GU infections

Question 1

Types of GU tract infections

Answer 1

• acute cystitis
• acute pyelonephritis
• acute bacterial prostatitis
• infectious stone disease
• epididymitis
• fournier’s gangrene

Question 2

What is acute cystitis? (causes)

Answer 2

inflammation of the bladder due to:

• bacterial infections (most common)
• stones
• interstitial cystitis
• radiation (prostate and colon cancer)
• bladder cancer

Question 3

What is the most common infection in women?

Answer 3

• bacterial cystitis
• occurs in 25-30% of women b/t 30-40 you
• 1/3 women have an infection before the age of 24
• it is uncommon for men until around the age of 50 when the prostate enlarges and can cause bladder outlet obstruction

Question 4

What is the most common cause of nosocomial acute cystitis?

Answer 4

• catheter associated infections

- bacterial colonization with catheterization occur at a rate of 5%/ day and reaches 100% in 30 days

Question 5

RFs for acute cystitis

Answer 5

• incomplete bladder emptying due to: BPH, diabetics, neuologic (pinched nerve), MS
• sexual intercourse
• benign prostatic enlargment
• stones

Question 6

Pathogenesis of acute cystitis

Answer 6

• female urethra is short, making it easy for bacteria to enter the bladder in retrograde fashion
• E. coli (most commonly found in the bowel) is the most common bacteria accounting for 85 of CA-infections and 50% of nosocomial infections

Question 7

What other organisms other than E. coli cause acute cystitis?

Answer 7

• proteus, klebsiella, pseudomonas, Enterococcus faecalis, and Staph saprophyticus
• Proteus, klebsiella pneumonia, staph saprophyticus, increases the urine pH and can lead to stone formation.
• see proteus: think stone

Question 8

Clinical presentation of acute cystitis?

Answer 8

irritative voiding symptoms:

- frequency, urgency, dysuria, hematuria (culture to make sure infection), suprapubic discomfort

Question 9

work up of acute cystitis?

Answer 9

• physical exam: pts may have suprapubic tenderness otherwise exam is usually normal
• lab work: UA, urine culture

Question 10

Tx of acute cystitis

Answer 10

1-3 days of single dose abx therapy (if complicated: 5-10)

abx therapy: 1s line

• nitrofurantoin
• Trimethoprim-sulfamethoxazole (if allergic to sulfas -> just do trimethoprim)
• cephalosporins
• fluoroquinolones should be used for comp. infections due to increasing resistant E. coli strains

Question 11

What is acute pyelonephritis and the causative agents?

Answer 11

it is an infection of the upper urinary tract including the renal pelvis and renal parenchyma

- gram - most common:
E. coli
proteus
klebsiella
enterobacter
pseudomonas

Question 12

RFs of acute pyelonephritis

Answer 12

• obstruction of the urinary tract
• stones
• UPJ obstruction, vessel crossing over
• vesicoureteral reflux: urine shoot back up when urinating
• diabetes mellitus
• female gender

Question 13

Pathogenesis of acute pyelonephrititis

Answer 13

• pathogenesis: bacteria ascend from the lower urinary tract into collecting ducts
• hematogenous route: staph aureus or candida in the bloodstream
• lymphatic: very unusual, gains access into kidney from an intraperitoneal abscess

Question 14

Clinical presentation of acute pyelonephritis

Answer 14

• fever
• chills
• flank pain
• malaise
• N/V
• irritative voiding symptoms

PE: CVA tenderness

Question 15

lab work up of acute pyelonephritis

Answer 15

CBC: leukocytosis
UA: hematuria, bacteriuria, pyuria

urine culture: positive
blood cultures: may also be positive -> pretty sick

Question 16

Imaging for acute pyelonephritis

Answer 16

renal ultrasound

abdominal and pelvic CT scan w/ and w/o contrast

Question 17

Tx of acute pyelonephritis

Answer 17

10-14 days 
parenteral or oral abx: start with IV until afebrile, then switch over to oral
- IV ampicillin or gentamicin
- IV cefazolin
- IM ceftriaxone (rocephin)
Trimethoprim-sulfamethoxazole or fluoro

Question 18

What causes acute bacterial prostatitis?

Answer 18

infection and inflammation of the prostate by:
- E. coli
- klebsiella
- enterobacter
- staph aureus
accounts for 1/4 of males office visits for GU tract sxs

Question 19

RFs of acute bacterial prostatitis

Answer 19

• BPH
• urethral stricture disease (straining)
• urethral catheterization
• neurogenic bladder
• calculi
• diabetes

Question 20

Pathogenesis of acute bacterial prostatitis

Answer 20

bacteria ascend up the urethra into the bladder and infected urine reflux into the prostatic ducts

Question 21

Clinical presentation of acute bacterial prostatitis

Answer 21

• present with vague pelvic and systemic sxs
• irritative voiding sxs
• dysuria
• perineal and low back pain
• difficulty voiding or retention

PE: prostate may be enlarged, tender or boggy
- avoid prostate massage

Question 22

Lab work on acute bacterial prostatitis

Answer 22

CBC: leukocytosis
UA: positive leukocytes, blood, and nitrites
- urine culture is +

