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FM28 Family Medicine
Common Presenting Problems
Toronto Notes 2019
UTI Clinical Decision Aid
Arch Intern Med 2007;67:2201-2206 • Dysuria
• +Leukocytes
• +Nitrites
If 2 or more criteria MET, then treat without culture, otherwise culture required prior to
treatment
Risk Factors for Complicated UTI
• Male
• Pregnancy
• Recent urinary tract instrumentation
• Functional or anatomic abnormality of the
urinary tract
• Chronic renal disease
• DM
• Immunosuppression
• Indwelling catheter
Cranberries for Preventing Urinary Tract Infections
Cochrane DB Syst Rev 2008;1:CD001321 Study: Meta-analysis of 10 RCTs (n=1,049). Patients: All populations.
Intervention: Cranberry juice vs. placebo, juice or water was evaluated in seven studies, and cranberry tablets vs. placebo in four studies. Main Outcome: UTIs – symptomatic and asymptomatic.
Results: Cranberry products significantly reduced the incidence of UTIs at 12 mo (RR 0.65, 95% CI 0.46-0.90) compared with placebo/control. Conclusion: There is some evidence that cranberry products may decrease the number of symptomatic UTIs over a 12 mo period, particularly for women with recurrent UTIs.
Prevention of UTIs
• Maintain good hydration (especially with cranberry juice) (recommendation level I)
• Wipe urethra from front to back to avoid contamination of the urethra with feces from the rectum
• Avoid feminine hygiene sprays and scented douches
Investigations
• CXR, ECG
• PFTs,ABGacutelyifindicated
Management
• ABCs:sendtoEDifinsevererespiratorydistress • dependsoncause
Dysuria
• seeUrology,U11 Definition
• thesensationofpain,burning,ordiscomfortonurination
Epidemiology
• inadulthood,morecommoninwomenthanmen
• approximately25%ofwomenreportoneepisodeofacutedysuriaperyr • mostcommoninwomenage25-54andinthosewhoaresexuallyactive • inmen,dysuriabecomesmoreprevalentwithincreasingage
Etiology
• infectious
■ most common cause
■ presents as cystitis, urethritis, pyelonephritis, vaginitis, cervicitis, epididymo-orchitis, or prostatitis
• non-infectious
■ hormonal conditions (hypoestrogenism), obstruction (BPH, urethral strictures), allergic reactions,
radiation, drugs/chemicals, foreign bodies, trauma, neoplasm, kidney stones, inflammatory diseases, endometriosis, psychogenic
Table 14. Etiology, Signs and Symptoms of Common Causes of Dysuria
Infection
UTI/Cystitis
Urethritis Vaginitis Prostatitis Pyelonephritis
Etiology
KEEPS bacteria (Klebsiella, E. coli, Enterobacter, Proteus mirabilis, Pseudomonas, S. saprophyticus)
C. trachomatis, N. gonorrhoeae, Trichomonas, Candida, herpes
Candida, Gardnerella, Trichomonas, C. trachomatis, atrophic, herpes, lichen sclerosis
E. coli, C. trachomatis, S. saprophyticus, Proteus mirabilis, Enterobacter, Klebsiella, Pseudomonas
E. coli, S. saprophyticus, Proteus mirabilis, Enterobacter, Klebsiella, Pseudomonas
Signs and Symptoms
Internal dysuria throughout micturition, frequency, urgency, incontinence, hematuria, nocturia, back pain, suprapubic discomfort, low grade fever (rare)
Initial dysuria, urethral/vaginal discharge, history of STI
External dysuria/pain, vaginal discharge, irritation, dyspareunia, abnormal vaginal bleeding
Dysuria, fever, chills, urgency, frequency, tender prostate, rectal pain
Internal dysuria, fever, chills, flank pain radiating to groin, CVA tenderness, N/V
Investigations
• Empty bladder immediately before and after intercourse
• noinvestigationsnecessarywhenhistoryandphysicalconsistentwithuncomplicatedUTI–treat empirically (urinalysis can be performed when indicated by dipstick or microscopy)
• urinalysis/dipstick: positive for nitrites and leukocytes • urineR&M:pyuria,bacteriuria,hematuria
• urineC&S
• CBCanddifferentialifsuspectingpyelonephritis
• ifvaginal/urethraldischargepresent:wetmount,Gramstain,KOHtest,vaginalpH,cultureforyeast and trichomonas, endocervical/urethral swab or urine PCR for N. gonorrhoeae and C. trachomatis
• radiologicstudiesandotherdiagnostictestsifatypicalpresentation • see Pediatrics, P58 for UTI
Management
• UTI/cystitis
■ pregnant women with bacteriuria (2-7%) must be treated even if asymptomatic, due to increased
risk of pyelonephritis, preterm labour, low birth weight and perinatal mortality; need to follow with
monthly urine cultures and retreat if still infected
■ patients with recurrent UTIs (>3/yr) should be considered for prophylactic antibiotics ■ if complicated UTI, patients require longer courses of broader spectrum antibiotics
• urethritis
■ positive swab or PCR for chlamydia or gonorrhea must be reported to Public Health ■ all patients should return 4-7 d after completion of therapy for clinical evaluation