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2012-11-08 07:57:18

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  1. 20% women annually
    UT abnormalities, caths
    sexually active
    young kids, elderly
    cystitis occurence
  2. risk factors:
    inc sexual activity, diaphragm, spermicide
    incomplete voiding
    neurogenic bladder
    reflux (VUR)
    urinary instrumentation
  3. causative organisms:
    #1 gram - bacilli most common: E. coli
    #2 gram +: Staph saprophyticus

    other gram negs: Proteus, Klebsiella, Pseudomonas, Serratia
  4. patho:
    infection--inflammatory edema in bladder--stretch receptors cz urgency and frequency--prostaglandins released--pain and vascular permeability--hematuria
  5. HX, SX:
    -dysuria, frequency, urgency, nocturia, hematuria (direct   correlation between amt of blood and pathology)
    -foul smelling urine
    -suprapubic heaviness/pressure
    -ask about fever, chills, N/V, abd/back pain, blood in urine
    --ask about number of previous UTI's
  6. DDX:
    -vaginitis: Gonorrhea, Chlamydia= must ask GYN HX
  7. PE cystitis
    • check temp
    • abd exam
    • CVAT
    • pelvic if HX suggests
  8. DX cystitis:
    • urine dipstick for nitrities, WBC's, RBC's
    • midstream UA
    • UC not always necessary (consider if resistane strains bacteria)
  9. Most common findings in UA w/cystitis:
    • + WBC or pyuria (sens 90%)
    • presence of bacteria (sens 83%)
    • + nitrites
    • IF all of these +, sensitivity 99%
  10. casts/hematuria suggest what type of UTI
    upper UTI
  11. TX for cystitis in uncomplicated cases w/o allergy
    bactrim x3 days
  12. TX for cystitis if allergy or resistant strain
    • fluoroquinolones
    • (ciprofloxacin, levaquin)
  13. TX cystitis if have had ATB's recently
    Macrobid 100mg BID x 5-7 days
  14. TX cystitis complicated
    (caths, comorbidities)
    fluoroquinolones 7-14 days
  15. reason for 3 day ATB use for cystitis
    cost effective and decreases risk of Candida
  16. mgmt cystitis
    • 1. analgesics- pyridium
    • 2. anticholinergics- ditropan
    • 3. CAM- cranberry 300mg BID in caps to preveny bacteria from sticking to bladder wall
  17. UTI in pregnancy- why is TX so important?
    associated with premature delivery
  18. TX UTI in pregnancy:
    (use for 7 days)
    • Amoxi 500mg BID
    • Macrodantin 100mg BID
    • Keflex 500mg  BID
    • Augmentin
  19. RX to avoid in pregnancy when TX UTI?
    fluoroquinolones bc they have effects on fetus bone and cartilage formation
  20. pt education cystitis
    • -avoid full bladder
    • -increase PO fluids
    • -void after sex
    • -wipe front to back lacks research
    • -consider alternative birth control if currently using spermicide or diaphragm
    • -no F/U needed if uncomplicated
  21. how to prevent "honeymoon cystitis"
    macrodantin 50mg pre coitus
  22. most common organism for peds UTI
    and #2
    • #1- E. coli
    • #2- Staph, Strep
  23. cz of UTI in peds
    urinary stasis, constipation, bubble baths, sexual abuse
  24. peds at greater risk of what w/chronic UTI's
    renal scarring
  25. Sx UTI in peds:
    enuresis, squatting, unexplained fever, irritability, abd pain
  26. PE in peds UTI
    • -check BP for HTN
    • -temp
    • -check for abd or flank mass
    • -palpate bladder
    • -check for abn genitalia
    • -check for abn urinary stream
  27. 1. DX peds UTI
    2. How to obtain
    • 1. urine culture
    • 2. infant- suprapubic asp, cath
    • 2. older kids- clean voided midstream
  28. definition recurrent UTI in peds
    • >2 UTI's in period of 6mo
    • refer these pts bc they have increased risk of renal scarring
  29. peds TX UTI
    • same as adults:
    • keflex
    • macrodantin
    • amoxi
    • augmentin
  30. when to recheck UC in peds UTI pts:
    recheck UC 3-7 days post TX
  31. pyelonephritis definition
    upper GU tract infection involving renal parenchyma. Can be bilateral or unilateral
  32. pyelo usually cz by:
    ascending infection form bladder
  33. chronic pyelo may lead to:
    scarring and renal failure from deformity
  34. risk factors for pyelonephritis
    DM, anatomic abn, recurrent UTI's, pregnancy, cath's, elderly women
  35. Sx pyelonephritis:
    • flank pain
    • N/V
    • fever/chills
    • HA, malaise
    • CVAT
    • tenderness on deep abd palp
    • poss hematuria
    • urinary frequency
  36. DX pyelo:
    • UA- look for pyuria and WBC casts
    • UC- should always be done if pyelo suspected
    • may need pelvic exam to R/O PID
  37. dont rely on dipstick for what urinary disorder?
