Debbie King FNP, PNP

1
Genitourinary

• Debbie King FNP, PNP
• 8800

2
Great article on urinalysis/physical
properties/results/false results/causes/diseases

• http//www.aafp.org/afp/2005/0315/p1153.html
• Urinalysis A Comprehensive ReviewJEFF A.
  SIMERVILLE, M.D., WILLIAM C. MAXTED, M.D., and
  JOHN J. PAHIRA, M.D., Georgetown University
  School of Medicine, Washington, D.C
• FYI-PRINT and use with power points, text and
  study guide for exam

3
Dysuria

• Is the subjective experience of pain or burning
  on urination
• Associated with a bladder problem and frequent
  voiding
• Common causes
• Inflammatory lesions
• Bladder/urethral infections
• Less common causes
• Tumors, renal failure, STDs

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Hematuria

• Defined as blood in the urine and can be gross or
  occult
• More than 3 RBC per high power field
• There is a direct relationship to quantity of
  blood and the probability of pathology

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Hematuria

• Two types
• Transient
• Occurs on one occasion
• Persistent
• Occurs on two or more consecutive occasions
• Both can be a sign of serious disease

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Hematuria

• Differentials
• Dietary substances
• Caffeine, spices, tomatoes, chocolate, alcohol
  citrus, soy sauce, some herbal meds
• Medications
• Beta-lactam antibiotics, sulfonamides, NSAIDS,
  Cipro, allopurinol, Tagamet, Dilantin
• Anticoagulation and papillary necrosis
• Warfarin, heparin, asa, NSAIDS
• Glomerulonephritis
• Hydrocarbons-(glue, paint), NSAIDS
• Urolithiasis
• Menses

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Hematuria

• Patho- depends on the cause
• Diagnostic test and findings
• UA blood
• Urine culture with ID and sensitivities
• Microscopic urine exam- more than 3 RBC per high
  power field
• If not more than 3- explore hemoglobinuria
• If more that 3 -test for cause
• ANA, immunoglobulins, CMP, CBC, ASO, Anti-DNASE
  B, VDRL, PT, PTT, ESR
• PPD
• Intravenous pyelogram(IPV) to assess structure
• CT
• Cystoscopy to evaluate the Upper tract

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Hematuria

• Causes grouped according to anatomic site of
  source and other findings
• Isolated with no other abnormal findings
• Anywhere in the renal pelvis to the urethra
• Along with cast in the urine
• Associated with kidney disease
• Along with bacteria in the urine
• Cystitis and urethritis
• Along with protein in the urine
• Nephritis
• Along with flank pain
• Kidney stone
• Along with HTN, sore throat
• Glomerulonephritis
• Gross hematuria is associated with malignancy

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Proteinuria

• Indicative of renal pathology, most often
  glomerular in origin
• Can be functional and appears as intermittent
• Illness, stress, exercise, or benign
• Can develop from overproduction of filterable
  plasma proteins, may be associated with multiple
  myeloma
• Continuous is associated with renal pathology
• Best test for this is a 24 hour urine
• More than 165 mg of protein is abnormal
• More than 3.5 grams is indicative of nephrotic
  disease

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Proteinuria

• Differentials
• Benign or functional causes
• Orthostatic proteinuria, exercise, environmental
  conditions, fever, illness, CHF, injury
• Bence Jones protein suggest multiple myeloma
• Nephrotic syndrome

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Proteinuria

• Patho- depends on the cause
• Diagnostic tests for nonfunctional proteinuria
• 24 hour urine
• Measure protein and creatinine
• If excretion rate is above 3.0- 3.5 g/day the
  patient has nephrotic syndrome
• Full chemistry panel- FBS
• Lipid profile
• UN/UC with ID and Sensitivity
• CBC with diff
• Test for Bence Jones is characterized as a free
  monoclonal light chain of protein, if this test
  is positive it suggests multiple myeloma
• Only used for low-risk patients- nondiabetic or
  nonpregnant
• If this test is positive do a serum protein
  electrophoresis

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Proteinuria

• Management is complicated!
• With positive nephrotic syndrome per 24 hour
  urine
• REFER
• With 2grams of protein in 24 hour urine
• Test renal function
• With normal renal function test urine on
  awakening before upright for one minute and after
  standing for 2 hours
• If first test is normal and second shows protein
  -refer
• With abnormal renal function refer for biopsy
• Maybe managed with and ACE- by nephrology and
  primary care
• With coexisting HTN and hyperlipidemia aggressive
  treatment is warranted for all conditions to
  prevent renal failure

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Urinary Incontinence

• Definition- is the involuntary loss of urine from
  the bladder.
• Is so common in women that many consider it
  normal
• Common in older men with enlarging prostate
• Can affect quality of life
• Patho- three major components are involved in
  urine storage and release the central nervous
  system, the bladder, and the bladder outlet
  (urethral sphincters)

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PATHO- SUMMARY

• Bladder smooth muscle (the detrusor) contracts
  via parasympathetic nerves from spinal cord
  levels S2 to S4. Urethral sphincter mechanisms
  include proximal urethral smooth muscle (which
  contracts with sympathetic stimulation from
  spinal levels T11 to L2), distal urethral
  striated muscle (which contracts via cholinergic
  somatic stimulation from cord levels S2 to S4),
  and musculofascial urethral supports. In women,
  these supports form a two-layered "hammock" that
  supports and compresses the urethra when
  abdominal pressure increases.

