Urology 2- Infectious COPY Flashcards
(88 cards)
1
Q
Is Cystitis an upper or lower UTI? Pyelonephritis?
A
Cystitis= lower
Pyelonephritis= Upper
2
Q
The following are risk factors for what?
- Immunocompromise (DM, HIV, steroids, etc)
- Urinary stasis/obstruction (urinary retention, ureteral obstruction, vesicoureteral reflux, bladder diverticulum)
- Congenital GU abn
- Sex
- Spermicide/diaphragm use
- Urinary Incontinence
- Cystocele/ pelvic prolapse
A
Cystitis
3
Q
What role do the following play in cystitis?
- Voiding after intercourse
- Wiping from front to back
- Tight clothing
- Voiding as soon as feel urge
- Hot tubs
- Douches
- Tampons
A
Non-factors of Cystitis
4
Q
Presentation of what?
- Irritative voiding sxs (dysuria, urgency, freq)
- Malodorous urine
- Suprapubic discomfort
- Fever
- Mental status change
A
Cystitis
5
Q
What is the presentation of cystitis in a patient with a spinal cord injury? (2)
A
Autonomic dysreflexia
Increased muscle spasticity
6
Q
What 4 findings are seen on urinalysis and is indicative of Cystitis?
A
- Leukocyte esterase
- Nitrite positive
- Pyuria >5
- Bacteria
**Urine culture is definitive dx)
7
Q
What is seen on urine culture in cystitis? (2 things)
A
>100,000 organisms, monoculture
8
Q
What is the MC pathogen causing cystitis?
A
E-coli
9
Q
What 4 bacteria might be seen on a urine culture that are part of the normal perineal flora and are indicative of skin contamination, NOT UTI
A
- Lactobacillus
- Corynebacterium
- Streptococcus
- Staphylococcus epidermidus
(“Lazy Staph Stretch Epic Corny movie plots”)
10
Q
How do you tx Cystitis? (2 options)
A
- Trimethoprim/Sulfamethoxazole DS x3d
- Nitrofurantoin x5-7d
- (Ampicillin/Amox effective against enterococcus)
11
Q
T/F: Fluoroquinolones (Ciprofloxacin, Levofloxacin) are NOT 1st line in the tx of cystitis?
A
TRUE (b/c of side effect profile including tendinitis/tendon rupture)
12
Q
What are the 2 main options for empiric tx of cystitis?
A
- Nitrofurantoin
- SMX/TMP DS (if <20% resistance locally)
13
Q
If you have a pt c/o persistent sxs after treatment of cystitis, what should you do in order to re-evaluate?
A
- Ensure compliance
- Re-culture
- Check post void residual
- Pelvic (vaginitis)
14
Q
How do you tx a patient with persistent sxs post tx of cystitis? (symptomatic tx for urgency? dysuria? pelvic pain?)
A
- Patience (inflammation > infection)
- Symtomatic tx for urgency- antimuscarinics
- Symptomatic tx for dysuria- phenazopyridine
- Symptomatic tx for pelvic pain- NSAIDS
- Diet
- Quercetin
- Constipation
- Stress
- Prevent re-infection (+/- topical vaginal estrogen, +/- abx prophylaxis, etc)
15
Q
The following are indications of what?
- Immunosuppression
- Pregnancy
- Male
- Pediatric
- Indwelling urinary catheter, stent, drain
- Anatomic abnormality (ex: vesicoureteral reflux, etc)
- Urinary obstruction
- Urolithiasis
- Renal insufficiency
A
Complicated Cystitis
16
Q
T/F: In a patient with a chronic indwelling catheter, Bacteria/colonization in urine does NOT equal infection
(KNOW THIS)
A
TRUE
So don’t tx or do a urine on someone that is asymptomatic w/ a chronic indwelling catheter!
17
Q
How do you tx a pt w/ a chronic indwelling catheter who has UTI sxs (ex: mental status changes)–> 3 steps
A
- Remove catheter (to remove biofilm)
- Replace catheter and obtain urine culture
- Antibiotics
18
Q
What are 5 possible non-infectious causes of urethritis?
A
- Trauma
- Reiter’s
- Urethral stricture
- Urethral stone
- Urethral lesions
(“Reita Tries to teach _Les_sons and is Stone cold Strict”)
19
Q
What are the common infectious causes of urethritis? (3)
A
Gonococcal (GNID’s)
Non-gonococcal= Chlamydia trachomatis, Mycoplasma genitalium
20
Q
What are the 3 sxs of Urethritis?
