral tubular dysfunction

Answer 16

Inability to reabsorb Na+ throughout the nephron —> salt wasting

Downregulation of receptor and enzyme activity poorly understood — may be related to ischemia, decreased ATP or changes in PGE2 levels

Question 17

Changes in fluid volume regulation in bilateral tubular dysfunction

Answer 17

Presence of volume expansion; ANP blocks effects of renin —> decreased angiotensin II —> net result is diuresis and natriuresis

Question 18

Changes in urine concentrating ability with tubular dysfunction d/t obstruction

Answer 18

Inability to absorb Na+ in the TAL and dilute the filtrate in the DCT —> excretion of solutes

Defective urea recycling: transporter defect reduces concentrating effect and allows urea to be excreted

Question 19

What changes in potassium take place in tubular dysfunction d/t obstruction?

Answer 19

Low-flow luminal state —> high urinary K+ concentrations in CD —> loss of gradient between cell and lumen —> HYPERKALEMIA

Question 20

In terms of the “big picture”, a patient presenting with what 3 things should cause you to think about urinary tract obstruction?

Answer 20

Azotemia
Hyperkalemia
Metabolic acidosis

Question 21

Congenital causes of ureteral obstructtion

Answer 21

Ureteropelvic junction narrowing or obstruction

Ureterovesical junction narrowing or obstruction and reflux

Ureterocele

Retrocaval ureter

Question 22

Congenital causes of bladder outlet obstruction

Answer 22

Bladder neck obstruction

Ureterocele

Question 23

Congenital causes of urethral obstruction

Answer 23

Posterior urethral valves
Anterior urethral valves
Stricture
Meatal stenosis
Phimosis

Question 24

Acquired intrinsic defects causing ureteral obstruction

Answer 24

Calculi
Inflammation
Infection
Trauma
Sloughed papillae
Tumor
Blood clots

Question 25

Acquired intrinsic defects causing bladder outlet obstruction

Answer 25

``` BPH Prostate Ca Bladder Ca Calculi Diabetic neuropathy Spinal cord dz Anticholinergic drugs and alpha adrenergic antagonists ```

Question 26

Acquired intrinsic defects causing urethral obstruction

Answer 26

``` Stricture Tumor Calculi Trauma Phimosis ```

Question 27

Acquired extrinsic defects causing ureteral obstruction

Answer 27

``` Pregnant uterus Retroperitoneal fibrosis Aortic aneurysm Uterine leiomyomata Ca of uterus, prostate, bladder, colon, rectum Lymphoma PID, endometriosis Accidental surgical ligation ```

Question 28

Acquired extrinsic defects causing bladder outlet obstruction

Answer 28

Carcinoma of cervix, colon | Trauma

Question 29

Acquired extrinsic defects causing urethral obstruction

Answer 29

Trauma

Question 30

How might adults develop secondary VU reflux?

Answer 30

Adults with voiding difficulties may develop reflux that predisposes them to complciations like UTI, pyelo, and hydronephrosis

Question 31

Although BPH is a benign process, eventually the pressure in the bladder will increase such that urine is forced into the ureters causing ______; it has a vague pain pattern that may include the low back, perineum, or suprapubic area

Answer 31

Hydronephrosis

Question 32

_____ incontinence = neurogenic loss of detrusor function causing emptying phase abnormality; bladder empties when capacity is exceeded

Answer 32

Overflow/bypass

Question 33

Overflow incontinence is often diagnosed based on what test?

Answer 33

Post-void residual — US eval to see how much is left in bladder after voiding >100 ml indicates incomplete emptying

Question 34

Cause of stress incontinence

Answer 34

Increased intraabdominal pressure in those with defective fascial support of UV junction [may see bulging of anterior vaginal wall on straining, indicative of posterior rotation d/t defective support] [note increased risk in women who have given birth]

Question 35

Causes and description of neurogenic bladder

Answer 35

Spinal cord trauma Spinal myelomeningocele Less common: spinal stenosis, herniated discs Disruption of coordination of relaxation of sphincter during bladder contraction — as volume increases, resting pressure rises [>40 cm H2O increases risk for hydronephrosis and subsequent decrease in GFR — so requires regular monitoring to avoid irreversible injury]

Question 36

_____ is the imaging technique preferred for dx of renal lithiasis

Answer 36

CT

Question 37

Patients with outlet obstruction d/t malignancy often present with constitutional symptoms. What types of cancer might be implicated?

Answer 37

Transitional cell CA obstructing ureter at UPJ or UVJ Can also be GI or urogenital — colon cancer, ovarian cancer, lymphoma

Question 38

Postobstructive diuresis is a normal physiologic event after bilateral ureteral obstruction — what does this process consist of?

Answer 38

Combination of fluid overload, urea accumulation, and electrolyte imbalance Rate 250 mL/h but can be as high as 750 ml/h Results from downregulation of Na transporters during obstruction; ANP released in response to cardiac preload during obstruction Tx is fluid replacement in response to diuresis (75% of urine volume) and careful monitoring of urine and serum osmolality as well as serum electrolytes