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PATHO- SUMMARY

• Micturition is coordinated by the central nervous
  system Parietal lobes and thalamus receive and
  coordinate detrusor afferent stimuli frontal
  lobes and basal ganglia provide signals to
  inhibit voiding and the pontine micturition
  center integrates these inputs into socially
  appropriate voiding with coordinated urethral
  relaxation and detrusor contraction until the
  bladder is empty. Urine storage is under
  sympathetic control (inhibiting detrusor
  contraction and increasing sphincter tone), and
  voiding is parasympathetic (detrusor contractor
  and relaxation of sphincter tone

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Urinary Incontinence

• Subjective Presentation
• History
• Medical (DM, CA, illness)
• Medications such as sedatives, hypnotics,
  diuretics, narcotics, alpha-blockers,
  antispasmodics, antihistamines, calcium channel
  blockers, decongestants, alcohol,
  anticholinergics
• Surgical
• Date of onset
• Number of voids day and night
• Fluid intake
• Types of fluid
• Characteristics of the incontinence
• Sneezing, nocturia, urgency or dysuria

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Urinary Incontinence

• Objective
• Physical exam
• ID underlying pathophysiologic causes
• Maybe more than one
• May need to Test for Infection, CHF, DM, DI
• Neuro assessment
• CVA, Parkinson's
• Cognitive ability and mobility
• Abdominal exam
• Rule out constipation (common cause)
• Masses
• Distended bladder

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Urinary Incontinence

• Physical continued
• Pelvic exam
• Check muscle strength
• Uterine prolapse
• Perineal structures
• Skin around this area
• Atrophic vaginitis
• Skin breakdowns-
• In men check for foreskin, penis or perineum
  abnormalities
• Rectal
• Check sphincter tone
• Prostate size in men

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Urinary Incontinence

• Heart and Lungs
• Assess for CHF
• Cough stress test- observe for leaking

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Urinary Incontinence

• Tests/Findings
• UI or pad test
• Patient takes Pyridium wears a pad and checks for
  staining at determined intervals
• UA/UC
• Serum electrolytes
• Blood urea nitrogen (BUN), creatinine, calcium,
  glucose
• Post void catheterization

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Urinary Incontinence

• Further testing depends on test results so far
  and if the onset is acute
• Urine shows no infection but is positive for
  sugar
• Urine shows infection may need further workup
• Urine shows increased RBCs work up for tumor or
  infection
• Other test that may be indicated
• Cystometry, cystometrogram, video-urodynamics,
  ultrasound

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Urinary Incontinence

• Differentials
• Four major types of incontinence
• Stress
• Urge
• Overflow
• Functional
• Other types
• Overactive bladder
• Compensated incontinence
• Elderly
• Transient
• Other major illness

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Urinary Incontinence

• Stress UI
• Involuntary loss of urine caused by increased
  pressure- coughing, laughing, sneezing ECT
  caused by hypermobility of the bladder neck,
  intrinsic sphincter deficiency, neurogenic
  sphincter deficiency, or medications.
• Typically have a history of vaginal deliveries
• Workup includes- history, pelvic exam, the pad
  test, cough stress test, ua, uc,
  video-urodynamics, and maybe a cystometrogram

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Urinary Incontinence

• Stress UI continued
• Management includes- pelvic floor exercises,
  weight loss, electrical stimulation, HRT,
  medications such as a alpha-adrenergic agonist,
  surgical correction, periurethral bulking
  injections
• Feel free to refer these patients who are not
  easily managed!

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Urinary Incontinence

• Urge UI- also known as detrusor instability with
  leakage of urine resulting form the inability to
  delay voiding. It is the failure to store urine
  due to urinary tract infection, vaginitis,
  bladder stones and tumors. May also be caused by
  brain lesions, CVA, dementia, MS, or medications

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Urinary Incontinence

• Urge UI continued
• Workup includes- exam of perineal hygiene, pelvic
  exam , vaginal discharge smear, neurologic exam,
  assessment of mental status, UA, UC, Maybe a
  cystometrogram and video-urodynamics
• Treatment begins conservatively- pelvic floor
  exercises, scheduled voiding, management of fluid
  intake, medications as needed such as antibiotics
  if infection is present. Other medications may
  be used such as topical estrogen,
  anticholinergics, smooth muscle relaxers,
  tricyclic antidepressants to improve the
  neuromuscular function. Surgical treatment as
  needed for stones or tumors.

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Urinary Incontinence

• Overactive Bladder
• Overactive Bladder or OAB- is a syndrome of
  symptoms that include urgency, frequency, and
  nocturia all of which are associated with
  involuntary contractions of the detrusor muscle.
  
• 1/3 have urge incontinence, such as stress
  incontinence
• This often mistaken for Urge UI

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Urinary Incontinence

• Overactive Bladder continued
• The cause is multifactorial- it can include
  disorders of the lower urinary tact, alcohol and
  caffeine use, may be associated with certain
  medications, or with neurologic conditions
• Is most common in women
• Often results in anxiety and depression due to
  restriction of daily living
• Sexual dysfunction can occur due to fear of urine
  leakage

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Urinary Incontinence

• OAB continued
• Work up the same as Urge UI
• Treatment begins with identifying women with the
  problem
• 6-27 seek treatment
• Nonpharmacologic methods as used for Urge UI are
  also tried here
• Medications such as antimuscarinic agents are the
  most commonly used as the block the
  parasympathetic stimulation of the detrusor
  muscle by blocking acetylcholine

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Urinary Incontinence

• Overflow incontinence is the involuntary leakage
  of small amounts of urine. It is caused by an
  over-distended bladder in a patient who does not
  feel the need to void due to an anotic detrusor
  muscle, outlet obstruction, BPH, or medications
• The history and PE may indicate hesitancy,
  dribbling, nocturia, decreased stream, feeling of
  not emptying the bladder, and/or constipation
• The PE should include a neurologic exam and
  prostate exam

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Urinary Incontinence

• Overflow UI continued
• Testing should include UA, UC, serum creatinine,
  biding cystometrogram and maybe a
  video-urodynamics
• Treatment consists of treating the underlying
  disease-may include scheduled toileting, creed's
  maneuver, medications such as alpha-blockers

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Urinary Incontinence

• Functional urinary Incontinence- is the
  incontinence that occurs in a normal functioning
  urinary system. The leakage is caused by factors
  outside the lower urinary tract and can be
  transient in nature
• Causes vary and include delirium, impaction,
  immobility problems, medications such as
  diuretics, decongestants, alcohol.

