Urinary Tract Urinary Tract DisordersDisorders

ObjectivesObjectives

Distinguish types of UTI, including bacteriuria, urethritis, cystitis, Distinguish types of UTI, including bacteriuria, urethritis, cystitis, and pyelonephritisand pyelonephritis

Describe the pathophysiology related to UTI, such as organisms Describe the pathophysiology related to UTI, such as organisms and host factorsand host factors

Describe pathophys of common forms of nephrolithiasis, including Describe pathophys of common forms of nephrolithiasis, including risk factors for development of nephrolithiasisrisk factors for development of nephrolithiasis

Describe typical clinical presentations, and elicit a pertinent Describe typical clinical presentations, and elicit a pertinent history, in a patient with UTI or nephrolithiasishistory, in a patient with UTI or nephrolithiasis

Describe the diagnostic methods and diagnostic criteria for the Describe the diagnostic methods and diagnostic criteria for the various types of UTIvarious types of UTI

Summarize the methods used for dx of nephrolithiasisSummarize the methods used for dx of nephrolithiasis Describe modes of therapy for acute, chronic, and complicated Describe modes of therapy for acute, chronic, and complicated

UTI, including prophylaxis for recurrent infectionUTI, including prophylaxis for recurrent infection Summarize therapeutic options for nephrolithiasis, and strategies Summarize therapeutic options for nephrolithiasis, and strategies

to prevent recurrenceto prevent recurrence

Urinary Tract InfectionUrinary Tract Infection

LowerLower

urethritisurethritis

cystitiscystitis

prostatitisprostatitis

UpperUpper

pyelonephritispyelonephritis

intrarenal and perinephric abscessintrarenal and perinephric abscess

Also categorized intoAlso categorized into

Non-catheter associated (commum. Non-catheter associated (commum. acquired)acquired)

Catheter associated (hosp. acquired)Catheter associated (hosp. acquired) Any category may be sx or asxAny category may be sx or asx

Urinary Tract InfectionUrinary Tract Infection

Pathogenic microorganisms in urine, urethra, Pathogenic microorganisms in urine, urethra, bladder, kidney, prostatebladder, kidney, prostate

Usually growth > 10Usually growth > 1055 organisms per milliliter organisms per milliliter From midstream “ clean catch” urine sampleFrom midstream “ clean catch” urine sample If sx or from catheter specimen can be If sx or from catheter specimen can be

significant with 10significant with 1022 or 10 or 1044 organisms per mL organisms per mL

EtiologyEtiology

Most common is Gram neg. bacteriaMost common is Gram neg. bacteria E. coli = 80% of uncomp. acute UTIE. coli = 80% of uncomp. acute UTI Proteus – assoc. with stonesProteus – assoc. with stones Klebsiella – assoc. with stonesKlebsiella – assoc. with stones EnterobacterEnterobacter SerratiaSerratia PseudomonasPseudomonas

EtiologyEtiology

Gram pos. cocciGram pos. cocci Staphylococcus saprophyticus 10-15 % Staphylococcus saprophyticus 10-15 %

acute sx UTI in young femalesacute sx UTI in young females Enterococci – occas. in acute uncomp. Enterococci – occas. in acute uncomp.

cystitiscystitis Staphylococcus aureus – assoc. with renal Staphylococcus aureus – assoc. with renal

stones, instrumentation, increased susp. of stones, instrumentation, increased susp. of bacteremic kidney infectionbacteremic kidney infection

EtiologyEtiology

Urethritis from chlamydia, gonorrhea, Urethritis from chlamydia, gonorrhea, HSV – acute sx female with sterile pyuriaHSV – acute sx female with sterile pyuria

Ureaplasma urealyticumUreaplasma urealyticum Candida or other fungal species – Candida or other fungal species –

commonly assoc. with cath. or DMcommonly assoc. with cath. or DM MycobacteriaMycobacteria

PathogenesisPathogenesis

Usually ascent of bacteria from urethra to Usually ascent of bacteria from urethra to bladder to kidneybladder to kidney

Vaginal introitus, distal urethra colonized Vaginal introitus, distal urethra colonized by normal floraby normal flora

Gram negative bacilli from bowel may Gram negative bacilli from bowel may colonize at introitus, periurethracolonize at introitus, periurethra

??

