1. Infectious Diseases of the GU tract Clinical Medicine I Patrick Carter MPAS, PA-C March 14, 2011
2. Objectives Define irritative voiding symptoms Briefly describe normal and abnormal findings with dipstick urinalysis Briefly describe normal and abnormal findings with microscopic urinalysis For each of the following diseases describe the etiology, epidemiology, pathophysiology, risk factors, signs and symptoms, diagnostic work-up, and treatment: Prostatitis Epididymitis
3. Objectives List the classifications of urinary tract infections (UTI) Describe differences in susceptibility to UTI’s for women and men Discuss the differences in diagnostic work-up and management of cystitis in men and women. Describe the studies required in children with UTI. Describe the importance of UTI and asymptomatic bacteriuria (ASB) in pregnancy
4. Objectives Describe the treatment of UTI and ASB in pregnancy Describe the etiology, epidemiology, risk factors, signs and symptoms, diagnostic work-up, and treatment of pyelonephritis
5. Patient History Renal pain is usually located in the ipsilateral flank; pain usually constant with infection Nausea and vomiting may occur with renal pain due to reflex stimulation of the celiac ganglion Acute cystitis pain is usually referred to the distal urethra and lower abdomen
6. Irritative Voiding Symptoms Definitions Urgency – sudden desire to void (gotta go right now) Dysuria – painful urination, usually related to inflammation Frequency – increased number of voids during the day Nocturia – increased number of voids during the night
7. Physical Exam – Kidney Right kidney is lower than the left; and the lower pole of the right kidney may be palpable Left kidney usually not palpable unless greatly enlarged
8. Physical Exam – Bladder Bladder not palpable unless filled with 150 ml of urine Percussion better that palpation to detect bladder distention Full bladder will have be dull to percussion
10. Urinary Tract Infections Acute community-acquired UTIs account for >7 million office visits annually in the US Majority of acute symptomatic infections involve young women Markedly increased incidence with the onset of sexual activity in adolescence First infections in young women tend to be uncomplicated
11. Urinary Tract Infections Infections in men are rare & implies pathological process Infections that recur after antibiotic therapy Persistence of the originally infecting strain Infection with a different pathogen Ascending infection - from the urethra, most common route
12. Susceptibility Factors Bladder has intrinsic defense mechanisms Flushing and dilutional effects of voiding Antibacterial properties of the urine (high urea concentration, low pH) and bladder mucosa (secrete cytokines and chemokines upon interaction with bacteria) Prostatic secretions – antibacterial properties Upper tract involvement more likely with vesicoureteral reflux, decreased renal blood flow, or intrinsic renal disease
13. Female Specific Susceptibility Factors Proximity to the anus Short urethra (~4cm) Sexual intercourse introduces bacteria into the bladder Voiding after intercourse reduces risk of cystitis Use of spermicidal compounds alters the normal flora and increases the risk of cystitis
14. Male Specific Susceptibility Factors Higher incidence seen in uncircumsizedmales Male prostate normally secretes zinc which reduces ascending infection Men with bacterial prostatitis have lower zinc levels Insertive rectal intercourse increases the risk of cystitis
15. Acute Cystitis Infection of the bladder Usually from an ascending source Causative organisms E. coli (causes ~80%) Other gram negative rods – Proteus, Klebsiella, Gram-positive bacteria – enterococci, Staph saprophyticus (young females)
16. Acute Cystitis Signs and symptoms Irritative voiding Suprapubic discomfort Urine may be grossly cloudy and malodorous Women Gross hematuria (30%) Symptoms often appear following sexual intercourse Examination is often unremarkable Systemic toxicity is absent **If there is a genital lesion or vaginal discharge present – consider STD
17. Acute Cystitis Lab findings U/A will show pyuria and bacteriuria; also may see hematuria Laboratory findings do not correlate with degree of symptoms Urine Culture growth of >105 bacteria/ml from a properly collected midstream “clean catch” urine signifies infection Imaging only needed in pyelonephritis, recurrent infections, suspected abnormalities of anatomy, males (need to figure out the underlying cause)
18. Differential Diagnosis Vulvovaginitis and PID in women Urethritis and prostatitis in men Noninfectious causes of these symptoms include pelvic irradiation, chemotherapy, carcinoma, interstitial cystitis, etc.