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Urinary Incontinence

• Functional UI continued
• History and PE should include assessment for
  fecal impaction, sleep pattern problems, mental
  status, hearing and vision, functional ability,
  fluid intake, accessibility, infection, and neuro
  deficits

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Urinary Incontinence

• Functional UI
• Treatment consists of removing barriers,
  education regarding a scheduled bowel and bladder
  program, PT, OT, habit training. Patient may
  need caregiver assistance. Patients may need
  catheters. Medications should be used in
  conjunction with other treatments such as Kegel
  exercises, vaginal rings, surgical interventions
  for prolapsed uterus, obstructions, enlarged
  prostate, or tumors may be indicated

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Interstitial Cystitis

• Be careful using this diagnosis
• Insurance does not like it and may cause
  difficult with ins changes ECT..
• Definition chronic bladder inflammation syndrome
  characterized by pelvic pain and irritative
  voiding symptoms
• Unknown patho, related to autoimmune, allergic,
  infection etiologies
• Is a diagnosis of exclusion

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Interstitial Cystitis

• Occurs mostly in women
• 10 are men
• Onset between 30-70 years of age
• Does occur in children and is under diagnosed

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Interstitial Cystitis

• Symptoms
• Pain, relived by voiding small amounts
• Uncomfortable constant urge to void
• May worsen the week before menstruation
• Differential Diagnosis
• UTI, prostatitis, cystitis
• GYN conditions such as vaginitis and
  endometriosis
• Neuropathic bladder dysfunction
• Neoplasm
• Overactive bladder

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Interstitial Cystitis

• Diagnostic Test
• UA, UC, and maybe a potassium sensitivity test-
  slow instillation of 40ml of sterile water into
  the bladder, the patient grades the pain 0-5.
  This is the baseline, then empty bladder and
  repeat with potassium chloride solution. IC is
  suggested when there is a 2 point increase in
  pain or urgency
• Cystoscopy and hydro distention under anesthesia
  confirms diagnosis

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Interstitial Cystitis

• Plan
• Education
• IC is not a malignancy, has an organic basis, no
  specific cure, is chronic, will treat symptoms,
  avoid acidic food, caffeine, alcohol artificial
  sweeteners, chocolate, cigarette smoking, drink
  plenty of water, bladder retraining may help

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Interstitial Cystitis

• Medication treatments
• Tricyclic antidepressants
• Antihistamines
• Nonsteroidal
• Pyridium, Ditropan, Procardia may help ??
• May require long acting opioids
• Refer- for further treatments

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Vulvovaginitis

• Definition inflammation and infection of the
  vulva/vagina
• Etiology/Incidence
• Commonly caused by trichomonas vaginalis,
  bacterial vaginosis, or candida albicans

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Vulvovaginitis

• Trichomonas-transmitted through intercourse
• Bacterial vaginosis- most frequently diagnosed
  symptomatic vaginitis, may not be STD, is
  associated with premature rupture of membranes..
• Candida vaginitis-occurs in close to 40-75 of
  women, not considered an STD, predisposed by
  pregnancy, diabetes, antibiotic, corticosteroids
  , heat, moisture, occlusive clothing

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Vulvovaginitis

• Signs and Symptoms
• Bacterial vaginosis
• Trichomoniasis
• Malodorous yellow-green discharge with pruritus
• Dyspareunia
• Dysuria, partner may also have this symptom
• Malodorous, white (fishy) discharge
• Spotting
• 50 are asymptomatic
• Candida vaginitis
• Thick discharge with pruritus
• Erythema of vagina and vulva

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Vulvovaginitis

• Differential diagnosis
• Chlamydia
• Gonorrhea
• Herpes
• Condylomata acuminata
• Allergy, contact dermatitis
• Atrophic vaginitis

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Vulvovaginitis

• Physical findings
• Trichomoniasis
• Diffuse erythema, inflamed lesions on cervix-
  strawberry patches (also on vaginal wall)
• Discharge- white /watery to thick and frothy
• Vaginal pH- higher that 4.5

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Vulvovaginitis

• Physical findings
• Bacterial vaginosis
• Watery, grayish or white homogenous discharge,
  fish odor
• Discharge slightly adherent to vaginal walls
• Candida vaginitis
• White , cottage-cheese- discharge
• Marked vulvovaginal erythema/edema with intense
  pruritus

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Vulvovaginitis

• Tests/Findings
• Wet prep microscopic exam of vaginal secretions
• Trich-mixed with saline will show motile
  protozoan
• BV- mixed with saline will show clue cells, and
  amine-like odor when mixed with 10-20 potassium
  hydroxide (KOH) whiff test
• Candida vaginitis mixed with 10 KOH will show
  pseudohyphae

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Vulvovaginitis

• Further Testing
• Test for concomitant infection from other STD
• HIV, Syphilis, Warts, Gonorrhea, Chlamydia
• Treatments
• Trich- Metronidazole 2 gram orally or 500 mg bid
  for 7 days. Treat partner
• BV- Clindamycin cream 2 intravaginally times 7
  nights or Metronidazole 500 bid x 7 day
• Candida many different ways to treat, exp.
  Miconazole, or PO Diflucan

49
Vulvovaginitis

• Education
• Discuss treatment plans
• Avoid intercourse until cured
• Education on prevention, transmission
• Emphasize importance of BV treatment for pregnant
  women
• Education regarding dangers of douching and
  incidence of infection
• Education regarding PID, association with BV

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FYI

• All other female problems
• STDs common in teens will be covered in peds
• STDs, PID, dysmenorrhea, amenorrhea, PMS, ECT
  will be covered in the fall in repoductive health.