  38. Do blood cultures if pt is hospitalized w/what?
    • pyelo
    • (10-20% pts w/mild to mod pyelo have urosepsis)
  39. indications for admission of pyelo:
    • pregnant
    • chronic dz
    • non-compliant
    • unable to take PO fluids or meds
    • toxic looking
  40. Outpatient TX for pyelo:
    • must be closely monitored
    • may stabilize w/IM/IV ATB's in office
    • refer of sx dont improve in 12-48hrs
    • --telephone F/U in 12 hrs, OV in 48hrs
    • --F/U cultures in 2 wks and 3months for recurrent cases
  41. meds for pyelo:
    • gram neg= fluoroquinolones 14days
    • gram pos= augmentin
  42. renal stones- most common?
  43. other types of renal stones
    • struvite (15%)
    • uric acid (7%)
    • cystine (1%)
  44. risks for calcium stones
    • hypercalciuria, hyperuricosuria, low calcium intake, high animal protein diet, high animal fat diet, low fluid intake, high vit C intake
    • previous HX stones, family HX stones
    • freq UTI's, vasectomy, HTN, marathon runners, sedentary
    • high soda intake (phosphoric acid)
    • high oxalate (leafy greens, chocolate, spinach)
  45. risks for uric acid stones
    • acidic urine
    • gout
    • chronic diarrhea states
  46. risks for struvite stones
    UTI caused by Klebsiella, Proteus
  47. Sx renal stones
    • mild to severe pain that waxes and wanes (20-60min intervals)
    • flank pain (upper ureteral, renal pelvis)
    • pain radiates to testicles or labia (lower ureteral obstruction)
    • hematuria (gross or micro)
    • can have N/V dysuria, frequency, urgency
  48. DX stones:
    • CT scan gold standard
    • may do IVP w/abd films
    • can do U/S if have to avoid radiation
  49. TX renal stones:
    • attempt to manage w/hydration and analgesics until stone passes
    • if sotne >7mm, usually too big to pass and pt needs urology consult
  50. prevention of renal stones in general:
    increase fluids, decrease soda intake
  51. prevention of calcium stones:
    • low oxalate diet
    • increased citrate
    • thiazide diuretics (for recurrent cases)
  52. prevention of uric acid stones:
    • low purine diet
    • allopurinol
  53. prevention of struvite stones:
    avoid UTI's
  54. prevention of cystine stones:
    (all of these RX bind to cystine to prevent crystal formation)
    • penicillamine
    • tiopronin
    • captopril
  55. hematuria- age cut-offs
    • dont rely on dipstick
    • do UC on all pts w/hematuria
    • pt <40yoa= monitor monthly for 3mo, if persists then refer
    • pt >40yoa= refer to urology
  56. hematuria
    • common in long distance runners
    • gross or occult
    • transient or persistent
  57. most important test for hematuria
  58. correlation w/what and gross hematuria very important
  59. important HX to ask w/hematuria
    • drug and dietary HX, many irritate the bladder
    • check menstrual HX
  60. definition stress incont-
    cz by what?
    can be from what?
    • failure to store d/t hypermobility of bladder neck
    • cz by intrinsic sphincter deifiency
    • can be from hormone changes, vaginal deliveries, sedative, anti-spasmodics
  61. TX stress incont
    • kegels
    • wt loss
    • estrogen creams
    • alpha blockers
    • surgery
  62. urge incontinence, from what?
    • failure to store
    • r/t UTI, vaginitis, stones, tumors, Parkinson's, diuretics, narcs
  63. TX urge incontinence
    • ATB's
    • estrogen cream
    • anticholinergics
    • TCA's
    • kegel's
    • prompted voiding schedule
  64. overflow incontinence...
    due to?
    • failure to empty
    • d/t underactive detrusor muscle, outlet obstruction, DM, anti-cholinergics, antihistamines, CCB's
  65. TX overflow incontinence?
    • scheduled toileting (Credes maneuver)
    • tx underlying condition
    • alpha blockers
  66. functional incontinence from...
    delirium, fecal impaction, immobility, diuretics, ETOH, decongestants
  67. TX functional incontinence
    • remove barriers
    • B&B training
    • PT
    • habit training
    • collection devices