seminar 1

1
seminar 1
2
Patient history

• First visit to hospital 18/7/2540
• Patient profile ????????????????????? 76 ??
• Chief complaint ???????????? 1 ????? PTA
• ??????????????????????????????

3

• History
• Voiding disfunction
• Irritative symptom
• Frequency
• Nocturia
• Urgency
• Dysuria

4

• Obstructive symptom
• Weak stream
• Urinary Hesistancy
• Straining
• Prolonged micturition
• Intermittency
• Postvoid dribbing
• Feeling of incomplete emptyness
• Acute Chronic urinary Retention

5

• Associate symptom
• - Fever, N/V, CVA tenderness, shivering
• - abdominal pain and radiation
• - characteristic of urine

6

• Past history
• - Previous history of urinary tract disease
• - Underlying disease
• DM
• Neurological disease
• Gyne - STD
• Immunocompromised host
• - SI
• - Current drug ATB
• - History of radiation, chemotherapy
• - History of urinary catheter or stent

7
Present illness

• ??????????????????????????? 1 ????? ????????
  ????????????????????????? ????????????????????????
  ????
• personal history - Menopause ????????? 50 ??
• - ?????? 5 ??

8
?????????????????????????
9
Physical Examination

• Complete Examination
• Per vagina MIUB, Vg, Cx, Ut, Adnexa
• Suprapubic tenderness
• Costovertebral angle tenderness

10
Patient history

• Physical examination
• PV
• MIUB - Atrophy
• Vagina - Atrophy
• Cervix - No lesion
• Uterus - Normal size
• Adnexa - No mass

11
????????? Investigation ???????? ?
12
Investigation ???????????????

• UA
• Urine culture
• PAP smear

13

• Routine Urinalysis result
• Color Yellow
• Clarity Cloudy
• SG 1.025 Blood 3
• pH 6.0 Bili Negative
• Prot 3 Uro Normal
• Glu Negative Nitri Negative
• Keto Negative Leuco 2
• Microscopic Examination result
• WBC Numerous/HP
• RBC Many/HP
• Epith Squamous cell 3-5/HP
• Epith Translational cell 0-1/HP

14

• Impression
• 1. Vaginal atrophy
• 2. Cystitis

15
Management ???????????????

• Norfloxacin (200 mg) 2 tab PO bid pc 20
• Follow up 1 week for urine culture results, UA
  before visit doctor

16

• Routine Urinalysis result
• Color Yellow
• Clarity Cloudy
• SG 1.020 Blood 2
• pH 5.5 Bili Negative
• Prot 1 Uro Normal
• Glu Negative Nitri Negative
• Keto Negative Leuco 2
• Microscopic Examination result
• WBC Many/HP
• RBC 10-15/HP
• Epith Translational cell 1-2/HP

17
Second visit (25/7/2540)

• ???????????????? ?????????????????????????
  ??????????????????
• Urinalysis ????????????? WBC, RBC
• ??????????? first visit ??????????
• Urine culture Streptococcus spp. 5000
  CFU/ml
• Corynebacterium spp.5000
  CFU/ml
• ????? urine culture ??????????

18
Urine Culture

• Clean Voided Specimen
• Normal lt10,000 organisms per ml
• Urinary Tract Infection
• Boys
• Organisms gt10,000 per ml suggests UTI likely
• Girls
• Organisms gt100,000 per ml suggests UTI
• Organisms gt10,000 per ml needs repeat urine
  culture

19

• Transurethral Catheterization
• Normal lt1,000 organisms per ml
• Urinary Tract Infection
• Organisms gt100,000 per ml suggests UTI (95)
• Organisms gt10,000 per ml suggests UTI
• Organisms gt1,000 per ml needs repeat urine
  culture

20
Second visit (25/7/2540)

• ????????????????????????????? ????????????????????
  ????? Cystitis
• ???????????????????????????????

21
Third visit (2/2/2541)

• Chief complaint ???????????????????? ???????????
  ????????????????????

22

• Routine Urinalysis result
• Color Yellow
• Clarity Turbid
• SG 1.025 Blood 3
• pH 5.5 Bili Negative
• Prot 2 Uro Normal
• Glu Negative Nitri Negative
• Keto Negative Leuco 3
• Microscopic Examination result
• WBC Many/HP
• RBC 30-35/HP
• Epith Squamous cell rare/HP
• Epith Translational cell rare/HP

23
Third visit (2/2/2541)

• ?? UA ?? pyuria, hematuria, proteinuria
• Impression Cystitis
• Medications Norfloxacin (200 mg) 2 tab PO
  bid pc 28
• Follow up 7 days, UA before visit doctor

24
Fourth visit (9/2/2541)

• Chief complaint ??????????????

