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Toronto Notes 2019 Infectious and Inflammatory Diseases Urology U15 Interstitial Cystitis
(Painful Bladder or Bladder Pain Syndrome)
Definition
• bladderpain,chronicurgencyandfrequencywithoutotherreasonablecausation
Classification
• non-ulcerative(morecommon)andulcerative
Etiology
• unknown
Epidemiology
• prevalence: 20/100,000
• 90%ofcasesareinfemales,94%areCaucasian
• medianageis40yr(non-ulcerativeseeninyoungertomiddle-aged,whileulcerativeseeninmiddle-
aged to older)
Clinical Features
• pelvicpain(typicallysupra-pubictenderness)
• storagesymptoms(frequency>urgency>nocturia)
• negativeU/A,urineC&S,urinecytology
• cystoscopy:glomerulations(submucosalpetechiae),Hunner’slesions
Differential Diagnosis
• Uro:non-infectiouscystitis(radiation,chemical,eosinophilic,TB),OAB,bladdercalculi,prostate- related pain
• Gyne:endometriosis,vulvardisorders
• Neuro:pudendalnerveentrapment
• MSK:pelvicfloordisorders
• Drugs:ketamineabuse
Investigations
• Hx,P/E,frequencyvolumechart
• symptomscorestoestablishbaselineandresponsetotreatment • U/A,urineC&S,urinecytology
• cystoscopy
Treatment
• firstline:patienteducation,dietarymodifications,bladderretraining,stressmanagement ■ pelvic floor physiotherapy can be added for patients with pelvic floor dysfunction
• secondline:guidedbysymptomphenotype
■ oral: amitriptyline, cimetidine, hydroxyzine, pentosan polysulfate (PPS), gabapentin, quercetin ■ intravesical: dimethylsulfoxide (DMSO), heparin, lidocaine, PPS, oxybutynin
• thirdline:hydrodistension,botulinumtoxinA,sacralneuromodulation
■ endoscopic treatment if Hunner’s lesions (cauterization, resection, triamcinolone injection)
• fourthline:radicalsurgery(substitutioncystoplastyorurinarydiversion±cystectomy)
Acute Pyelonephritis
Definition
• infectionoftherenalparenchymawithlocalandsystemicmanifestations • clinicaldiagnosisofflankpain,feverandelevatedWBC
Etiology
• ascending(usuallyGNbacilli)orhematogenousroute(usuallyGPcocci) • causativemicroorganisms
■ gram positives: Enterococcus faecalis, S. aureus, S. saphrophyticus
■ gram negatives: E. coli, Klebsiella, Proteus, Pseudomonas, Enterobacter • commonunderlyingcausesofpyelonephritis
■ stones, strictures, prostatic obstruction, vesicoureteric reflux, neurogenic bladder, catheters, DM, sickle-cell disease, PCKD, immunosuppression, post-renal transplant, instrumentation, pregnancy
Clinical Features
• rapidonset(<24h)
• LUTSincludingfrequency,urgency,hematuria;NOTdysuriaunlessconcurrentcystitis • fever, chills, nausea, vomiting, myalgia, malaise
• CVAtendernessand/orexquisiteflankpain
Cystoscopic evaluation is not necessary to make a diagnosis