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Urinary Tract Infection

• Definition Inflammation and infection of the
  urinary bladder urethra may be involved
• Etiology/Incidence
• Most common causative organisms
• E coli- women
• Proteus species- men

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Urinary Tract Infection

• Etiology/Incidence- continued
• More common in women, urological evaluation
  required for men with UTI
• 30-40 of women will experience at least one UTI
• Patho-lower UTIs usually occur as a result of
  contamination from the patients own GI tract.
• Patho-Causes include poor hygiene, shortened
  urethra, intercourse, compromised patients,
  catheters, DM with elevated pH, renal stones,
  vesicoureteral reflux

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Urinary Tract Infection

• Contributing factors in women
• Sexual intercourse
• Pregnancy
• Diabetes
• Catheterization
• Instrumentation
• Retaining urine in bladder despite urge to go
• Constipation
• Diaphragm use
• Meatal stenosis
• Bowel incontinence

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Urinary Tract InfectionFYI

• Oral antibiotic treatment cures 85 of
  uncomplicated urinary tract infections, although
  the rate of recurrence remains high. There is
  some debate over whether to treat young sexually
  active women with high bacterial counts but no
  symptoms (asymptomatic bacteriuria). Given
  growing bacterial resistance to antibiotics and
  the benign nature of this condition, many experts
  do not recommend routine treatment

55
Urinary Tract Infection

• Specific Antibiotics Used. The antibiotics used
  most often for uncomplicated UTIs are either
  trimethoprim-sulfamethoxazole (TMP-SMX) or an
  antibiotic known as a fluoroquinolone. Pregnant
  women should not take fluoroquinolones. For
  uncomplicated UTIs, better options during
  pregnancy may be sulfisoxazole or a
  cephalosporin. See Box Specific Antibiotics Used
  for Most UTIs.

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Urinary Tract InfectionFYI

• Duration of Treatment. Studies are now reporting
  that uncomplicated female UTIs can often be
  successfully diagnosed over the phone. In such
  cases, a health professional provides the patient
  with a three-day antibiotic regimen without even
  requiring a urine test. A single oral dose of
  antibiotics, usually TMP-SMX (Bactrim, Cotrim,
  Septra) or a fluoroquinolone, is sometimes
  prescribed in mild cases, but cure rates are
  generally lower than with the three-day regimens.
  (Longer-term therapy, given for seven to 10 days,
  is now mostly limited to men, children, the
  elderly, people with diabetes with any UTI, and
  women with pyelonephritis or who are pregnant.)
  After a week of antibiotic treatment, most
  patients are free of infection. If the symptoms
  do not clear up within the first few days of
  therapy, physicians generally suggest that women
  submit a urine sample for culturing in order to
  identify the specific organism causing the
  condition.

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Urinary Tract Infection

• Treatment for Relapsing Infection
• A relapsing infection (caused by the same
  organism as the first episode) occurs within
  three weeks in about 10 of women. Relapse is
  treated similarly to a first infection but the
  antibiotics are continued for at least two weeks.
  (Relapsing infections may be due to structural
  abnormalities, abscesses, or other problems that
  may require surgery, and such conditions should
  be ruled out.)

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Urinary Tract Infection

• Bacterial Resistance to Antibiotics
• Of major concern for physicians and the public is
  the emergence of strains of common bacteria,
  including E. coli, that are resistant to specific
  antibiotics. The prevalence of such bacteria has
  dramatically increased worldwide, in large part
  due to widespread use of antibiotics in people
  and animal feeds.

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Urinary Tract Infection

• Preventive Antibiotics (Prophylaxis).
  Prophylaxis (preventive antibiotics) is an
  option for women who experience two or more
  symptomatic UTIs within six months or three or
  more over the course of a year. A woman's own
  perception of discomfort should guide her
  decisions on whether to use preventive
  antibiotics or not. The increasing use of
  antibiotics for many common infections is causing
  concern because of emerging strains of common
  bacteria that have become resistant to standard
  antibiotics.

60
Urinary Tract Infection

• Antibiotics for Urethritis in Men
• Urethritis in men has typically been treated with
  a seven-day regimen of doxycycline. Some research
  is showing that a single dose of azithromycin may
  be just as effective while causing fewer side
  effects. One-dose treatment also improves
  compliance, so cure rates may even be better than
  with a long-term regimen. Of concern, however, is
  an infection that spreads to the prostate gland,
  which is harder to treat, so most physicians
  still prefer the longer regimen. It should be
  noted that azithromycin and similar antibiotics
  do not cure the infection and may mask the
  symptoms of an accompanying sexually transmitted
  disease, such as gonorrhea. Tests for such
  diseases should be conducted if urethritis is
  diagnosed
• -SO, men always need to be cultured and treated
  for all STDs on the day of service as well as
  for urethritis.

