Seminar Complicated Cystitis

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SeminarComplicated Cystitis
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Patient profile ???????????????? 76 ??
????????????????? ?. ????? Chief complaint
????????????? ???? ? ??? ? ?? 1 ?????
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????????????????????????????????? ?
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Present illness ????????????????????????????????
????? ???????? ?????????????????????????
???????????????????????????? Past history
Menopause ????????? 50 ?? No underlying disease
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Physical examination Vital signs
Febrile?? PV MIUB Atrophy Vagina
Atrophy Cervix No lesion Uterus
Normal size Adnexa No mass
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Problem List
Terminal Dysuria
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Differential Diagnosis

• Cystitis
• Vaginitis
• Urethritis

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?????? Investigation ????????????????? ?
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Investigation

• Urinalysis
• Urine culture

• Pap smear

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Urinalysis 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
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Urine culture

• Streptococcus SPP.
• 5000 CFU/ml
• Corynebacterium SPP.
• 5000 CFU/ml

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Pap smear

• Normal

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Impression

Cystitis
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Treatment

• Norfloxacin (400) 1 tab po bid x 3 day

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Second visit (25/7/2540)

• ???????????????? ?????????????????????????
  ??????????????????
• Urinalysis ????????????? WBC, RBC ????
  ????????????????????

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Second visit (25/7/2540)
Urinalysis
Color Yellow Clarity Cloudy SG 1.020 Blood
2 pH 5.5 Bili Negative Prot 1 Uro Nor
mal Glu Negative Nitri Negative Keto Negative
Leuco 2 Microscopic Examination result WBC
Many/HP RBC 10-15/HP Epith
Translational cell 1-2/HP
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Second visit (25/7/2540)

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

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..7 months later..
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Third visit (2/2/2541)

• Chief complaint ???????????????????? ???????????
  ????????????????????
• UA ?? WBC, RBC numerous

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Third visit (2/2/2541)
Urinalysis
Color Yellow Clarity Turbid SG 1.025 Blood
3 pH 5.5 Bili Negative Prot 2 Uro Nor
mal 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
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Third visit (2/2/2541)

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

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Fourth visit (9/2/2541)

• Chief complaint ??????????????
• PV Normal
• UA ?? WBC, RBC numerous ??????????????

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Fourth visit (9/2/2541)
Urinalysis
Color Yellow Clarity Turbid SG 1.025 Blood
3 pH 5.5 Bili Negative Prot 3 Uro Nor
mal Glu 3 Nitri Negative Keto Negative Leuc
o 3 Microscopic Examination result WBC
Numerous/HP RBC 3-5/HP Epith
Translational cell rare/HP Bact Bacilli
Cocci few/HP
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Fourth visit (9/2/2541)
Impression

• Chronic cystitis
• suspected for underlying disease

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Fourth visit (9/2/2541)

• Medications Norfloxacin (200 mg)
• 1 tab qid pc PO 20
• Urine culture
• Follow up 3 days

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Problem list
Persistant pyuriaPersistant hematuriaNoresponse
to medication
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Differential Diagnosis
Chronic cystitisUrolithiasis
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Chronic cystitis

• Unresolved or persistent bladder infection
• 3 or more bouts of bladder infection occurring
  in the course of 1 year

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Chronic cystitis
Infectious Tuberculosis (Sterile pyuria)
Associated with Infectious
vaginitis Urethitis
Renal infection
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Non infectious Calculi Hormonal
deficiency - Senile Vaginitis
- Urethitis Interstitial cystitis
Allergic cystitis Radiation cystitis
Chemotherapeutic agent gtgtCystitis
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Differential Diagnosis
Chronic cystitis

• Infectious
• Tuberculosis (Sterile pyuria)

• Non infectious
• Hormonal deficiency
• - Senile Vaginitis
• - Urethritis
• Interstitial cystitis

Urolithiasis
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Differential Diagnosis

• Urolithiasis

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Fifth visit (13/2/2541)

• Urine culture results negative
• CXR normal
• and plan for IVP at 23/2/2541

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????? IVP ????????????????????????????????????
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Indication for IVP

• To detect radioluscent calculi.
• Recurrent urinary infection to find out renal
  abnormality.
• Congenital abnormalities of the Urinary tract
  like horse shoe kidney, double ureters etc.
• Neoplastic disease of the urinary tract.
• In abdominal and renal trauma.
• To study obstructive diseases of urinary tract.

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Sixth visit (23/2/2541)

• IVP - No opaque stone
• - Focal caliectasis of left lower pole
• kidney, possibly non opaque stone
• - Contract bladder with thicken wall,
  most likely 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
• Reevaluate IVP ? Normal study
• Plan for cystoscope at 7/4/2541
• Medications Flavoxate, Imipramine

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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) 4)
abnormal cells found in urine sample 5) painful
urination or unexplained pelvic pain associated
with urination 6) poor bladder emptying due to
prostate enlargement or stricture of the
urethra 7) any abnormal growth, lesion, or tumor
seen on other imaging studies.
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Cystoscope ?????????????????????????????
?????????
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Eighth visit (7/4/2541)

• Cystoscope findings
• Generalized hyperemia of bladder mucosa
• Bleeding when dilatation with water
• No tumor mass
• Impression Interstitial cystitis
• Biopsy bladder was done
• Plan Urine culture 3 days, Urine AFB
• Rx Norfloxacin
• Follow up 2 week

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Ninth visit (24/4/2541)

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

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Tenth visit (19/6/2541)

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

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TB cystitis
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TB cystitis

• Chronic cystitis that refuse to response to
• adequate therapy
• Finding of pus without bacteria in a methylene
  
• blue stain or culture of urine sediment
• Gross /Microscopic hematuria
• Non tender ,enlarged epididymis with beaded or
• thickened vas
• Chronic draining scrotal sinus
• Induration or nodulation of prostate and
• thickening of one or both seminal vesicles
• (especially in a young man )

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???????????????????????????????????? complicated
cystitis
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SeminarComplicated Cystitis