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20% women annually
UT abnormalities, caths
sexually active
young kids, elderly
immunosuppressed
pregnant
cystitis occurence
-
risk factors:
DM
inc sexual activity, diaphragm, spermicide
pregnancy
incomplete voiding
neurogenic bladder
reflux (VUR)
urinary instrumentation
cystitis
-
causative organisms:
#1 gram - bacilli most common: E. coli
#2 gram +: Staph saprophyticus
other gram negs: Proteus, Klebsiella, Pseudomonas, Serratia
cystitis
-
patho:
infection--inflammatory edema in bladder--stretch receptors cz urgency and frequency--prostaglandins released--pain and vascular permeability--hematuria
cystitis
-
HX, SX:
-dysuria, frequency, urgency, nocturia, hematuria (direct correlation between amt of blood and pathology)
-foul smelling urine
-suprapubic heaviness/pressure
-ask about fever, chills, N/V, abd/back pain, blood in urine
--ask about number of previous UTI's
cystitis
-
DDX:
-UTI
-pyelonephritis
-vaginitis: Gonorrhea, Chlamydia= must ask GYN HX
-urethritis
cystitis
-
PE cystitis
- check temp
- abd exam
- CVAT
- pelvic if HX suggests
-
DX cystitis:
- urine dipstick for nitrities, WBC's, RBC's
- midstream UA
- UC not always necessary (consider if resistane strains bacteria)
-
Most common findings in UA w/cystitis:
- + WBC or pyuria (sens 90%)
- presence of bacteria (sens 83%)
- + nitrites
- IF all of these +, sensitivity 99%
-
casts/hematuria suggest what type of UTI
upper UTI
-
TX for cystitis in uncomplicated cases w/o allergy
bactrim x3 days
-
TX for cystitis if allergy or resistant strain
- fluoroquinolones
- (ciprofloxacin, levaquin)
-
TX cystitis if have had ATB's recently
Macrobid 100mg BID x 5-7 days
-
TX cystitis complicated
(caths, comorbidities)
fluoroquinolones 7-14 days
-
reason for 3 day ATB use for cystitis
cost effective and decreases risk of Candida
-
mgmt cystitis
- 1. analgesics- pyridium
- 2. anticholinergics- ditropan
- 3. CAM- cranberry 300mg BID in caps to preveny bacteria from sticking to bladder wall
-
UTI in pregnancy- why is TX so important?
associated with premature delivery
-
TX UTI in pregnancy:
(use for 7 days)
- Amoxi 500mg BID
- Macrodantin 100mg BID
- Keflex 500mg BID
- Augmentin
-
RX to avoid in pregnancy when TX UTI?
fluoroquinolones bc they have effects on fetus bone and cartilage formation
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pt education cystitis
- -avoid full bladder
- -increase PO fluids
- -void after sex
- -wipe front to back lacks research
- -consider alternative birth control if currently using spermicide or diaphragm
- -no F/U needed if uncomplicated
-
how to prevent "honeymoon cystitis"
macrodantin 50mg pre coitus
-
most common organism for peds UTI
and #2
- #1- E. coli
- #2- Staph, Strep
-
cz of UTI in peds
urinary stasis, constipation, bubble baths, sexual abuse
-
peds at greater risk of what w/chronic UTI's
renal scarring
-
Sx UTI in peds:
enuresis, squatting, unexplained fever, irritability, abd pain
-
PE in peds UTI
- -check BP for HTN
- -temp
- -check for abd or flank mass
- -palpate bladder
- -check for abn genitalia
- -check for abn urinary stream
-
1. DX peds UTI
2. How to obtain
- 1. urine culture
- 2. infant- suprapubic asp, cath
- 2. older kids- clean voided midstream
-
definition recurrent UTI in peds
- >2 UTI's in period of 6mo
- refer these pts bc they have increased risk of renal scarring
-
peds TX UTI
- same as adults:
- keflex
- macrodantin
- amoxi
- augmentin
-
when to recheck UC in peds UTI pts:
recheck UC 3-7 days post TX
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pyelonephritis definition
upper GU tract infection involving renal parenchyma. Can be bilateral or unilateral
-
pyelo usually cz by:
ascending infection form bladder
-
chronic pyelo may lead to:
scarring and renal failure from deformity
-
risk factors for pyelonephritis
DM, anatomic abn, recurrent UTI's, pregnancy, cath's, elderly women
-
Sx pyelonephritis:
- flank pain
- N/V
- fever/chills
- HA, malaise
- CVAT
- tenderness on deep abd palp
- poss hematuria
- urinary frequency
-
DX pyelo:
- UA- look for pyuria and WBC casts
- UC- should always be done if pyelo suspected
- may need pelvic exam to R/O PID
-
dont rely on dipstick for what urinary disorder?
pyelo
-
Do blood cultures if pt is hospitalized w/what?
