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Flashcards in Dysuria: A urinary tract infection Deck (23):

Dysuria is the cardinal symptom for a urinary tract infection/ What is it?

Pain whilst passing urine, often a burning/stinging sensation.

  • Something in the urine that irritates pain fibres and/or
  • sensitive mucosa so the pain fibres get stimulated


What other questions do we want to ask?

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  • Seek evidence that there is bladder dysfunction
    • Frequency
    • Hesitiancy (need to go but not much comes out)
    • Inflammed, boggy, not doing its job
    • cramping pain (strangury): suprapubic
    • If these are there, very likely cystitis. 
  • If there is not urgency, it's likely urethritis
  • Contraception?


How do you diagnose cystitis?

  • Mid-stream urine collection ($35): Microscopy, culture, susceptability.
    • Urine will become contaminated by colonising bacteria as you pee, so the first part flushes this away, and we collect a more sterile collection more representitive of the bladder
    • if they grow anything in a resonable amount they'll do a susceptable testi (only if it grows at a reasonable amount as it could just be due to contamination)
  • Urine dipstick: WBC/leucocyte esterase. Cheap plastic with chromatograph that measure pH, sugar content8 and leukocyte esterase
    • A high amount of leukocyte esterase correllates with a high number of neutrophils in the urine**** so there will be inflammation of the bladder
    • IS THERE PYURIA (WBC in urine)


What is the common sense, cost saving approach to diagnosing and treating UTI?

  1. Typical SYmptoms? y/n
  2. Dipstick shows pyuria? y/n
    • 96% of people with symptomatic UTI have >10mill WBC/litre
    • dipstick sensitivity is >8million WBC/litre so will usually always show
    • pyuria in the absence of symptoms does NOT indicate cystitis
  3. Treat further problems? y/n
  4. Reassess and send MSU to lab
    • microscopic visualisation of bacteria correlates with culture contamination is important issue (w > m)


what to do

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Answer: A

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How common is cystitis

Women > Men

Sexually active young women 2-4%
Post menopause: increases due to the drop of oestrogen, (which usually supports healthy flora), different bacteria can now take place.

Institutionalised (no longer independent): Mostly due to bladder dysfunction  20-50%


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What factors can increase the risk of a UTI in both Males and Females?

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What are the main causitive feature in elderly peopl?


  • post menopause
  • Urinary tract abnormalities
    • urethrocele, rectocele, bladder diverticula
  • Neurological disease
  • incomplete bladder emptying (usually we fill to ~400ml and then completely empty)


  • strictures
  • stones
  • prostatic disease 
  • Neurological disease


What are the bacteria that cause Cystitis?

  • E coli: 80% of the time!
    • also causes most of pylonephritis!
  • Staphylococcus saprophyticus: common in young women
    • Good at colonising urethra but cannot get to kidneys! can catalase peroxide, 
    • Therefore never seen in hospital!

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Why is E.coli the main causer of cystitis?

  • Sequesters Iron (Fe): ones that can't fo this aren't as virulent.
  • Fimbriae: Mediate attachment to urothelium. Can change from type II (bladder) to type I (renal)
  • Polysaccharide Capsule: resist phago cytosis and opsonisation, also protect bacteria against changing pH and osmolality
    • N. gonorreiae: never causes disease as it cannot live in urine
  • Alpha haemolysin released that damages epithelial cells

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What happens once the urothelium is damaged?

It releases cytokines, these causes symptoms and recruit neutrophils

Neutrophils come to bladder wall and in the urine, and this is when the dysuria, burning pain comes to play once the bladder become boggy and odematous


What stops us from getting urinary tract infections all the time

our innate immune system, highly devloped in bladder (unlike meninges)

  • Microbial flora: lactobacilli produce hydrogen peroxide which kills competeing flora Staphylococcus saprophyticus can de-toxify H2O2 the flor changes in post menopausal women
  • Urine: is inhospitable: low pH, pH and osmolarity changes, organic acids. Bacteria that produce glycine survive better.
  • Urination: bacteria that produce type 1 fimbriae are able to stick to urothelium
  • Tamm-Horsfall protein: formed in loop of Henle, bind to bacteria (esp type 1 fimbriae) bacteria that can switch to type II or III can avoid TH protein
  • Prostatic fluid: inhibits bacterial growth 


What treatment is required to treat cystitis and would it resolve if none was given?

Although most cases will resolve, this can take many weeks-months. 

If no symptoms = then no anitbiotics should be given!!!

Antimocrobials are required: if the right anitbiotics the symptoms will resolve within 1-2days

  • effective
  • low chance of adverse drug reactions 
  • narrow spectrum as possible



Commonly used anti-folate drug used to treat cystitis!

  • Folate is required from bacteria to produce nucleotides (purines) 
  • Broad spectrum antibiotic!
  • INTERFERE with bacterial division: "bacteriostatic"
  • Stops dihydroteroic acid → dihydrofolic acid

also sulphonomides discovered earlier and used

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How could E. coli bacteria overcome the inhibiting effects of trimethprim

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  1. By making excess enzyme (dihydrofolate synthetase) and saturating the trimethoprim, overwhelming its effects
  2. Dump this pathway altogether and get the needed folate elsewhere that is around using transporters
  3. Pump trimethoprim out of themselves via cell membrane pumps!

These all lead to antibiotic resistance


What are the two folate antagonists used in NZ?

  1. co-trimoxazole
    • sulfamethoxazole (400mg) and trimethorpim (80mg)
    • inhibits pathway at 2 points
  2. trimethoprim
    • rapidly cleared by the kidneys, so in high amounts there but not anywhere else





Augmentin: too many toxic effects

Phosphomycin: (98%) people have to pay for it, use for those with super resistant bacteria

Nitroferotoin (99%) now used in hospitals



Don't give anti-folates to....

  • pregnant women (obviously)
  • high doses for long periods can suppress bone marrow function
  • allergy: rash, can be very severe  (***see pic Steven Johnson syndrome)
    • SJ syndrome: allergy of both skin and mucosa surfaces, (mouth, face, genitourinary systems). Can be equal to burns, end up in critical care. A second attack will be worse!!!
    • mostly the sulfur drugs causing issues

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Good options to treat cystitis. WHich one do you use?

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  • trimethprim (71%)
  • nitrofuratoin (98%)

You would use the nitrofuratoin as more effective BUT as it's needed to be taken 4x a day is a nuisance and decreases compliance.

Use trimethprim at bedtime so you aren't going to pee the drug out and it can linger in the bladder.


What factors can contribute to recurrent cystitis?

  1. intercourse
  2. form of contraception
  3. abnormal urinary tract or urodynamics (measures flow/efficiency of urination): not common in women, more common in men (urethral valve issues)


Does cranberry juice protect against cystitis??

no it doesn't actually work!! 


What is this?

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  • FEVER with UTI is a way to distinguish
  • Bacteraemia (15-30%) 
  • mortality (10%)
  • many  patients are admitted and treated in hosptials 
  • investigate: blood cultures and urine cultures, blood tests to look for organ impairment (eg; renal function)
  • Radiological studies (US scan): NOT required to make diagnosis, but if used if suspected abnormaluty of UT (eg; stones) but if people deteriorate despite treatment


Treatment of pylonephritis

  • Often IV at first then rapid change to oral treatment when responds
    • gentamicin 5mg/kg (lean BW) daily IV
    • cefuroxime/amoxycillin-clavulanate are alternative
  • used to be 14 days but now shorter courses 7-10 days are used for uncomplicaed cases
    • Be watchful for signs/ymptoms of septic shock
    • anti-folates not used as they're bacteriostatic