Page 1332 - TNFlipTest

U14 Urology
Infectious and Inflammatory Diseases Toronto Notes 2019
• decreasedresistancetoorganisms
■ DM, malignancy, immunosuppression, spermicide use, estrogen depletion, antimicrobial use
• otherfactors
■ trauma, anatomic abnormalities, female, sexual activity, menopause, fecal incontinence
Clinical Features
• storagesymptoms:frequency,urgency,dysuria
• voidingsymptoms:hesitancy,post-voiddribbling,dysuria
• other:suprapubicpain,hematuria,foul-smellingurine
• pyelonephritis–ifpresent:typicallypresentswithmoreseveresymptoms(e.g.fever/chills,CVA
tenderness, flank pain)
Indications for Investigations
• pyelonephritis
• persistenceofpyuria/symptomsfollowingadequateantibiotictherapy • severeinfectionwithanincreaseinCr
• recurrent/persistentinfections
• atypicalpathogens(ureasplittingorganisms)
• Hxofstructuralabnormalities/decreasedflow
Investigations
• U/A,urineC&S
■ UA: leukocytes ± nitrites ± hematuria
■ C&S: midstream, catheterized, or suprapubic aspirate
• ifhematuriapresent,retestpost-treatment,ifpersistentneedhematuriaworkup(seeMicroscopic Hematuria, U6)
• U/S,CTscanifrecurrentortreatment-resistantUTIs,suspectedanatomicabnormalities,history indicates complicated cystitis
Treatment
• seeTable8,U13,AntibioticTreatmentofUrologicalInfections
• iffebrile,consideradmissionwithIVtherapyandruleoutobstruction
Prevention of UTIs
• maintaingoodhydration(debatableevidencere:cranberryjuice)
• voidregularly(donotholdurineforprolongedperiodsoftime)
• wipefromfronttobacktoavoidcontaminationoftheurethrawithfecesfromtherectum • avoidfemininehygienespraysandscenteddouches
• emptybladderimmediatelybeforeandafterintercourse
Organisms
• typicalorganisms:SEEKPP(E.coli75-95%) • atypicalorganisms
■ tuberculosis (TB)
■ Chlamydia trachomatis
■ Mycoplasma (Ureaplasma urealyticum) ■ fungi (Candida)
Recurrent/Chronic Cystitis
Definition
• ≥3UTIs/yr
Etiology
• bacterialreinfection(80%)vs.bacterialpersistence(relapse) ■ bacterial reinfection
◆ recurrence of infection with either 1) a different organism, 2) the same organism if cultured >2 wk following therapy, or 3) with any organism with an intermittent sterile culture
■ bacterial persistence
◆ same organism cultured within 2 wk of sensitivity-based therapy
Investigations
• assesspredisposingfactors
• investigationsmayincludecystoscopy,U/S,CT
Treatment
• lifestylechanges(limitcaffeineintake,increasefluid/H2Ointake)
• ABx(variousstrategies):continuouslow-dosedailysuppressionvs.post-coitalonlyvsself-starttherapy • post-menopausalwomen:considertopicalorsystemicestrogentherapy
• notreatmentforasymptomaticbacteriuriaexceptinpregnantwomenorpatientsundergoingurinary
Prevention of UTIs
• Maintain good hydration (try cranberry juice)
• Wipe from front to back to avoid contamination of the urethra with feces from the rectum
• Avoid feminine hygiene sprays and scented douches
• Empty bladder immediately before and after intercourse
tract instrumentation