19. Treatment and Prognosis Acute, uncomplicated - treat with 3 days of antibiotics TMP-SMX (Septra), nitrofurantoin or fluoroquinolone Resistance has been increasing against TMP-SMX (if local resistance >20%, don’t use) Warm sitz baths and urinary analgesics (phenazopyridine) help with symptoms Infections typically respond within 48-72 hours
20. Treatment and Prognosis Complicated UTIs Catheterization, instrumentation, anatomic or functional abnormalities, stones, obstruction, diabetes Typically due to antibiotic-resistant strains Fluoroquinolone for 10-21 days Urine C&S Follow up cultures 2-4 weeks after completing therapy to demonstrate cure Women > 3 infections per year are candidates for prophylactic antibiotics
21. Pediatric UTI Imaging studies of children with their first documented UTI in boys >6 months, in girls <4 years Renal U/S to evaluate for gross structural defects, lesions that are obstructive, positional abnormalities, and renal size/growth
22. Pediatric UTI VCUG done when patient is asymptomatic and cleared of bacteriuria to evaluate for vesicoureteral reflux; indicated in boys >6 months, girls <4 years and those >5 years with recurrent or febrile Referral to a pediatric urologist if studies reveal obstructive lesion, high-grade vesicoureteral reflux changes on voiding cystourethrogram (VCUG)
23. UTI in Pregnancy UTIs are detected in 2-8% of pregnant women Increased predisposition to infection results from decreased ureteral tone, decreased ureteral peristalsis and temporary incompetence of the vesicoureteral valves
24. UTI in Pregnancy Urine culture should be used as the primary method of screening all pregnant patients in their 1st trimester Asymptomatic bacteriuria has been associated with multiple complications in pregnancy including low birth weight, preterm delivery, hypertension, preeclampsia, and maternal anemia
25. UTI in Pregnancy Diagnosis of asymptomatic bacteriuria (ASB) is based on a clean-catch voided urine culture with >100,000 (105) colonies/ml of a single organism Left untreated, pyelonephritis will develop in up to 30% of these patients with ASB Pyelonephritis is the most common non-obstetric cause of hospitalization during pregnancy
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27. Acute pyelonephritis – hospitalization and IV antibiotic therapy (cephalosporin or ampicillin)Follow up culture should be done after treatment and then monthly cultures until delivery
28. UTI in Pregnancy Recurrent pyelonephritis has been implicated as a cause of fetal death and intrauterine growth restriction (IUGR) Patients with recurrent UTI or pyelonephritis during pregnancy need radiographic evaluation of the upper urinary tract when they are 3 months post-partum
30. Acute Pyelonephritis General considerations Most common causes are gram negative bacteria (E-coli, Proteus, Lebsiella, etc.) Infection usually ascends from the lower urinary tract Symptoms generally develop rapidly over a few hours or a day Renal infections need prompt adequate treatment to reduce risk of loss of renal function & Sepsis
31. Acute Pyelonephritis Signs and symptoms Fever/shaking chills Flank pain/abdominal pain Dysuria, urgency, frequency May be associated N/V and/or diarrhea CVA tenderness
32. Acute Pyelonephritis Laboratory studies Urine may show leukocyte casts and/or hematuria Positive urine culture CBC leukocytosis with left shift Blood cultures may also be positive Differential diagnosis Appendicitis, cholecystitis or pancreatitis Acute prostatitis or acute epididymitis
33. Acute Pyelonephritis Treatment Hospitalization for severe infections or complicating factors IV ampicillin + gentamycin 24 hours after fever resolution, start oral antibiotics to complete a 14 day course Outpatient, fluoroquinolone for 7-14 days Usually responds to appropriate therapy within 48-72 hours If >72 hours and fever or symptoms persist, need urologic imaging (CT or U/S)
34. Acute Pyelonephritis Complications Sepsis with shock Renal scarring Chronic pyelonephritis Renal abscess Prognosis Usually good Complicating factors may have less favorable outcome
37. Epididymitis Two categories Sexually transmitted Usually men <35 years of age Associated with urethritis Most commonly C. trachomatis or N. gonorrheae Non-sexually transmitted Males >35 years of age Associated with UTI’s and prostatitis Gram negative rods (urinary pathogens)
38. Epididymitis Signs and symptoms May follow acute physical strain, trauma or sexual activity May be associated with urethritis or cystitis Fever Irritative voiding symptoms Painful enlargement of epididymis- leading to scrotal swelling and pain Prostate may be tender on palpation Prehn Sign – elevation of the scrotum above pubic symphysis improves pain. (helpful/not reliable)
