Station 5

Question 1

34F 4 UTIs in 6 months

Assess

Answer 1

I would assess this lady in a general urology clinic with a pre-filled bladder diary, having reviewed previous urine cultures to assess for persistence versus re-infection and appropriate antibiotic prescribing.

History
Loin pain, Fever
Urological History, STI Symptoms,
Associated Triggers - Intercourse, Travel, Foods
HPC - ?Admissions, ?Childhood, ?Pyelo

RFs New Sexual Partner, Spermicidal Lubricants, Pregnancy, Functional or anatomical urological abnormalities, Menopausal status, Bowel Function.

Red Flags - Haematuria, Pyuria, Faecaluria, Weight Loss, Neurological Symptoms

Lifestyle - Fluid intake, Caffeinated Beverages, Carbonated Beverages, Smoking

PMH - Urological (Stones, procedures), Obstetric/Gynaecological Factors (Children, menopause, pregnancies), Medical (immunosuppression, diabetic, neurological)

Allergies -? Antibiotics, HRT

SH - Smoker, Job, Exericse

QOL??

Question 2

34F 4 UTIs in 6 months
Examination
Investigations

Answer 2

Examination
?BMI
Palpable bladder/Loin tenderness
Genital Exam
- Atrophic Vaginitis
- SUI?
- Bimanual - PF contraction, ?Masses
- Speculum - Rectocele/ Cystocele

Ix
Reveiw urine cultures
Bloods - renal function
Bladder Diary
Flow Rate + PVR
US KUB
+/- Flexible Cystoscopy

Question 3

Define Recurrent Uncomplicated UTI

Answer 3

2 or more infections per six months
or
3 or more infections in twelve monhts

Question 4

What makes UTI Complicated

Answer 4

UTI is in a non pregnant female with no known medical predisposing factor, functional or anatomical urological abnormality

Specifically:

Anatomy - (Cystovele, Diverticulum, Fistula)
Iatrogenic (Surgery/Catheter)
Voiding Dysfunction
Obstructive
Pregnancy
Stones
Diabetic
Immunosuppressed

Question 5

Conservative Management

Answer 5

Fluid intake
Bicarbonate of soda - reduces acidity of urine and helps with symptoms
Avoid - bubble baths, talcum powder, vaginal deoderants etc.
Showers better than bath
Washing around coitus
Use lubrication
Empty bladder after intercourse
Cranberry juice/tablets
Avoiding spermicidal lubricants

Question 6

Antibiotics?
Alternatives?

Answer 6

3 Day Self - Start Course
Post Coital Single Dose
Long term antibiotics

Alternatives
Hipprex - Methanimine Hippurate -> Becomes formaldehyde when excreted
D-Mannose - prevents bacterial adherence. (Recurrence 15% with D Mannose cf 60% placebo 20% nitro)
Glycosaminoglycan replenishment - Intravesical

Question 7

Mx of Staghorn calculus with UTIs

Answer 7

Discuss with patient if identified on USS and explain further investigations required + discussion in the stone multi-disciplinary team meeting

Ix:
CT KUB
DMSA
Renal Function Assessment

Stone MDT - PCNL versus Benign Nephrectomy

Question 8

Should you conservatively manage staghorn?

Answer 8

Individualised approach considering the patient factors as well as disease factors.
MDT Discussion

Blandy paper - 28% disease specific mortality in conservatively managed patients versus 7%. Severe infection in 27% of patients managed conservativel

2020 Alsawi paper - 20 % mortality rate and 8 percent severe infection.

Question 9

Predisposing factors in:

Young
Old

Answer 9

Young - Sexual Intercourse, Use of spermicidal lubricants, New sexual partners

Old - Cystocele, Atrophic Vaginitis, Incontinence, High Post Residual Volume, Poor functional status, Catheterisation