Predisposing conditions to Predisposing conditions to UTIUTI

FemaleFemale Short urethra, proximity to anus, termination Short urethra, proximity to anus, termination

beneath labiabeneath labia Sexual activitySexual activity

PregnancyPregnancy 2-3% have UTI in preg, 20-30% with asx bacteriuria 2-3% have UTI in preg, 20-30% with asx bacteriuria

may lead to pyelo may lead to pyelo Increased risk of pyelo = decreased ureteral tone, Increased risk of pyelo = decreased ureteral tone,

decreased ureteral peristalsis, temp. incomp of decreased ureteral peristalsis, temp. incomp of vesicoureteral valvesvesicoureteral valves

??

Predisposing conditionsPredisposing conditions

Neurogenic bladder dysfunction or bladder Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying)diverticulum (incomplete emptying)

Age - Postmenopausal women with uterine or Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, of estrogen, decreased normal flora, concomitant medical conditions such as DMconcomitant medical conditions such as DM

Vesicoureteral refluxVesicoureteral reflux Bacterial virulenceBacterial virulence GeneticsGenetics Change in urine nutrients, DM, goutChange in urine nutrients, DM, gout

Urethritis Urethritis ??

Acute dysuria, frequencyAcute dysuria, frequency Often need to suspect sexually Often need to suspect sexually

transmitted pathogens esp. if sx more transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic than 2 days, no hematuria, no suprapubic pain, new sexual partner, cervicitispain, new sexual partner, cervicitis

CystitisCystitis

Sx: frequency, dysuria, urgency, Sx: frequency, dysuria, urgency, suprapubic painsuprapubic pain

Cloudy, malodorous urine (nonspec.)Cloudy, malodorous urine (nonspec.) Leukocyte esterase positive = pyuriaLeukocyte esterase positive = pyuria Nitrite positive (but not always)Nitrite positive (but not always) WBC (2-5 with sx) and bacteria on urine WBC (2-5 with sx) and bacteria on urine

microscopymicroscopy

PyelonephritisPyelonephritis

FeverFever chills, N/V, diarrhea, tachycardia, gen. chills, N/V, diarrhea, tachycardia, gen.

muscle tenderness muscle tenderness CVAT or tenderness with deep CVAT or tenderness with deep

abdominal tendernessabdominal tenderness Possibly signs of Gram neg. sepsisPossibly signs of Gram neg. sepsis

??

PyelonephritisPyelonephritis

LeukocytosisLeukocytosis Pyuria with leukocyte casts, and bacteria Pyuria with leukocyte casts, and bacteria

and hematuria on microscopyand hematuria on microscopy Complications: sepsis, papillary necrosis, Complications: sepsis, papillary necrosis,

ureteral obstruction, abscess, decreased ureteral obstruction, abscess, decreased renal function if scarring from chronic renal function if scarring from chronic infection, in pregnancy – may increase infection, in pregnancy – may increase incidence of preterm laborincidence of preterm labor

Catheter-Catheter-Associated Associated ?? Urinary Tract InfectionsUrinary Tract Infections

10-15% of hosp. patients with indwelling 10-15% of hosp. patients with indwelling catheter develop bacteriuriacatheter develop bacteriuria

Risk of infection is 3-5% per day of Risk of infection is 3-5% per day of catheterizationcatheterization

UTI after one-time bladder cath approx. 2%UTI after one-time bladder cath approx. 2% Gram neg. bacteremia most significant Gram neg. bacteremia most significant

complication of cath-induced UTIcomplication of cath-induced UTI Greater antimicrobial resistanceGreater antimicrobial resistance