61
Urinary Tract Infectionback to the basics

• Contributing factors in men
• Residual urine (prostatic enlargement)
• Naturopathic bladder
• Calculi
• Prostatitis
• Catheterization
• Instrumentation
• Meatal stenosis

62
Urinary Tract Infection

• Signs and Symptoms
• Dysuria, frequency, urgency
• Suprapubic discomfort
• Foul smelling urine

63
Urinary Tract Infection

• Differential Diagnosis
• Vaginitis- females
• Prostatitis-males
• Gonorrhea
• Chlamydia infection
• Renal calculi
• Pyelonephritis
• Epididymitis

64
Urinary Tract Infection

• Physical Findings
• Urinary meatus may be erythematous/edematous
• Negative costovertebral angle tenderness
• Negative pelvic or prostate examination
• May have suprapubic tenderness on palpation

65
Urinary Tract Infection

• Diagnostic tests/findings
• Pyuria--- 10 WBC/HPF
• Complete urinalysis (clean catch) with culture
  and sensitivity testing
• Bacteria count over 100,000 organisms per ml in
  fresh clean catch midstream specimen is
  reliable indicator of active urinary tract
  infection women with acute cystitis may have
  more than 10 to the 3rd but less that 10 to the
  5th per mL in mid stream urine cultures

66
Urinary Tract Infection

• Urinalysis- continued
• Dipstick results
• Leukocyte esterase dipstick test-positive means
  there are WBCs in the urine
• False positive from
• Kidney stones, tumors, urethritis, contamination
• Nitrite positive testgram negative infections
• False negative from diuretics, inadequate dietary
  nitrate, or gram positive bacteria
• Urine dipstick positive for protein, blood,
  nitrites suggestive of UTI

67
Urinary Tract Infection

• Other tests may be required for very ill patient
  or any male with true UTI
• CBC with diff, BC, ESR STD screen for all
  males and for females when indicated
• Male with UTI- VCUG or IVP, renal ultrasound

68
Treatments for UTI

• Management/Treatment/Uncomplicated/ female
• Single dose regimens-Septra DS-2 tabs,
  Amoxicillin 500mg-6 tabs
• Three day regimens Septra DS 1 tab bid for 3
  days is standard of care for women
• Fluoroquinolones-
• used in area with high resistant rates to sulfa
  drugs
• Used when a sulfa has been used in the last 6
  months
• Used for women who were recently in the hospital
• Nitrofurantoin and Monurol
• Useful if resistance to others increases

69
Treatments for UTI

• Treatment Complicated/Female
• Based on Culture Results
• Gram negative organism
• Septra DS- 10-14 days
• Fluoroquinolone- 14 days
• Gram positive organism
• Amoxil 875 bid for 10-14 days
• Augmentin 875 bid for 10-14 days
• Is best to culture urine before and after
  treatments

70
Treatments for UTI

• Recurrent/Female
• Culture before and after treatment
• Consider treating longer- up to 8 weeks
• Tests BUN/ Creatinine, IVP or VCUG, LYTES,
• Explore causes- diaphragm, voiding timely
• Advise to increase H2O and decrease carbonated
  drinks
• Refer to specialist!

71
Treatments for UTI

• UTIs related to intercourse
• May prescribe
• Septra DS 2 tabs after coitus
• Macrodantin 200 mg tab after coitus

72
Acute Pyelonephritis

• Definition an acute bacterial infection of the
  upper urinary tract (kidney and renal pelvis)
  usually result of ascending infection
• Etiology/incidence
• E. coli (gram negative) 80
• Staphylococcus saprophyticus and Streptococcus
  faecalis (gram positive)-5-10
• Majority are young women/ rare in men under 50
• Most common patients- pregnant, disruptive
  urinary flow, neurogenic bladder, or
  vesicoureteral reflux

73
Acute Pyelonephritis

• Patho
• Acute pyelonephritis results from bacterial
  invasion of the renal parenchyma. In all age
  groups, episodes of bacteriuria occur commonly,
  but most are asymptomatic (ABU) and do not lead
  to infection. Infection is influenced by
  bacterial factors and host factors.2
• Most bacterial data are derived from research
  with Escherichia coli, which accounts for 70-90
  of uncomplicated UTIs and 21-54 of complicated
  UTIs

74
Acute Pyelonephritis

• Signs and Symptoms
• Shaking chills
• Malaise, generalized muscle tenderness
• Nausea, vomiting, and diarrhea
• Flank pain- can be either bilateral or unilateral
• Abdominal
• Dysuria, frequency or urgency- may or may not be
  present

75
Acute Pyelonephritis

• Differential Diagnosis
• Cystitis
• Prostatitis
• Musculoskeletal back pain
• Appendicitis
• Diverticulitis
• Pelvic inflammatory disease
• Ectopic pregnancy

76
Acute Pyelonephritis

• Physical findings
• Fever, tachycardia
• CVA tenderness
• Peritoneal signs-usually absent
• Ill appearing

77
Acute Pyelonephritis

• Diagnostic Tests/Findings
• Microscopic urinalysis
• 5-10 WBC/HPF
• Occasional erythrocytes
• White cell casts-!!
• Mild proteinuria
• Urine culture
• 100,000 bacteria per ml of urine, ID and
  sensitivity testing must be done

78
Acute Pyelonephritis

• Tests/findings- cont
• CBC will see left shift
• Increase in ESR
• BUN and creatinine are usually normal
• Electrolytes- may be abnormal, esp. if dehydrated

79
Acute Pyelonephritis

• Management/treatment
• MD- specialist consult
• Inpatient treatment
• If pregnant, have underlying illness, have
  underlying illness, have decreased renal reserve,
  very toxic, unable to tolerate PO therapy, most
  all men
• Out patient treatment
• Antibiotics- based on culture and WBC results (I
  give Rocephin pending results, but have a BC
  pending first)
• Follow up in office in 24 hours- resting until
  recheck
• Repeat UC in two weeks
• Instruct no intercourse
• Educate for emergency signs and symptoms
• Second episode is referral for sure

80
Acute Pyelonephritis

• Females-diagnostics and management
• Males the same as females- plus
• Consult with a specialist
• Suggests a structural problem
• Indication for hospitalization
• IV meds- only(almost always)
• IVP, US- workup

