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Debbie King FNP, PNP

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Genitourinary DEBBIE KING FNP, PNP 8800 Signs and Symptoms Painful, scrotal swelling- pain may radiate up into lower abdomen Sensation of scrotal heaviness Symptoms ... – PowerPoint PPT presentation

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Title: 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

4
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

5
Hematuria
  • Two types
  • Transient
  • Occurs on one occasion
  • Persistent
  • Occurs on two or more consecutive occasions
  • Both can be a sign of serious disease

6
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

7
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

8
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

9
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

10
Proteinuria
  • Differentials
  • Benign or functional causes
  • Orthostatic proteinuria, exercise, environmental
    conditions, fever, illness, CHF, injury
  • Bence Jones protein suggest multiple myeloma
  • Nephrotic syndrome

11
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

12
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

13
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)

14
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.

15
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

16
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

17
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

18
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

19
Urinary Incontinence
  • Heart and Lungs
  • Assess for CHF
  • Cough stress test- observe for leaking

20
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

21
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

22
Urinary Incontinence
  • Differentials
  • Four major types of incontinence
  • Stress
  • Urge
  • Overflow
  • Functional
  • Other types
  • Overactive bladder
  • Compensated incontinence
  • Elderly
  • Transient
  • Other major illness

23
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

24
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!

25
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

26
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.

27
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

28
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

29
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

30
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

31
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

32
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.

33
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

34
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

35
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

36
Interstitial Cystitis
  • Occurs mostly in women
  • 10 are men
  • Onset between 30-70 years of age
  • Does occur in children and is under diagnosed

37
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

38
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

39
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

40
Interstitial Cystitis
  • Medication treatments
  • Tricyclic antidepressants
  • Antihistamines
  • Nonsteroidal
  • Pyridium, Ditropan, Procardia may help ??
  • May require long acting opioids
  • Refer- for further treatments

41
Vulvovaginitis
  • Definition inflammation and infection of the
    vulva/vagina
  • Etiology/Incidence
  • Commonly caused by trichomonas vaginalis,
    bacterial vaginosis, or candida albicans

42
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

43
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

44
Vulvovaginitis
  • Differential diagnosis
  • Chlamydia
  • Gonorrhea
  • Herpes
  • Condylomata acuminata
  • Allergy, contact dermatitis
  • Atrophic vaginitis

45
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

46
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

47
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

48
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

50
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.

51
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

52
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

53
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

54
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.

56
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.

57
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.)

58
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.

59
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
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