UTI and IC

Question 1

Outflow obstruction, inadequate fluid intake, neurogenic bladder

Answer 1

Reduced urine flow

Question 2

sexual activity, spermicide use, estrogen depletion, recent antimicrobial use

Answer 2

Promote colonization

Question 3

Catheterization and urinary incontinence

Answer 3

facilitate ascent

Question 4

CP of cystitis

Answer 4

HISTORY IMPORTANT! Dysuria, Fq, urgency, +/- hematuria, +/- suprapubic discomfort

Question 5

PE of cystitis

Answer 5

Typically normal except for 10-20% that experience suprapubic tenderness

Question 6

PE elements to perform for cystitis

Answer 6

assessment
signs of dehydration
check for CVA tenderness
Abd exam
\+/- pelvic exam in women
genital exam in men, +/- DRE

Question 7

What does urethral discharge in a female usually indicate?

Answer 7

urethritis, not cystitis

Question 8

What is the most valuable diagnostic tool in testing for UTI?

Answer 8

Pyuria evaluation
Abnormal is >10 leukocytes/mL
+hematuria (normal finding)
+nitrites

Question 9

Which test is the most specific for UTI?

Answer 9

leukocyte esterase

Question 10

What can you see a false + nitrite test with?

Answer 10

phenAZOpyridine (pyridium) OR

exposure to air causes false positives across the board

Question 11

Is a culture indicated for acute cystitis?

Answer 11

No

Question 12

When can you feel comfortable getting a urine culture?

Answer 12

if you suspect pyelonephritis, if sx don’t resolve, if sx recur, any atypical presentation

Question 13

What is considered diagnostic for uncomplicated cystitis?

Answer 13

> 10^3 CFU if uncomplicated

>10^2 if it looks complicated

Question 14

What other diagnostic test might be appropriate for a new UTI?

Answer 14

PGN test

Question 15

What might a UTI look like? (DDx)

Answer 15

Vaginitis
urethritis
structural urethral abnormalites
IC/Painful bladder syndrome
PID

Men: prostatitis, urethritis

Question 16

What is first-line treatment for uncomplicated cystitis in women?

Answer 16

Bactrim 160/800
Nitrofurantoin (macrobid)
Fosfomycin

Question 17

second-line treatment for uncomplicated cystitis in women

Answer 17

Fluoroquinolones

Question 18

For acute uncomplicated cystitis 3rd-line

Answer 18

Beta-lactams

Question 19

First line for complicated cystitis in nonpregnant female

Answer 19

Fluroroquinolone- try parenteral if can’t tolerate oral

Question 20

For acute uncomplicated cystitis in men (still kind of considered complicated)

Answer 20

bactrim then fluoro

Question 21

What is the DOC for woman in PGN with any kind of UTI?

Answer 21

Amoxicillin-clavulanate (augmentin) then
Nitrofurantoin (avoid near term)
NEVER USE A FLUOROQUINOLONE

Question 22

What will a pyelonephritis UA reveal?

Answer 22

positive pyuria
+/- hematuria
WBC casts (not always seen, but if you see it, you have this)

Question 23

What will a urine culture for pyelonephritis reveal?

Answer 23

> 10^5 CFU/mL

Question 24

What will a CBC and BMP reveal in pyelonephritis?

Answer 24

leukocytosis with left shift

+/- impaired renal function

Question 25

When is imaging indicated for pyelonephritis?

Answer 25

When there is no improvement or when there is a recurrence OR if the patient is severely ill

Question 26

What is the image of choice for pyelonephritis?

Answer 26

CT with contrast (caution nephropathy) | renal U/S and MRI too

Question 27

What might pyelonephritis look like?

Answer 27

``` Appendicitis diverticulitis cholecystitis lower lobe pneumonia PID NEPHROLITHIASIS with colick-y pain, not only with CVA tenderness ```

Question 28

What is used to treat mild-moderate pyelonephritis outpatient? What about if there is resistance detected?

Answer 28

FLUOROQUINOLONES. If there is resistance, do quinolones PLUS CEFTRIAXONE shot

Question 29

When must you follow up with pyelopnephritis (aka SEE THEM IN OFFICE)?

Answer 29

24-48 hours after diagnosis

Question 30

What is the CP in pyelonephritis?

Answer 30

hx of lower or upper UTI in PMH, FEVER, chills, n/v/pain, CVA TENDERNESS, possible suprapubic tenderness

Question 31

What are indications for hospitalization of acute pyelonephritis?

Answer 31

``` DM kidney disfunction liver or heart dz Male LOOKS SICK SEVERE PAIN FEVER OVER 103 UNABLE TO DRINK LOW BP ```

Question 32

When is IC most commonly diagnosed?

Answer 32

in the 30s, sometimes even in peds

Question 33

What does IC often exist with?

Answer 33

Other chronic pain conditions such as fibromyalgia, IBS, VULVODYNIA

Question 34

What else do many IC patients experience besides urinary sx?

Answer 34

Depression, sexual disfunction

Question 35

What is the most important central finding in IC?

Answer 35

altered urothelium of GAG layer (hyperplasia)

Question 36

What small lesion will you find in IC?

Answer 36

granulations of petechiae

Question 37

What percentage of IC patients have ulcerative IC? Nonulcerative?

Answer 37

10% (Hernen ulcers) | 90%

Question 38

What is the CP of IC like?

Answer 38

SUPRAPUBIC/BLADDER PAIN, OFTEN WORSE WITH BLADDER FILLING AND RELIEF WITH EMPTYING, +/- pain anywhere else +/- urinary urgency, fq, nocturia +/- dyspareunia, vaginal bleeding +/- painful ejaculation, sexual dysfunction

Question 39

How is the clinical diagnosis of IC made?

Answer 39

DURATION OF SX FOR 6 WEEKS PMH: Prior recurrent UTIs, pelvic trauma, etc Use bathroom more because it hurts not to how many times a day do they void?

Question 40

What should a PE of IC include?

Answer 40

Abd, BIMANUAL PELVIC, rectal exam in males | +/- pelvic floor muscle spasm due to irritable nerves

Question 41

Since IC is a diagnosis of exclusion, what must you do to rule it in?

Answer 41

UA with microscopy and culture to r/o infection and hematuria, if hematuria, then cytology and cystology CYTOLOGY IMMEDIATELY if smoking history (no blood needed) Urine culture if sexually active +/- postvoid residual urine volume test +/- cystoscopy (not required for dx)

Question 42

Treatment of IC

Answer 42

voiding log First-line: lifestyle changes, behavioral modification, low-impact exercise, psychotherapy Second-line: NON-FDA APPROVED but fast: Amitriptyline FDA-APPROVED but slow (3-6 months): Elmiron (pentosan polysulfate) Histimines for mast cell stabalization Intravesicular meds (DMSO, heparin, lidocaine) Physical Therapy

Question 43

When to refer patient with IC?

Answer 43

Heme, PAIN WITH INCONTINENCE | Have not responded with initiall tx of oral meds