81
Acute Pyelonephritis

• Follow up
• Based on situation, severity of illness, number
  of past episodes, results of workup- esp. men
• After first two outpatient visits if stable may
  switch to PO meds and follow up in 2 weeks and
  repeat uc
• Recheck uc again in 3 months

82
Acute Bacterial Prostatitis

• Definition inflammation/infection of the
  prostate gland
• Etiology/Incidence
• E. coli or other gram-negative bacteria-common
• Occasionally acute urinary retention
  develops-requires suprapubic drainage ,NO CATHS
• Absence of zinc in prostatic fluid can predispose
• Young men more prone to nonbacterial
• WBC are present in expressed prostatic
  secretions, but no organisms culture out
• Causative agents include mycoplasma, gonorrhea,
  and chlamydia

83
Acute and Chronic Bacterial Prostatitis

• Patho
• Mechanisms
• Ascending infection from infected urethra
• Direct or lymphatic spread from rectum
• Hematogenous spread
• Organisms
• Aerobic Gram Negative Rods (Enterobacteriaceae)
• Escherichia coli (80)
• Klebsiella
• Gram Positive Bacteria
• Streptococcus faecalis
• Staphylococcus aureus
• Pseudomonas (hospitalized patients)

84
Acute Bacterial Prostatitis

• Physical findings
• Fever
• Bladder distention may be present
• Prostate- edematous, firm or boggy, warm and
  tender
• Avoid vigorous massage, it may lead to bacteremia

85
Chronic Bacterial Prostatitis

• Uncommon type
• Men 50-80
• Symptoms are slow in onset-varying degrees of
  bladder obstruction-dribbling, hesitancy, loss of
  stream force
• Hematuria, hematospermia, or painful ejaculation
• Hallmark feature is recurrent UTI, asymptomatic
  between episodes

86
Chronic Nonbacterial prostatitis/Chronic Pelvic
Pain Syndrome (CPPS)

• Most common type
• Men 30-50
• Symptoms are indistinguishable from bacterial
  Type II
• In men with Type IIIB pelvic pain is the
  predominant complaint

87
Asymptomatic inflammatory prostatitis

• Diagnosed incidentally with eval of other
  disorders
• Limited research on natural history, clinical
  presentation
• FYI all types can have dangerous sequelae and
  lead to urinary retention, renal parenchymal
  infection, or bacteremia, chronic infection and
  may produce prostatic stones

88
Prostatitis

• Classifications
• Type I- acute infection
• Type II- chronic or recurrent
• Type III- chronic genitourinary pain in absence
  of infection and uropathogenic bacteria in gland
• Type IIIA- inflammatory- WBCs in semen, expressed
  secretions, or post prostate massage urine
• Type IIIB-noninflammatory- No WBCs in any
  secretions
• Type IV- asymptomatic inflammatory- No subjective
  symptoms- diagnosis by biopsy, or WBCs in
  secretions

89
Classifications- update

• While the original 1995 classification system was
  not officially revised, consensus participants
  felt that there was little evidence to show that
  chronic bacterial and nonbacterial (category II
  and category III) patients responded differently
  to antibiotic treatment. Therefore, the guideline
  advocating clinical use of localization studies
  to differentiate category II and III prostatitis
  was downgraded from "mandatory" to "recommended."
  The panel members also concluded that classifying
  CP/ CPPS into inflammatory and noninflammatory
  (category IIIA and IIIB) based on leukocyte
  counts "appears to offer little clinically useful
  information." Thus, the labor-intensive 4-glass
  localization test was downgraded to "optional."
  The more convenient "2-glass test," in which the
  postprostatic massage fluid is cultured and
  compared with pre-massage urethral cultures, was
  suggested as a replacement by some members of the
  panel. Any pathogens present in the massage
  fluids and absent in the urethral swab are
  considered to localize to the prostate and
  deserve antimicrobial treatment.

90
Prostatitis

• Signs and symptoms
• Men 40-60 years
• May have painful intercourse
• Fever/chills, malaise, myalgias
• Low back pain
• Dysuria, urgency, nocturia, frequency
• Perineal pain increased with defecation
• Abscess is a possible complication, consider if
  patient is not responding to treatment

91
Prostatitis

• Differential Diagnosis
• Acute/chronic bacterial cystitis
• Chronic prostatitis
• Nonbacterial prostatitis
• Prostatic seminal vesicle abscesses
• BPH
• Prostatic cancer
• Epididymitis
• Acute diverticulitis
• Nongonococcal urethritis

92
Prostatitis

• Diagnostic Tests/findings
• Urine culture-is positive
• Prostatic secretions-expressed prostatic
  secretions-WBC greater than 20 cells/HPF is
  abnormal
• Diagnosis is best make by performing simultaneous
  quantitative bacterial cultures
• Of urethral urine, bladder urine, and expressed
  secretions- the glass test
• Patient often treated based only on physical exam
  and urine culture

93
Prostatitis

• Management/treatment
• Acute bacterial
• Treat with Septra 4-6 weeks
• Normal sexual activity is OK
• With severe symptoms- hospitalization with IV
  antibiotics, aggressive with abscess
• Chronic bacterial
• 3-4 month Bactrim DS bid
• Consider prophylactics
• Evaluate PRN for stones with x-ray
• Cultures every 4-6 weeks
• Prostatic massage once or twice a week for 4
  weeks may be helpful

94
Prostatitis

• Chronic nonbacterial-
• No effective treatments available
• Can try meds such as doxycycline, erythromycin or
  Bactrim
• Reassure
• Counseling
• Nonsteroidal
• Ditropan
• Alpha-adrenergic blocking drugs

95
Prostatitis

• Asymptomatic inflammatory prostatitis
• Limited research to guide treatments
• With elevated PSA may try antibiotics
• Education
• Avoid alcohol, coffee, or tea
• Discontinue and avoid OTC drugs with
  anticholinergic properties such cold meds
• Recheck is four to six weeks

96
Epididymitis

• Definition Inflammation of the epididymis, with
  an acute intrascrotal infection
• Patho
• Epididymitis is usually caused by the spread of a
  bacterial infection from the urethra or the
  bladder. The most common infections that cause
  this condition in young heterosexual men are
  gonorrhea and chlamydia. In children, homosexual
  men and older men, E. coli is much more common.
  