Diagnosis of UTIDiagnosis of UTI

HistoryHistory Physical examPhysical exam LabLab

Urinalysis with micro = WBC, bacteriaUrinalysis with micro = WBC, bacteria Urine culture Urine culture Sensitivities of culture for tailored antibiotic therapySensitivities of culture for tailored antibiotic therapy May dx acute uncomp. cystitis based on hx, PE, and May dx acute uncomp. cystitis based on hx, PE, and

UA alone, no need for culture to treatUA alone, no need for culture to treat

DiagnosisDiagnosis

UrinalysisUrinalysis Leuk. Esterase pos. = pyuriaLeuk. Esterase pos. = pyuria Nitrite pos. from urea prod. bact. (but not Nitrite pos. from urea prod. bact. (but not

always)always) Micro – WBC (even 2-5 in patient with sx)Micro – WBC (even 2-5 in patient with sx) Micro – BacteriaMicro – Bacteria

DiagnosisDiagnosis

Urine cultureUrine culture Once 10Once 1055 colonies per mL considered colonies per mL considered

standard for dx but misses up to 50%standard for dx but misses up to 50% Now, 10Now, 1022 to 10 to 1044 accepted as significant if accepted as significant if

patient symptomaticpatient symptomatic Needed in upper UTI, comp. UTI, and in Needed in upper UTI, comp. UTI, and in

failed treatment or reinfectionfailed treatment or reinfection Sensitivities for better tailoring of txSensitivities for better tailoring of tx

Treatment Treatment ??

Uncomp. cystitis with less than 48 hours Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx of sx, non-pregnant, usu. 3 days tx sufficientsufficient Bactrim DS, Septra DSBactrim DS, Septra DS Cipro or other FQ (avoid in preg.)Cipro or other FQ (avoid in preg.) Nitrofurantoin (7 days)Nitrofurantoin (7 days) AugmentinAugmentin Bladder analgesis, PyridiumBladder analgesis, Pyridium

TreatmentTreatment

Uncomp. cystitis in pregnant patientUncomp. cystitis in pregnant patient Requires longer tx of 7-14 daysRequires longer tx of 7-14 days Cephalosporin, nitrofurantoin, augmentin, Cephalosporin, nitrofurantoin, augmentin,

sulfonamides (do not use near term, inc. sulfonamides (do not use near term, inc. kernicterus)kernicterus)

AsymptomaticAsymptomatic ?? BacteriuriaBacteriuria

101055 org/mL growth org/mL growth Empiric treatment of all asymptomatic Empiric treatment of all asymptomatic

bacteriuria (ASB) in pregnancy. Screening bacteriuria (ASB) in pregnancy. Screening at first visit.at first visit.

ASB if untreated = inc. PTD and LBW, 20-ASB if untreated = inc. PTD and LBW, 20-30% develop pyelo. 30% develop pyelo.

Do TOC in 2 weeks and each trimester.Do TOC in 2 weeks and each trimester. Screen Sickle cell trait each trimester. Screen Sickle cell trait each trimester.

Twofold inc. risk of ASBTwofold inc. risk of ASB

Asymptomatic BacteriuriaAsymptomatic Bacteriuria

Treatment failures: repeat tx based on Treatment failures: repeat tx based on sensitivities for 1 week, then prophylactic sensitivities for 1 week, then prophylactic therapy for remainder of pregnancytherapy for remainder of pregnancy

Prophylaxis: Nitrofurantoin, Ampicillin, Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMXTMP/SMX

TreatmentTreatmentRecurrent uncomp. UTIRecurrent uncomp. UTI

3 or more episodes in one year, 2 in 6 months3 or more episodes in one year, 2 in 6 months Bactrim DS ( or septra DS) QD for 3-6 months Bactrim DS ( or septra DS) QD for 3-6 months

once infection eradicated, self-admin. Single once infection eradicated, self-admin. Single dose at symptom onset or one DS tab post-dose at symptom onset or one DS tab post-coituscoitus