A
- Dysuria
2. Urethral Discharge (profuse purulent if gonorrhea, clear/purulent/absent if chlamydia)
3. Urethral Pruritis
(highlight= how different from cystitis)
21
Q
In a patient with urethritis, what is the difference in the urethral discharge change if the cause is gonorrhea vs chlamydia?
A
Gonorrhea: profuse purulent discharge
Chlamydia: Clear or purulent or absent discharge
22
Q
What are the 2 lab options for evaluation of urethritis and what will each test show if positive?
A
- First void urinalysis- Leukocyte esterase, >10 WBC
- Gram stain of urethral discharge: >5 WBC
23
Q
In order to test for gonorrhea or chlamydia as the cause of urethritis, how long after voiding should you wait before obtaining a culture (via swab) or NAAT (via urethral/cervical swab or urine)?
A
>1 hour
24
Q
Evaluation of Urethritis:
When testing for Gonorrhea, what is the pro of obtaining a culture (via swab) vs using NAAT (via urethral/cervical swab or urine)?
A
- Culture- gives sensitivities
- NAAT- No sensitivities (usually doesn’t matter b/c can guess right with Ceftriaxone)
25
What are 2 ways you can test for Gonorrhea as the cause of Urethritis?
* Gonorrhea **culture** via urethral swab
* Nucleic Acid Amplified Test (**NAAT**) via urethral/cervical swab or urine
26
How do you **treat Gonorrhea** as the cause for **urethritis**?
Ceftriaxone IM x1 dose
27
How do you **treat Chlamydia** as the cause for **Urethritis**?
Azithromycin 1g PO x 1 dose
or
Doxycycline BID x 7 days
28
How long should you advise a patient to **abstain from sex** if they are being treated for **gonorrhea/chlamydia** as a cause of urethritis?
Until 7 days after treatment initiated
29
When should you **follow up** with a patient who has urethritis caused by **gonorrhea** if they received **alternative treatment**?
(Cefixime is alternative to Ceftriaxone)
Test of cure 1 week after treatment AND at 3 months after treatment
30
When should you **follow up** with a patient who has urethritis caused by **gonorrhea** if they received the **recommended treatment** (Ceftriaxone IM)?
Test of Cure- **_3 months after treatment_**
(this is for both recommended AND alternative treatment)
31
When should you perform a **test of cure** in a patient who has uncomplicated urethritis caused by **Chlamydia** that was **responsive to tx** (Azithromycin 1g x1 dose)?
Follow up testing not necessary
32
When should you perform a **Test of cure** in a patient who has urethritis caused by **Chlamydia** if they are **_PREGNANT_**?
Test for cure **_3-4 weeks_** after completion of treatment
33
T/F: In treatment of urethritis, you should **refer sex partners for evaluation** and **tx those who had sexual contact w/in the 60 days before** onset of patients sxs
TRUE
34
What is orchitis?
Inflammation of the testicle
35
What are the 3 causes of epididymitis?
1. **Behcet's Disease** (painful oral/genital ulcers, uveitis, non-mucous membrane skin lesions)
2. Amiodarone (accumulation in epididymis)- RARE
3. Testis or epididymal **tumor**
36
What is the MCC of **epididymitis** in men **_\< 35y/o_**?
Neisseria gonorrhea or Chlamydia
37
What is the MCC of **Epididymitis** in men **_\>35y/o_**?
E. coli
38
**The following are causes of what condition?**
1. Acute bacterial infection ( \<35= Gonorrhea/chlamydia, \>35= E.coli)
2. Viral
3. Granulomatous (TB)
4. Other (Fungus, ureaplasma, Trichomonas)
Epididymitis
39
**The following is the presentation of what condition?**
* Testicular pain
* +/- urethral discharge and urethritis sx (if STD)
* Edematous tender testicle, epididymis, spermatic cord
* Hydrocele
Epididymitis
40
**Evaluation of what?**
* Diagnose on clinical findings, H&P
* Urine culture
* Test for STDs if STD suspected
Epididymitis
41
How do you treat Epididymitis if STDs are suspected? (5)
* Scrotal support
* Analgesia
* Cold
* Empiric tx: **_Ceftriaxone and Doxycycline_**
42
How do you treat Epididymitis if STDs are _NOT_ suspected? (5)
* Scrotal support
* Analgesia
* Cold
* **_Levofloxacin_** (empiric)
43
Chronic epididymitis last \> ____ months
\> **_3_** months
44
How do you evaluate chronic epididymitis? (5)
* H&P
* **UA**
* **Urine C&S and other cultures as indicated**
* Scrotal ultrasound w/ doppler
* CT (e.g. stones)
45
**The following are conservative treatment options for what?**
* Analgesics
* Pain clinic
* Scrotal support
* Modification of activities
* Moist heat
* Spermatic cord block
* Antibiotics
("SPASM in the AM")
Chronic Epididymitis
46
What are the 5 **surgical** options used to treat **chronic epididymitis**?