• Mycobacterium tuberculosis (TB) and Ureaplasma
  can occur as epididymitis
• Another cause of epididymitis is the use of
  amiodarone, which prevents abnormal heart
  rhythms.

97
Epididymitis

• Etiology/Incidence
• Caused by infection from the bladder, the
  prostate, or ascending urethral infection
• Common affliction of men 35 and younger
  chlamydia usual cause, gonorrhea far less common,
  E coli in some situations
• May be caused by cath or surgery
• Sterile may be caused by vigorous activity,
  caused by vasal reflux of sterile urine which
  leads to chemical inflammation of the epididymis
• In boys may indicate underlying congenital
  anatomic abnormalities
• Is usually unilateral
• May be complicated by development of testicular
  necrosis, atrophy or infertility

98
Epididymitis

• Signs and Symptoms
• Painful, scrotal swelling- pain may radiate up
  into lower abdomen
• Sensation of scrotal heaviness
• Symptoms of prostatitis or UTI may be present
• Systemic symptoms may develop-fever/chills
• Nausea/vomiting rare
• May have hydrocele and palpable swelling

99
Epididymitis

• Differential Diagnosis
• Mumps
• Testicular torsion
• Testicular abscess
• Tumor of testicle with or with out hemorrhage
• Hydrocele
• Trauma
• Infarction

100
Epididymitis

• Diagnostic Tests/Findings
• Men
• STD testing
• Urinalysis
• Culture of urine
• Scrotal ultrasonography
• CBC- may show increased WBC and left shift
• Older man
• Search for obstruction at the bladder outlet, IVP

101
Epididymitis in Boys

• Requires more extensive work up
• Refer for consult
• IVP, VCUG, Scrotal US,
• Surgical exploration may be required

102
Epididymitis

• Physical exam
• Inspect for edema and erythema
• Palpate scrotum
• Will appear normal, with palpable swelling if
  epididymis is usually present
• Passive elevation of testis may relieve pain-
  Prehns sign
• Rectal exam, may elicit prostatic tenderness and
  lead to urethral discharge

103
Epididymitis

• Treatment
• Referral or consult if
• Patient is a child
• Systemic symptoms of infection- should be
  hospitalized
• Possible torsion of testes

104
Epididymitis

• Treatment cont
• Men less than 35 year, with probable STD
• Ceftriaxone 250mg IM plus doxycycline
• Men less than 35 years, with enteric organisms or
  allergic to tetracyclines and or cephalosporins
• Ofloxacin 200-400mg bid for 10 days (17years and
  older)
• Or Levofloxacin 500 QD times 10 days
• Septra DS Bid x 2-3 weeks
• Treat sexual partners- PRN
• Instruct to avoid intercourse until all
  treatments completed

105
Epididymitis

• Men over 35 years, men allergic to cephalosporins
  and/or tetracyclines, and for cases most likely
  caused by enteric organisms
• Ofloxin 300 bid for 10 days
• Levaquin 500 bid for 10 days
• Septra DS bid x 2-3 weeks
• All cases- treatment
• Bed rest, scrotal elevation, analgesic, ice,
  heat, sitz baths
• Follow up
• Recheck in three days, reevaluate
• For older men reculture after treatment

106
Testicular torsion

• Definition twisting of spermatic cord which
  results in compromised blood flow
• Patho occurs when free floating testis rotates
  on the spermatic cord and occludes its blood
  supply, may occur in sleep or after activity or
  trauma (masturbation)

107
Testicular Torsion

• Seen in boys 6-12 and teens and in men over 21
• If not surgically treated there will be ischemic
  injury and necrosis of the testis
• May also have lower abdominal pain with leads to
  misdiagnosis
• Nausea and vomiting in about half the patients
• Remember vomiting with out fever or diarrhea is
  not a stomach bug!!
• MUST INTERVENE IN 4-8 HOURS

108
Benign Prostatic Hyperplasia

• Definition progressive, benign hyperplasia of
  prostate gland tissue
• Etiology/Incidence
• Cause is uncertain
• About 50 of men have BPH by age 60
• By age 85 is 90
• Most common cause of bladder outlet obstruction
  in men over 50
• Symptoms are attributed to mechanical obstruction
  of the urethra by the enlarged prostate gland

109
Benign Prostatic Hyperplasia

• Patho
• The prostate is a conduit between the bladder and
  the urethra. The gland is composed of several
  zones or lobes that are enclosed by an outer
  layer of tissue (capsule). These include the
  peripheral, central, anterior fibromuscular
  stroma, and transition zones. BPH originates in
  the transition zone, which surrounds the urethra.
  Microscopically, BPH is characterized as a
  hyperplastic process. The hyperplasia results in
  enlargement of the prostate that may restrict the
  flow of urine from the bladder

110
Benign Prostatic Hyperplasia

• Signs and symptoms
• Gradual worsening of the following
• Frequency, urgency, urge incontinence
• Nocturia, dysuria
• Weak urinary stream, dribbling, hesitancy
• Sensation of full bladder even after voiding
• Retention

111
Benign Prostatic Hyperplasia

• Differential Diagnosis
• Urethral stricture
• Prostate or bladder cancer
• Neurogenic bladder
• Bladder calculus
• Acute or chronic prostatitis
• Bladder neck contractor
• Medications that affect micturition