25

• Routine Urinalysis result
• Color Yellow
• Clarity Turbid
• SG 1.025 Blood 3
• pH 5.5 Bili Negative
• Prot 3 Uro Normal
• Glu 3 Nitri Negative
• Keto Negative Leuco 3
• Microscopic Examination result
• WBC Numerous/HP
• RBC 3-5/HP
• Epith Translational cell rare/HP
• Bact Bacilli Cocci few/HP

26
Fourth visit (9/2/2541)

• UA ?? WBC numerous ,microscopic hematuria,
  bacteria-few
• PV Normal
• Impression suspected for underlying disease
• Medications Norfloxacin (200 mg) 1 tab qid
  pc PO 20
• ??? Urine culture
• Follow up 3 days and plan for IVP

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Fifth visit (13/2/2541)

• Urine culture results Negative
• CXR Normal
• Medication norfloxacin 1x4
• Made an appoint for IVP at 23/2/2541

28
?????????? indication ??????? IVP
??????????????????????????????????? IVP
?????????
29
IVP - Indication

• ??????????????????????????????
• ??????????????????????
• - stone disease (site of obstruction renal
  function)
• - Preoperative or base-lined ESWL
• - Acute colicky abdominal pain
• - Heamaturia screening
• - Suspect or unusual infection , TB
• - pre and post op urosurgery (transplant
  kidney)
• - Suspect uroepithilial tumor (TCC)
• - Quesionable abnormalities on nuclear medical
  and ultrasonogram

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IVP - contraindication

• ????????????? ??????????????????
  ???????????????????????????????? ??????
  ???????????????
• serum Cr gt 4 mg

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????????????????

• Bowel preparation
• Fluid restriction (becareful for kidney
  insufficiency Ex DM , MM and emergency case)

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????? IVP

• 1. ??????? plain KUB (scout film)
• 2. ??????????????
• 3. ????????????? plain KUB 5, 10, 25 ????
  ???????????????????? ??????? pelvocaliceal system
  ,????? ,bladder

33
Sixth visit (23/2/2541)

• ???????????????????? ????????????????????????
  RBC, WBC, No bacteria ??????????

34

• Routine Urinalysis result
• Color Yellow
• Clarity Turbid
• SG 1.025 Blood 3
• pH 6 Bili Negative
• Prot 3 Uro Normal
• Glu Negative Nitri Negative
• Keto Negative Leuco 2
• Microscopic Examination result
• Granular cast 1-2/LP
• WBC Numerous/HP
• RBC 3-5/HP
• Epith Squamous cell 2-3/HP
• Bact Cocci few/HP
• Yeast cell 1-2/HP

35
Sixth visit (23/2/2541)

• ?? IVP Scout film show no opaque stone
• Spondylosis with kyphoscoliosis
• Post intravenous injection of the contrat
  sodium,focal caliectasis of left lower pole
  kidney, probably non opaque stone
• Contracted bladder with thickened wall,
  chronic cystitis
• Impression
• - Frequent UTI
• - Abnormal lower pole of left kidney
• Consult urologist

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Seventh visit (27/2/2541)

• Terminal dysuria and Nocturia 4-5 ?????
• Reevaluate IVP ? Normal study

37
?????????????????????????????????
??????????????????????
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Seventh visit (27/2/2541)

• Plan for cystoscopy at 7/4/2541
• Medications Flavoxate, Imipramine

39
???????????????? cystoscopy ?????????????????????
???????? ????????????????????????????????? ?
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Indication for cystoscope

• 1) Frequent or persistent urinary tract
  infections
• 2) Blood in the urine (hematuria)
• 3) Loss of bladder control (incontinence)or
  overactive bladder
• 4) Painful urination, pelvic pain or interstital
  cystitis
• 5) Urinary blockageprostate enlargement or
  stricture of the urethra
• 6) Stone in the urinary tract
• 7) Any abnormal growth, lesion, tumor
• www.thedoctorslounge.net

41
Eighth visit (7/4/2541)

• Cystoscopy findings
• Extranal geniralia normal
• Urethra normal
• Generalized hyperemia of bladder mucosa
• Bleeding when dilatation with water
• No tumor mass
• DDx TB cystitis, I.C., CIS
• Biopsy bladder was done
• Plan Urine culture 3 days, Urine AFB
• Rx Norfloxacin
• Follow up 2 week

42

The photomicrograph shows 2 granulomatous foci in
the lamina propria underlying the lamina
propria.There is also an accompanying
lymphocytic infiltrate.
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Ninth visit (24/4/2541)

• ?? Terminal dysuria, Nocturia ????????????? 10
  ?????
• No CVA tenderness
• Biopsy result
• Granulomatous inflammation consistent with
  tuberculosis
• AFB stain negative
• Plan Start HRZE, CXR, Sputum AFB 3 days
• Rx Imipramine

44
Tenth visit (19/6/2541)

• Culture result Mycobacterium tuberculosis
• ??? 3 ????? UA before visit

45
??????????????????????????????????????????????
Complicated cystitis ?
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cystitis
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Causes

• Normal Host
• Escherichia coli (80)
• Staphylococcus saprophyticus (10-15 of young
  women)
• Nephrolithiasis associated infection
• Proteus (urease positive)
• Klebsiella
• Sexually Transmitted Diseases
• Chlamydia
• Neisseria gonorrhoeae
• Herpes Simplex Virus II (Genital Herpes)