* Testicular Dennervation
* Removal of sperm granuloma
* _If obstruction_- vasovasostomy or epididymectomy
* _If intermittent torsion_- bilateral orchiopexy
* Inguinal orchiectomy
47
What surgery do you perform if chronic epididymitis is due to obstruction (2)
Vasovastostomy or epididymectomy
48
What surgery do you perform if **chronic epididymitis** is due to **intermittent torsion**?
Bilateral orchiopexy
49
What is the difference between Acute and Chronic epididymitis in regards to duration of sxs?
Acute= \< 3 months
Chronic= \>3 months
50
What are the 4 types of prostatitis?
1. Acute Bacterial Prostatitis
2. Chronic Bacterial Prostatitis
3. Inflammatory Chronic Pelvic Pain Syndrome (Non-bacterial Prostatitis)
4. Non-inflammatory Chronic Pelvic Pain (Prostatodynia)
51
What is the hallmark sx of prostatitis?
\*\*\*\*know this\*\*\*\*\*
Prostatic pain
52
What condition?
* **Fever**
* Irritative sx (freq, urgency, etc)
* Warm **_boggy tender prostate_**
* **_Young_** men
* E. coli
Acute Bacterial Prostatitis
53
T/F: In a patient with suspected **Acute Bacterial Prostatitis**, you should always perform a **prostate massage prior to obtaining urine culture**
FALSE
(you only do a urine culture post prostate massage in CHRONIC bacterial prostatitis)
54
T/F: It is important to NOT perform a vigorous prostate exam on a patient with suspected acute bacterial prostatitis
TRUE
55
What 4 things do you do to evaluate a patient for acute bacterial prostatitis
1. H&P (no vigorous prostate exam)
2. **_Urine culture_** (NOT post-prostate massage)
3. CBC
4. Blood cultures
56
How do you tx **acute bacterial prostatitis** if there is **significant fever, highly elevated WBC, sepsis**?
* **Admit for IV abx**
* When no longer acutely toxic switch to PO abx
* Discharge and tx w/ **abx for 4-6 wks**
57
What should you order if you have a patient with **acute bacterial prostatitis that is persistently febrile**?
CT to r/o prostatic abscess
58
Which condition?
* pain in genitals, urinary tract, perineum, low back
* Irritative urinary sxs
* **Pain w/ ejaculation**
* **_Older_ men**
* E. coli
**Chronic bacterial prostatitis**
| (acute is more common in younger men)
59
MCC of chronic prostatitis?
E. coli
60
Someone with chronic bacterial prostatitis often will report a history of what? What will be seen on physical exam?
* Hx of **recurrent UTIs**
* Physical exam: Tender **boggy** prostate
61
What two tests are used to evaluate for chronic bacterial prostatitis?
* Expressed prostatic secretion
* **_Post prostate massage_** urine culture
62
How do you treat chronic bacterial prostatitis? (4)
* Empiric- **Flouroquinolones, SMX/TMP** (adjust based on culture) x8-16 weeks
* NSAIDs
* Alpha blockers ("-zosins")
* Anticholinergics/antimuscarinics (for relief in freq/urgency)
* Other: phytotherapy (Saw Palmetto), stress management, etc
63
In a patient with Inflammatory chronic pelvic pain syndrome what will the patient report a history of?
History of chronic UTI's but w/ negative cultures (b/c not bacterial)
64
How do you tell the difference b/w inflammatory chronic pelvic pain syndrome and chronic bacterial prostatitis?
Similar sxs
Inflammatory chronic pelvic pain syndrome: Prostatic fluid with **leukocytes, but cultures neg. for bacteria**
65
What is seen on labs in inflammatory vs noninflammatory chronic pelvic pain syndrome?
inflammatory: (-) bacteria, (+) leukocytes
Non-inflammatory: (-) bacteria, (-) leukocytes
66
How is inflammatory and non-inflammatory chronic pelvic pain syndrome similar to chronic bacterial prostatitis? How are they different?