112
Benign Prostatic Hyperplasia

• Physical findings
• Abdomen- may have distended bladder secondary to
  retention
• Prostate- nontender with asymmetrical or
  symmetrical enlargement, gross enlargement
  atypical
• Consistency is smooth and rubbery (eraser)
• Nodules may be present- differentiation from BHP
  and CA needs biopsy

113
Benign Prostatic Hyperplasia

• Tests/ Findings
• UA- NO hematuria or UTI
• Urinary flow rate- voided volume and peak urinary
  flow rate (Uroflowmetry) may show detect
  obstruction of flow
• Abdominal US- rules out upper tract pathology
• PSA levels should be normal
• Consider postvoid residual urine volume
• Creatinine to assess renal function, elevated
  levels suggest urinary retention or underlying
  renal disease- refer this patient

114
Benign Prostatic Hyperplasia

• Treatment/ Management
• Refer men who have the following
• Refractory urinary retention who have failed one
  attempt at cath removal
• Recurrent infection, recurrent retention,
  refractory hematuria, bladder stone, large
  bladder diverticulars, or renal insufficiency
  related to BPH
• Consider referral if complications exist or if
  patients have severe symptoms

115
Benign Prostatic Hyperplasia

• Management
• For men who have no indications for surgery
• Discuss risks and benefits of all options
• Watchful waiting (observation)
• Behavioral techniques to reduce symptoms
• Limit fluid after dinner
• Avoid medications such as. Antidepressant,
  antiparkinson agents, antipsychotic,
  antispasmodics, cold meds, and diuretics

116
Benign Prostatic Hyperplasia

• Medication treatments
• Alpha adrenergic blocker- for smaller prostates
• 5alpha adrenergic blocker for larger prostates
• Combo therapy is an a-adrenergic blocker and
  finasteride is used now for men with large
  prostates
• Surgery has the best chance for relief of
  symptoms, but has the greatest risks

117
Benign Prostatic Hyperplasia

• Follow up
• Teach signs of retention and obstruction
• If observing for now, recheck every 6-12 months
• If on meds recheck in 4-6 weeks
• If post surgery- follow up is at the discretion
  of the urologist

118
Nephrolithiasis

• Definition- condition in which renal calculi
  originate in the kidney. These stones cause
  acute episodes of urinary tract obstruction,
  infection, and abdominal pain
• Etiology
• Peak ages between 20-30 years old with a range of
  20-60 years
• Is seen in children, but is rare
• Affects about 2-5 of people sometime in lifetime
• Stones of calcium oxalate occur more in men
• Also associated with diets high in animal fat,
  animal protein
• Stones of struvite occur more in women
• Associated with UTIs, occur when the pH is high
  and urea splitting organism like proteus or
  klebsiella are present

119
Nephrolithiasis

• Risk factors
• Diets high in salt, animal fat, animal protein,
  and oxalate from green leafy vegetable
• Low calcium diet can lead to increased oxaluria
• Vasectomy
• Hypertension doubles the risk
• Loop diuretics promote calciuria
• IBS
• Hereditary
• Sedentary lifestyle
• Exposers to high environmental temperatures
• Infection
• Dehydration and urine concentration
• Increased intake of calcium or Vitamin D
• Vitamin A deficiency

120
Nephrolithiasis

• Patho
• Renal stone formation occurs when normally
  soluble mineral substances supersaturate the
  urine and deposit out of solution as crystals,
  which serve as nuclei for stone forming substance
  such as calcium oxalate, calcium phosphate,
  triple phosphate struvite, uric acid or cystine.
• There are four major types of stones (see Table
  11.7 in text)
• Calcium-Oxalate  75-80 These are the most
  common kidney stones.  They can be caused by
  eating too much calcium or vitamin D, some
  medicines, genetics and other kidney problems. 
  Talk to your doctor about ways to stop these
  stones from forming.  Do NOT limit calcium unless
  your doctor tells you to.
• Struvite  15 These stones affect women more
  than men.  They can grow very large and may harm
  the kidneys more than other stones.  Having
  kidney infections often may cause struvite
  stones.
• Uric Acid  7 These stones may be caused by
  eating too much animal protein or by genetics. 
  To prevent uric acid stones from forming, try
  eating less red meat.
• Cystine  lt1 These stones are very rare. 
  They are caused by cystinuria, a genetic kidney
  disease

121
Nephrolithiasis

• Differential Diagnosis
• Appendicitis
• Diverticulitis
• Mesenteric adenitis
• Pancreatitis
• Ileus
• Peptic ulcer disease
• Fallopian tubes and ovary abnormalities
• Ovarian cysts
• Ectopic pregnancy
• Gall bladder disease
• Abdominal aneurysms

122
Nephrolithiasis

• Signs and symptoms
• Varies depending on location, size, and type of
  stone
• Usually sudden onset
• Flank pain not relieved by position changes
• Pain may refer across the abdomen and down into
  the groin, perineal area and inner thigh
• Nausea is common and Vomiting may occur
• Chills may be reported
• Urinary frequency with or with out dysuria or
  hematuria
• Weakness
• May report a recent UTI
• Physical findings
• Abdominal distension and guarding with palpation
• Flank tenderness on percussion
• Decreased or absent bowel sounds
• Fever may be noted with increase pulse and
  respiratory rates

123
Nephrolithiasis

• Diagnostic tests
• UA
• Shows RBCs, WBC, crystals, casts, minerals.
  Bacteria, pus abnormal pH
• 24 hour urine
• May show increase levels of creatinine, uric
  acid, calcium, phosphorus, oxylate or cystine
• Serum Chemistry
• May show increased levels of magnesium, calcium,
  uric acid, phosphorus, protein and electrolytes
• Serum BUN and creatinine
• Shows BUN elevated secondary to urinary tract
  obstruction