- pyelo
- (10-20% pts w/mild to mod pyelo have urosepsis)
-
indications for admission of pyelo:
- pregnant
- chronic dz
- non-compliant
- unable to take PO fluids or meds
- toxic looking
-
Outpatient TX for pyelo:
- must be closely monitored
- may stabilize w/IM/IV ATB's in office
- refer of sx dont improve in 12-48hrs
- --telephone F/U in 12 hrs, OV in 48hrs
- --F/U cultures in 2 wks and 3months for recurrent cases
-
meds for pyelo:
- gram neg= fluoroquinolones 14days
- gram pos= augmentin
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renal stones- most common?
calcium
-
other types of renal stones
- struvite (15%)
- uric acid (7%)
- cystine (1%)
-
risks for calcium stones
- hypercalciuria, hyperuricosuria, low calcium intake, high animal protein diet, high animal fat diet, low fluid intake, high vit C intake
- previous HX stones, family HX stones
- freq UTI's, vasectomy, HTN, marathon runners, sedentary
- high soda intake (phosphoric acid)
- high oxalate (leafy greens, chocolate, spinach)
-
risks for uric acid stones
- acidic urine
- gout
- chronic diarrhea states
-
risks for struvite stones
UTI caused by Klebsiella, Proteus
-
Sx renal stones
- mild to severe pain that waxes and wanes (20-60min intervals)
- flank pain (upper ureteral, renal pelvis)
- pain radiates to testicles or labia (lower ureteral obstruction)
- hematuria (gross or micro)
- can have N/V dysuria, frequency, urgency
-
DX stones:
- CT scan gold standard
- may do IVP w/abd films
- can do U/S if have to avoid radiation
-
TX renal stones:
- attempt to manage w/hydration and analgesics until stone passes
- if sotne >7mm, usually too big to pass and pt needs urology consult
-
prevention of renal stones in general:
increase fluids, decrease soda intake
-
prevention of calcium stones:
- low oxalate diet
- increased citrate
- thiazide diuretics (for recurrent cases)
-
prevention of uric acid stones:
- low purine diet
- allopurinol
-
prevention of struvite stones:
avoid UTI's
-
prevention of cystine stones:
(all of these RX bind to cystine to prevent crystal formation)
- penicillamine
- tiopronin
- captopril
-
hematuria- age cut-offs
- dont rely on dipstick
- do UC on all pts w/hematuria
- pt <40yoa= monitor monthly for 3mo, if persists then refer
- pt >40yoa= refer to urology
-
hematuria
- common in long distance runners
- gross or occult
- transient or persistent
-
most important test for hematuria
UA
-
correlation w/what and gross hematuria very important
smokers
-
important HX to ask w/hematuria
- drug and dietary HX, many irritate the bladder
- check menstrual HX
-
definition stress incont-
cz by what?
can be from what?
- failure to store d/t hypermobility of bladder neck
- cz by intrinsic sphincter deifiency
- can be from hormone changes, vaginal deliveries, sedative, anti-spasmodics
-
TX stress incont
- kegels
- wt loss
- estrogen creams
- alpha blockers
- surgery
-
urge incontinence, from what?
- failure to store
- r/t UTI, vaginitis, stones, tumors, Parkinson's, diuretics, narcs
-
TX urge incontinence
- ATB's
- estrogen cream
- anticholinergics
- TCA's
- kegel's
- prompted voiding schedule
-
overflow incontinence...
due to?
- failure to empty
- d/t underactive detrusor muscle, outlet obstruction, DM, anti-cholinergics, antihistamines, CCB's
-
TX overflow incontinence?
- scheduled toileting (Credes maneuver)
- tx underlying condition
- alpha blockers
-
functional incontinence from...
delirium, fecal impaction, immobility, diuretics, ETOH, decongestants
-
TX functional incontinence
- remove barriers
- B&B training
- PT
- habit training
- collection devices
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