* **Similar presentations:** (recurrent prostatic infections, pain in genitals/urinary tract/perineum/low back, irritative urinary sxs, pain w/ ejaculation), **prostatic tendernes**s
* Differences (labs):
* _Inflammatory_- Prostatic fluid **w/ leukocytes** and **no bacteria** on culture
* _Non-inflammatory_- **No leukocytes** in prostatic fluid and **no bacteria** on culture
67
**Treatment for what?**
_Palliative measures:_
* **NSAIDs**
* **Anticholinergics** for urinary urgency
* **Alpha blockers**
* **Sitz baths**
* Stress reduction
* Prostate massage
* Dietary (caffeine, alcohol, spicy food)
* Benzos
* Tricyclic antidepressent
* Analgesics, pain specialist consult
Noninflammatory Chronic Pelvic Pain Syndrome (AKA Prostadynia)
68
**Definition of Pyelonephritis:**
\_\_\_\_\_\_ (upper or lower?) tract urinary infection involving kidney's
renal \_\_\_\_\_\_
**_Upper_** tract urinary infection involving kidney's
Renal **_Parenchyma_**
69
Presentation of what?
* Fever
* **_Flank pain_**
* N/V
* **_CVA tenderness_**
* If ascending infection: dysuria, urinary frequency/urgency, hematuria
* If hematogenous spread: no urinary sxs
Pyelonephritis
70
What are the 2 routes of infection for pyelonephritis?
* **Ascending infection** along urinary tract from bladder
* **Hematogenous** spread (IVDA, cutaneous infections)
71
What do you see on UA in pyelonephritis?
WBCs and **_WBC casts_**
72
When should you order **imaging** for evaluation of **pyelonephriti**s? (7)
* If very ill, unstable
* septic
* DM
* immunocompromised
* Structural abnormality of urinary tract
* Urinary obstruction, urinary stones
* Unresponsive to abx
73
What 2 types of imaging do you order for further evaluation of pyelonephritis (if indicated)?
* CT Urogram
* Renal U/S
74
What 4 findings would you see on CT Urogram in a patient with Pyelonephritis?
* Perinephric stranding
* Kidney enlargement
* **Decreased nephrogram**
* Renal collecting system dilated but not obstructed
75
What 2 findings would you see on Renal U/S in a patient with Pyelonephritis?
* Kidney enlargement (hydronephrosis)
* Abn kidney echogenicity
76
How do you treat a patient with **pyelonephritis** who is **mildly ill**?
* Outpatient
* **_Fluoroquinolone x7d_**
* Consider admission if febrile \>72hrs or if not sufficient clinical improvement
77
How do you treat a patient with **pyelonephritis** who is **moderately/severely ill** (high fever, high WBC, Vom, dehydration, sepsis)?
(7 steps)
* **_Admit_**
* **_IV abx_** (e.g. FQ, AMG, etc)
* Imaging for renal abscess
* adjust abx based on C&S
* PO when afeb x24-48hrs
* D/C home w/ 2wk PO abx
* F/U C&S after completed
78
Pyelonephritis is first on a spectrum with what 2 other conditions?
**Acute bacterial nephritis and Renal abscess**
(if a pt w/ suspected pyelo is not improving, consider dx of ABN or renal abscess)
79
What is the definition of Acute Bacterial Nephritis?
Bacterial interstitial nephritis of the renal cortex, causing a **_renal mass, but no liquifaction_**
80
What is a renal abscess?
Purulent fluid collection of kidney (perinephritic abscess is adjacent to kidney)
81
What patienst are renal abscesses often seen in?
DM, immunocompromised
82
Are most common pathogens that cause renal abscess gram negative or positive?
negative
(if hematogenous route- gram positives like staph aureus)
83
How do you treat a renal abscess? (4 steps)
* **IV abx**
* +/- percutaneous drainage
* Surgical drainage
* Follow patients clinical course and **follow w/ imaging to ensure resolution**
84
What is chronic pyelonephritis? What is it a result of?
* **Scarred, atrophic**, poorly functioning kidney
* Result of **prior infections**
85
How can chronic pyelonephritis result in HTN?
Kidney is scarred, atrophic and poorly functioning--\> low flow, high renin
86
What is the clinical presentation of Chronic Pyelonephritis? (5)
* **_HTN_**
* Anemia of chronic disease
* **Proteinuria**
* Renal insufficiency
* **Recurrent UTIs**
87
What is a radiographic finding of Chronic Pyelonephritis?
(\*Will be on exam\*)
Calceal blunting
88
What are the 3 treatments for Chronic Pyelonephritis?
* Manage UTI risk factors
* Control HTN
* **_Nephrectomy_**