48
Associated risk factors

• Sexually active women
• Men with Prostatitis or BPH
• Pregnancy
• Urinary Tract Obstruction
• Neurogenic bladder dysfunction
• Vesicoureteral reflux

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Symptoms

• Dysuria
• Urinary Frequency
• Urinary Urgency
• Suprapubic pain (especially after voiding)
• Hematuria (30)

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Differential Diagnosis

• Pain at onset of urination suggests urethritis
• External Dysuria suggests Vaginitis
• Long, insidious onset suggests Chlamydia
  trachomatis

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Labs

• Urinalysis
• Urine Leukocyte Esterase
• Urine Nitrite
• Urine White Blood Cells on microscopy
• Urine Culture
• Positive for gt100,000 organisms
• Women with Dysuria have lt100,000 organisms in 30
  cases

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52
Management

• General measures in women
• Women should clean perineum wiping front to back
• Women should empty bladder before, after
  intercourse
• Avoid Contraceptive Diaphragm

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Management

• Antibiotics
• Uncomplicated Treatment Course 3 days (except
  noted)
• Antibiotic Resistance increasing
• Trimethoprim Sulfamethoxazole (Septra) 9-18
• Ampicillin 28-33
• Nitrofurantoin resistance low
• Fluoroquinolone resistance low
• Avoid as first line agents if possible
• Consider in areas of high Septra resistance areas

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Management

• Acute Uncomplicated UTI
• Bactrim DS 1 po bid
• Nitrofurantoin 100 mg PO qid for 7 days
• Macrobid 100 mg PO bid for 7 days
• Cephalexin (Keflex) 250-500 mg PO qid
• Doxycycline 100 mg PO bid
• Augmentin 875 mg PO bid

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Management

• Resistant UTI organisms
• Ciprofloxacin 250 mg PO bid
• In healthy older women, 3 days equivalent to 7
  days
• Vogel (2004) CMAJ 170469-73
• Norfloxacin 400 mg PO bid
• Ofloxacin 200 mg PO bid

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56
Complication

• Infection that ascending to kidney
• ? pyelonephritis, renal failure, sepsis
• Vesicoureteral reflux in children pregnant
  women

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Complicated UTI

• A clinical syndrome in men or women
  characterized by the development of the systemic
  and local signs and symptoms of fever, chills,
  malaise, flank pain, back pain, and CVA pain or
  tenderness, occurring in the presence of a
  functional or anatomical abnormality of the
  urinary tract or in the presence of
  catheterization.

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Complicated bladder infections

• Bladder infections are classified as
  complicated when they affect people with an
  abnormality of the urinary system that makes
  these infections more difficult to treat. All
  bladder infections are considered complicated
  when they affect men, because the long male
  urethra should prevent bacteria from gaining
  access to the bladder.

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Complicated cystitis

• Unresolved or persistent bladder infection,
  whereas other use it to mean 3 or more bouts of
  bladder infection occurring in the course of 1
  year

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Inclusion Criteria for Complicated UTI

• 1. Documentation of pyuria
• 2. One or more of following (defined UTI)
• - dysuria - urgency
• - frequency - suprapubic pain
• - fever with chill - CVA tenderness

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• 3. Present of one or more (defined complicated
  UTI)
• -Instrument catheter or intermittent catheter
• -Impaired bladder emptying
• -Obstructive uropathy due to outlet obstruction
• Guidance for Industry
• Complicated Urinary Tract Infections and
  Pyelonephritis - Developing Antimicrobial Drugs
  for Treatment
• U.S. Department of Health and Human
  Services Food and Drug Administration Cent
  er for Drug Evaluation and Research
  (CDER) July 1998 Clin-Anti

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Complicated cystitis

• TB
• DM
• Immunocompromise

• Radiation cystitis
• Functional anomaly
• Structure anomaly
• Interstitial cystitis

63
General diagnosis/Evaluation

• Urine culture is necessary with complicated UTIs
  prior to treatment
• Urologic investigation Ultrasound, plain KUB,
  IVP, CT, Cystoscopy
• Baseline renal function studies need to be
  completed prior to contrast imaging

64
Peace out
65
Interstitial cystitis

• Definition
• clinical syndrome define by chronic symptoms of
  urgency ,frequency, and /or pain in the absence
  of any other resonable causation

66

• Etiology unknown
• Pathogenic role of mast cells in the detrusor
  and/or mucosal layers of the bladder
• Deficiency in the glycosaminoglycan layer on the
  luminal surface of the bladder, resulting in
  increased permeability of the underlying
  submucosal tissues to toxic substances in the
  urine
• Infection with a poorly characterized agent (eg,
  a slow-growing virus or extremely fastidious
  bacterium)
• Production of a toxic substance in the urine
• Neurogenic hypersensitivity or inflammation
  mediated locally at the bladder or spinal cord
  level
• Manifestation of pelvic floor muscle dysfunction
  or dysfunctional voiding
• Autoimmune disorder

67

• Pathophysiology
• A variety of etiologies have been proposed,
  none of which adequately explains the variable
  presentations
• Pathology
• lession on bladder wall
• mucosa ?????? ????? ????????

68
Interstitial cystitis ??????? ?