Difference between revisions of "Genitourinary infection"

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==Background==
 
==Background==
*Also known as acute cystitis; abbreviation = UTI
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[[File:2605 The Bladder.jpg|thumb|Anatomy of the bladder (male)]]
===Definitions===
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[[File:Prostatelead.jpg|thumb|Prostate anatomy]]
*UTI = significant bacteriuria in presence of symptoms
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{{UTI types}}
**Described by location: urethritis, cystitis, or pyelonephritis
 
*Relapse
 
**Recurrence of symptoms w/in month despite tx
 
***Caused by same organism and represents treatment failure
 
*Reinfection
 
**Development of symptoms 1-6mo after tx
 
**Usually due to a different organism
 
**If pt has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]]
 
*Men <50 yr: symptoms of dysuria or urinary frequency usually due to [[STI]]
 
*Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
 
*Uncomplicated UTI:
 
**No structural or functional abnormalities w/in urinary tract or kidney
 
**No relevant comorbidities that place pt at risk for more serious adverse outcome
 
**Not associated with GU tract instrumentation
 
===Risk factors for complicated UTI===
 
#Male sex
 
##In young males dysuria is more commonly d/t STI
 
##Suspect underlying anatomic abnormality in men with culture-proven UTI
 
#Anatomic abnormality of urinary tract or external drainage system
 
##Indwelling urinary catheter, stent
 
##Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
 
#Recurrent UTI (three or more per year)
 
#Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
 
#Nursing home residency (w/ or w/o indwelling bladder catheter)
 
#Neonatal state
 
#Comorbidities ([[DM]], sickle cell disease)
 
#Pregnancy
 
#Immunosuppression ([[AIDS]], immunosuppressive drugs)
 
#Advanced neurologic disease ([[CVA]] w/ disability, [[Spinal Cord Injuries]])
 
#Known or suspected atypical pathogens (Non–E. coli infection)
 
#Known or suspected abx resistance (resistance to Cipro predicts multidrug resistance)
 
  
===[[Microbiology]]===
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==Evaluation==
*Most common pathogen is [[E. coli]]
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{{Perinephric vs Renal Abscess}}
*[[Anaerobic]] organisms are rarely pathogenic (do not grow well in urine)
 
*Complicated UTIs more likely to be caused by [[pseudomonas]] or [[enterococcus]]
 
 
 
==Diagnosis==
 
===Clinical Features===
 
*UTI dx requires both bacteriuria and clinical symptoms
 
**Cystitis = Dysuria, [[hematuria]], frequency, urgency, suprapubic pain, CVAT
 
**Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
 
***CVAT alone may be referred pain from cystitis
 
***CVAT is only physical examination finding that increases likelihood of a UTI
 
*Urethritis
 
**In males more likely due to [[chlamydia]]/[[GC]]
 
**In females more likely due to [[chlam]]/[[GC]] if:
 
***Stuttering urination symptoms
 
***New sex partner or partner w/ urethritis
 
***Signs/symptoms cervicitis
 
***Sterile pyuria
 
*Complicated UTI
 
**Pts may not have classic symptoms; may only have [[weakness]], [[fever]], [[abd pain]], [[AMS]]
 
===Labs===
 
====UA====
 
=====WBC count=====
 
*WBC >5 in pt w/ appropriate symptoms is diagnostic
 
**Lower degrees of pyuria may still be clinically significant in presence of UTI sx
 
***False negative may be due to: dilute urine, systemic leukopenia, obstruction
 
**WBC 1-2 w/ bacteriuria can be significant in men
 
***More likely represents urethritis or [[prostatitis]] from [[STI]]
 
 
 
=====Nitrite=====
 
*Very high specificity (>90%) in confirming diagnosis of UTI
 
*Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
 
====[[Urine Culture]]====
 
*Indicated for:
 
**Complicated UTI
 
**Pyelonephritis
 
**Pregnant women
 
**Children
 
**Adult males
 
**Relapse/reinfection
 
====[[Blood Culture]]====
 
*Not indicated
 
**Organisms in blood cx matched those in urine cx 97% of time
 
 
 
===Imaging===
 
*Consider if [[pyelonephritis]] and any of the following:
 
#History of [[Renal Stone]]
 
#Poor response to [[antibiotics]]
 
#Male
 
#Elderly
 
#[[Diabetic]]
 
#Severely ill
 
 
 
==Differential Diagnosis==
 
===Major===
 
*[[Pyelonephritis]]
 
*Infected [[kidney stone]]
 
 
 
===Pelvic Pain===
 
{{Pelvic pain DDX}}
 
 
 
===Dysuria===
 
{{Dysuria DDX}}
 
 
 
==Management==
 
*Consider local resistance patterns (if >10-20% use a different agent)
 
*Avoid use of fluoroquinolones for uncomplicated cystitis if possible
 
 
 
;Consider longer course of complicated cystitis if:
 
*Symptoms >7d
 
*[[DM]]
 
*UTI in previous 4wk
 
*Men
 
*Age 65 yr
 
*Women who use spermicides or diaphragm
 
*Relapse
 
*Pregnancy
 
 
 
{{UTI Antibiotics}}
 
 
 
==Disposition==
 
===Uncomplicated UTI===
 
*Admit
 
**Unable to tolerate PO
 
*Discharge
 
**Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
 
===[[Pyelonephritis]]===
 
*Discharge
 
**Consider if young, otherwise healthy, tolerating PO
 
*Admission
 
**Consider if elderly, [[Renal Calculi]], obstruction, recent hospitalization/instrumentation, [[DM]]
 
 
 
==Complications==
 
*Suspect in pts who have inadequate or atypical response to tx for presumed [[pyelonephritis]]
 
#Acute bacterial nephritis
 
##CT shows ill-defined focal areas of decreased density
 
#Renal/Perinephric Abscesses
 
##Sign/symptoms similar to [[pyelo]] ([[fever]], CVAT, dysuria)
 
##Occurs in setting of ascending infection w/ obstructed pyelo
 
##Associated w/ [[DM]] and [[Renal Stones]]
 
##Also occurs due to bacteremia w/ hematogenous seeding (Staph)
 
#Emphysematous pyelonephritis
 
##Rare gas-forming infection nearly always occurring in pts w/ [[DM]] and obstruction
 
###Pts appear toxic and [[septic]]; nephrectomy may be required
 
 
 
==Special Populations==
 
===[[AIDS]]===
 
*[[TMP-SMX]] resistance is increased due to its use in [[PCP PNA]] prophylaxis
 
**[[Fluoroquinolones]] should be initial antibiotic of choice
 
*Most UTIs are caused by typical pathogens or common STI organisms
 
===Pregnant Women===
 
*Treat all cases of asymptomatic bacteriuria
 
  
 
==See Also==
 
==See Also==
 +
*[[Dysuria]]
 +
*[[Hematuria]]
 +
*[[Flank pain]]
 
*[[UTI (Peds)]]
 
*[[UTI (Peds)]]
*[[Dysuria]]
 
 
==Source ==
 
Tintinalli
 
  
[[Category:Nephro]]
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[[Category:Renal]]
 
[[Category:ID]]
 
[[Category:ID]]
[[Category:GU]]
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[[Category:Urology]]

Latest revision as of 10:32, 2 May 2020

Background

Anatomy of the bladder (male)
Prostate anatomy

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

Evaluation

Perinephric vs renal abscess

Perinephric Renal
Necrotic Area Perinephric fat between the renal cortex and Gerota's fascia Renal parenchyma
Cause Pyelonephritis (majority) Pyelonephritis (vast majority)
Risk of morbidity Higher Lower

See Also