Measures for prevention: voiding after Measures for prevention: voiding after intercourse, good hydration, frequent and intercourse, good hydration, frequent and complete voidingcomplete voiding

Treatment of Pyelonephritis Treatment of Pyelonephritis -- Outpatient-- Outpatient

Uncomp. Nonpreg pyeloUncomp. Nonpreg pyelo Primary – any FQ x 7 days, ciproPrimary – any FQ x 7 days, cipro Alt. -- Augmentin, TMP/SMX, or oral CSP Alt. -- Augmentin, TMP/SMX, or oral CSP

for 14 daysfor 14 days

Treatment ofTreatment ofPyelonephritis – Inpatient Pyelonephritis – Inpatient ??

Treat IV until patient is afebrile 24-48 hours. Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO medsThen, complete 2 week course with PO meds

Use FQ or amp/gent or ceftriaxone or Use FQ or amp/gent or ceftriaxone or piperacillinpiperacillin

If no improvement on IV, consider imaging If no improvement on IV, consider imaging studies to look for abscess or obstructionstudies to look for abscess or obstruction

All pregnant patients with pyelo get inpatient tx, All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediatelyappropriate IV antibiotics immediately

Treatment of Treatment of Complicated UTIComplicated UTI

Catheter relatedCatheter related Amp/gent or Zosyn or ticaricillin/clav or Amp/gent or Zosyn or ticaricillin/clav or

imipenem or meropenem x 2-3 weeksimipenem or meropenem x 2-3 weeks Switch to PO FQ or TMP/SMX when Switch to PO FQ or TMP/SMX when

possiblepossible Rule out obstructionRule out obstruction Watch out for enterococci and Watch out for enterococci and

pseudomonaspseudomonas

Nephrolithiasis Nephrolithiasis ??

Supersat. of urine by stone forming Supersat. of urine by stone forming constituentsconstituents

Crystals of foreign bodies act as nidiCrystals of foreign bodies act as nidi Freq. stone types: Calcium (most Freq. stone types: Calcium (most

common), struvite, oxalate, uric acid, common), struvite, oxalate, uric acid, staghornstaghorn

Risk factors: metabolic disturbances, Risk factors: metabolic disturbances, previous UTI, gout, geneticprevious UTI, gout, genetic

NephrolithiasisNephrolithiasis

Incidence = 2-3%Incidence = 2-3% MorbidityMorbidity

Obstruction Obstruction pain pain Chronic obstruction, may be asx Chronic obstruction, may be asx loss of loss of

renal functionrenal function Hematuria (rarely dangerous by itself)Hematuria (rarely dangerous by itself) Dangerous combo = obstruction + infectionDangerous combo = obstruction + infection

Nephrolithiasis Nephrolithiasis ??

More prev. in Asians and whitesMore prev. in Asians and whites Males > females, 3:1Males > females, 3:1 Struvite stones – from infection, Struvite stones – from infection,

increased in femalesincreased in females Ages 20-49Ages 20-49 RecurrentRecurrent Uncommon after 50 y.o.Uncommon after 50 y.o.

NephrolithiasisNephrolithiasisPatient History Patient History

??

Often dramatic pain, poss. infection, Often dramatic pain, poss. infection, hematuriahematuria

Even nonobst. May cause sxEven nonobst. May cause sx Bladder irritating sxBladder irritating sx Renal colic because of stone in ureterRenal colic because of stone in ureter

Severe, undulating cramps because of Severe, undulating cramps because of ureter peristalsis, sever pain, N/Vureter peristalsis, sever pain, N/V

Pain may migratePain may migrate

NephrolithiasisNephrolithiasisPatient HistoryPatient History

Duration, char, location of painDuration, char, location of pain Hx of stones?Hx of stones? UTI?UTI? Loss of renal function?Loss of renal function? FHx of stonesFHx of stones Solitary/ transplanted kidneySolitary/ transplanted kidney