Question 23

Tx of acute bacterial prostatitis

Answer 23

• acutely ill pts require hospitalization
• management with broad-spectrum abx ( ampicillin and gentamicin) until culture is back
• switch to oral abx after pt is afebrile for 24-48 hours
• 4- 6 weeks: trimethoprim-sulfamethoxazole or fluoroquinolone
• for urinary retention a percutaneous suprapubic tube should be placed

Question 24

Chronic bacterial prostatitis

Answer 24

can be a sequela of acute bacterial prostatitis, bacterial ascend up the urethra and into the prostate like ABP

• gram - rods: most common
• e. coli 80% of cases, klebsiella, pseuodomonas aeruginosa, and proteus less common
• pts presents same as ABP -> suprapubic pain
• some patients require a prostate massage
• meares-stamey four glass test
  1: test 2: midstream 3: massage prostate and test again 4: rest of the urine

Question 25

Tx of chronic bacterial prostatitis

Answer 25

- 4-8 weeks of abx - anti-inflammatories - hot sitz baths - alpha blocker

Question 26

What is infectious stone disease and struvite stones?

Answer 26

struvite stones: composed of combo of magnesium ammonium phosphate and carbonate apatite - more common in females - formed from urease producing organisms that split urea into ammonia

Question 27

What are the possible causative agents of struvite stones?

Answer 27

- proteus mirabilis most common - H. flu - staph aureus - klebsiella

Question 28

Where do the struvite stones end up?

Answer 28

known to encompass the entire collecting duct of the kidney, known as stag horn calculus - they are radiodense, CT scans, renal ultra sounds, KUB will detect stone ( KUB won't detect uric acid stones)

Question 29

Tx of struvite stones?

Answer 29

tx: fluoroquinolones, percutaneous nephrolithotomy (break up the stone -> get cultured, figure out what is causative agent. Stone needs to come out

Question 30

what is epididymitis? causative agents?

Answer 30

- most common cause of scrotal pain in adults in outpt setting - most commonly caused by infection - can be acute or chronic - chlamydia trachomatis and neisseria gonorrhoeae most common organisms in men under age of 35 - older men: suspect E. coli or pseudomonas

Question 31

presentation of acute epididymitis?

Answer 31

- severe swelling, and exquisite pain of surrounding structures - fevers - irritative voiding sxs - clinical features: palpation reveals induration and swelling of involved epididymis with pain - some develop a hydrocele if infection to testicle

Question 32

Dx and Tx of acute epididymitis?

Answer 32

dx: made clinically and may be confirmed with urine studies - scrotal US Tx: ceftriaxone 250 mg IM one dose + doxy 100 mg bid x 10 days - alt to doxy: azithro - if suspect abscess refer to urology

Question 33

chronic epididymitis presentation and findings

Answer 33

- scrotal or testicular swelling - discomfort - usually lack irritative voiding symptoms - think about other abnormalitis of GU tract: kidney stone? clinical features: subtle induration or tenderness, w/ or w/o swelling - may feel inflammatory nodule with nontender epididymis - UA usually negative TX: conservative

Question 34

What is Fournier's gangrene? clinical features?

Answer 34

- necrotizing fasciitis of the perineum caused by mixed infection of aerobic/anaerobic bacteria ``` clinical features: tense edema of scrotal wall blisters/ bullae subcutaneous gas fever tachycardia/ hypotension Dx: CT and MRI ``` ( this is seen in uncontrolled diabetics that are obese -> not painful so it goes unnoticed)

Question 35

Pathogens of mourner's gangrene?

Answer 35

GABS anaerobic species: bacteroides and clostridium Enterobacteriaceae: E. coli, enterobacter, klebsiella, proteus

Question 36

Tx of fournier's gangrene?

Answer 36

surgical | empiric: carbapenem or beta lactam + Beta lactamase inhibitor PLUS clindamycin PLUS agent against MRSA (vanco)

Question 37

Causes of acute cystitis?

Answer 37

- incomplete bladder emptying and sexual intercourse - more common in females - E. coli usual pathogen - just use fluoroquinolones for complicated infections

Question 38

Acute pyelonephritis summary?

Answer 38

gram - rod most common (E. coli) - flank pain, fever and chills at presentation - need to rule out obstruction

Question 39

Acute bacterial prostatitis summary?

Answer 39

E. coli most common pathogen - very tender prostate, prostate massage CI - may have to be hospitalized - tx includes IV and oral abx

Question 40

Chronic bacterial prostatitis summary

Answer 40

- gram - rods most common - physical exam can be normal - prostate massage useful for dx: meares - stamey four glass urine test - tx 4-6 weeks with TMP-SMX or fluoroquinolones * saw palmetto: herbal supplement for good prostate health and decreases inflammation

Question 41

Struvite stones summary

Answer 41

most common in females - composed of magnesium ammonium phosphate and carbonate apatite - proteus most common pathogen - can form in weeks or months -> usually form into stag horn calculi - pts usually need percutaneous nephrolithotomy for removal

Question 42

summary of epididymitis

Answer 42

swollen testicle, in young adults: think STI, tx with doxy plus cephalosporin (gonorrhea)

Question 43

Summary of fourneir's gangrene

Answer 43

- seen in obese uncontrolled diabetics - need imaging to evaluate extent - mixed aerobes/anaerobes or group A strep tx: surgery and combo abx: carbapenems, or B-lactam+ lactamase inhibitors + vanco + clindamycin