39. Epididymitis Laboratory findings CBC - Leukocytosis with left shift UA - Pyuria/bacteriuria/hematuria C&S of urethral discharge will demonstrate the pathogen Optional Gram staining of urethral discharge smear Scrotal U/S if needed
40. Epididymitis Differential diagnosis Tumor Testicular torsion Treatment Bed rest with scrotal elevation Sexually transmitted form – ceftriaxone 250 mg IM x 1 dose + doxycycline 100 mg BID x 10 days Non-sexually transmitted form – ciprofloxacin 250 – 500 mg PO BID x 3 weeks (Bactrim DS BID as alternative)
41. Epididymitis Prognosis Good if treated promptly Delayed treatment may result in: Decreased fertility Abscess formation
43. Prostatitis Term applies to various inflammatory conditions affecting the prostate Routes of infection include ascent up the urethra and reflux of infected urine into the prostatic ducts Categories Acute bacterial Chronic bacterial Chronic pelvic pain syndrome (CPPS) – formerly nonbacterial prostatitis and prostatodynia
44. Acute Bacterial Prostatitis General considerations Usually affects young men Gram negative urinary pathogens -E. coli, Pseudomonas and Klebsiella Symptoms and signs Perineal, sacral, or suprapubic pain Fever (usually high) Irritative voiding symptoms Urinary retention possible Exquisitely tender prostate on exam Gentle rectal exam, vigorous manipulation can result in septicemia
45. Acute Bacterial Prostatitis Laboratory findings CBC - leukocytosis with left shift U/A - pyuria, bacteriuria and hematuria Positive urine culture Differential diagnosis Acute epididymitis Acute pyelonephritis Diverticulitis
46. Acute Bacterial Prostatitis Treatment Hospitalization may be required IV ampicillin & aminoglycosideuntil urine culture and sensitivities are available Once afebrile for 24-48 hours, switch to oral medication and complete 4-6 weeks of therapy For urinary retention, percutaneous suprapubic tube is required Follow up urine culture to ensure eradication
47. Chronic Bacterial Prostatitis General considerations May evolve from acute infection although many men have no history of acute infection Usually affects middle-aged men and often present with a pattern of relapsing infection Usually Gram negative rods or Enterococcus
48. Chronic Bacterial Prostatitis Symptoms and signs Symptoms are often lacking between episodes Varying degrees of irritative voiding symptoms Perineal or suprapubic discomfort, usually dull and poorly localized Prostate usually feels normal on exam
49. Chronic Bacterial Prostatitis Laboratory findings U/A normal Expressed prostatic secretions Demonstrate increased WBC’s with lipid laden macrophages Culture of prostatic secretions or post massage urine specimen required to make diagnosis Differential diagnosis Chronic urethritis Anal disease
50. Chronic Bacterial Prostatitis Treatment Trimethoprim-sulfamethoxazole (Septra) DS for 12 weeks Alternatives Oral fluoroquinolone for 12 weeks Symptomatic relief with NSAIDS and sitz baths Prognosis Difficult to cure Symptoms (due to UTI) controlled by suppressive antibiotic therapy
51. Chronic Pelvic Pain Syndrome (CPPS) AKA Nonbacterial Prostatitis and prostatodynia General considerations Most common of the prostatitis syndromes Cause is unknown No history of UTI Mimics symptoms of chronic bacterial prostatitis Expressed prostatic secretions have WBC’s but are culture negative Diagnosis of Exclusion
52. CPPS Categories Based on the presence or absence of prostatic inflammation Inflammatory Young, sexually active males Noninflammatory Symptoms and signs Irritative voiding symptoms Perineal or suprapubic discomfort, usually dull in nature Physical exam is normal
53. CPPS Laboratory findings Urine cultures are negative Inflammatory – prostatic secretions and post massage urine contain at least tenfold more leukocytes than midstream urine or when the expresssed prostatic secretion contains >1000 leukocytes/μL Noninflammatory – normal leukocyte count
54. CPPS Treatment Inflammatory Some patients benefit from a 4-6 week course of antibiotics Erythromycin, doxycycline, TMP-SMX or fluoroquinolone NSAIDS and sitz baths Noninflammatory Pelvic floor dysfunction – biofeedback Bladder neck and urethral spasms – α blocking agents (terazosin, doxazosin)
55. CPPS Differential diagnosis Chronic bacterial prostatitis Bladder cancer – r/o in older patients with urinary cytologic examination and cytoscopy Prognosis May recur No serious sequelae