NephrolithiasisNephrolithiasisPhysical ExamPhysical Exam

Dramatic CVAT, may migrate as stone Dramatic CVAT, may migrate as stone movesmoves

Usu. Lacking peritoneal signsUsu. Lacking peritoneal signs Calculus often in area of maximum Calculus often in area of maximum

discomfortdiscomfort

NephrolithiasisNephrolithiasisWorkupWorkup

UrinalysisUrinalysis Evid. Of hematuria and infectionEvid. Of hematuria and infection 24-hour urinalysis helpful in identifying 24-hour urinalysis helpful in identifying

causecause

CMP, uric acid, CBCCMP, uric acid, CBC Calcium, oxalate, uric acid in the 24 hour Calcium, oxalate, uric acid in the 24 hour

urineurine

NephrolithiasisNephrolithiasisWorkupWorkup

Plain abd film (KUB)Plain abd film (KUB) Renal USGRenal USG IVPIVP Helical CT without contrast (stone Helical CT without contrast (stone

protocol)protocol)

NephrolithiasisNephrolithiasisTreatmentTreatment

If no obstruction or infection, stones < 5-6mm If no obstruction or infection, stones < 5-6mm may likely passmay likely pass

Restore fluid volume if dehyd.Restore fluid volume if dehyd. Analgesics – narcotics, nsaidsAnalgesics – narcotics, nsaids AntiemeticsAntiemetics Occasionally nifedipine (CCB) to relax ureteral Occasionally nifedipine (CCB) to relax ureteral

smooth muscle and prednisone usedsmooth muscle and prednisone used Urology consultUrology consult

NephrolithiasisNephrolithiasis

Treatment Treatment ??

Surgical intervention (call urology)Surgical intervention (call urology) Extracorporeal shock-wave lithotrypsy (not in Extracorporeal shock-wave lithotrypsy (not in

pregnancy)pregnancy) Ureteral stentUreteral stent Percutaneous nephrostomyPercutaneous nephrostomy UreteroscopyUreteroscopy Indications = pain, infection, obstructionIndications = pain, infection, obstruction Contraindications = active untx infection, Contraindications = active untx infection,

uncorrected bleeding diathesis, uncorrected bleeding diathesis, pregnancy (relative)pregnancy (relative)

NephrolithiasisNephrolithiasis

Prophylaxis Prophylaxis ??

Increase fluid intake (2 liters per day of Increase fluid intake (2 liters per day of UOP)UOP)

24 hour urine, eval calcium, oxalate, uric 24 hour urine, eval calcium, oxalate, uric acid to determine dietary preventionacid to determine dietary prevention

metabolic tests to determine cause (Ex: metabolic tests to determine cause (Ex: hyperparathyroidism)hyperparathyroidism)

Decrease salt intakeDecrease salt intake

ReferencesReferences

Braunwald et al. (2002) Harrison’s Principals of Internal Braunwald et al. (2002) Harrison’s Principals of Internal Medicine (15Medicine (15thth edition). New York: McGraw-Hill. edition). New York: McGraw-Hill.

Ling F., & Duff, P. () Obstetrics and Gynecology, Ling F., & Duff, P. () Obstetrics and Gynecology, Principles for Practice. 2001. New York: McGraw-Hill.Principles for Practice. 2001. New York: McGraw-Hill.

www.emedicine.comwww.emedicine.com ACOG Practice Bulletin, Clinical Mgmt Guidelines (No ACOG Practice Bulletin, Clinical Mgmt Guidelines (No

23, Jan 2001). Antibiotic Prophylaxis for Gyn 23, Jan 2001). Antibiotic Prophylaxis for Gyn ProceduresProcedures

Brankowski et al. The Johns Hopkins Manual of Brankowski et al. The Johns Hopkins Manual of Obstetrics and Gynecology. 2002. Philadelphia: LWWObstetrics and Gynecology. 2002. Philadelphia: LWW

The Sanford Guide to Antibiotic TherapyThe Sanford Guide to Antibiotic Therapy