URINARY TRACT INFECTIONS
URINARY TRACT INFECTIONS DEFINITIONS Bacteruria = bacteria in urine (not necc UTI) Urethritis = inflammation of the urethra UTI = inflammatory response of urothelium to bug in urine (includes upper and lower) Cystitis = lower urinary tract inflammation of bladder resulting in frequency, urgency, dysuria, suprapubic pain (infectious and non-infectious causes) Pyelonephritis = upper urinary tract inflammation of renal parenchyma and collecting system producing fever, anorexia, back and flank pain Uncomplicated UTI = structurally and functionally normal urinary tract Complicated UTI = structurally or functionally abnormal urinary tract (Ex: underlying neurologic condition, sturctural abnormality, metabolic disorder) Recurrent infection = same bug + > 10 days after stopping treatment Relapsing infection = same bug + < 10 days after stopping treatment Reinfection = different bug + > 10 days after stopping treatment Superinfectio = different bug + < 10 days after stopping treatment EPIDEMIOLOGY Febrile infant without source: overall 5% UTI rate UTI more common in neonatal boys but girls becomes more common in infancy and later Incidence of structural abnormalities Infant male: 97% Infant female: 50% Asymptomatic bacteruria also very common 1-4% Bacteruria rates gradually increase in women such that 5-10% at 70 and 10-20% at 80 yo have bacteruria on routine checks Bacteruria in men is less uncommon unless catheterized or scoped: rates do increase in elderly 3% at 70yo, 10% at 80yo PATHOPHYSIOLOGY Urine is normally sterile until external sphincter in men and bladder neck in women Complete bladder emptying with urination is a major defense to prevent bacteruria Any factor that prevents complete emptying (stricture, cath, fb, etc) and/or promotes stasis of urine increases infection rate Men normally have staph, strep in distal urethra without problems Women are more prone to UTI b/c of short urethra and fecal bug contamination in area Retrograde entry is by far the MCC of UTI Name risk factors for developing a UTI Catheter: 1% of outpatient caths get uti; 15% of pregnant or debilitated patients Cystosope Foreign body Ureteric or urethral strictures Obstruction from renal calculi Abnormal posterior urethral valves Vesicoureteral reflux Prostatic hypertrophy obstructing urine Diabetes b/c of increase glucose in urine (may be initial dx clue of recurrent uti) Pregnancy b/c of incomplete bladder emptying from uterine pressure What bugs cause UTIs? BUG NOTES K Klebsiella Occurs more often in institutionalized E E.coli Ecoli cause > 80% of UTIs E Enterococcus Occurs more often in institutionalized P Proteus Pseudomonas Occurs more often in institutionalized S Staphylococcus saprophyticus Coag -ve gram positive Causes 11% (2nd MCC of UTIs) Normal skin flora in perineum Serratia Adhesions = fimbriae that allow the bugs to attach to receptors on the uroepithelial cells and not be flushed out with urination Resistence to antibiotics common due to plasmid transfer (exchange of DNA between bugs) Is the distinction between lower and upper tract infections important? Lower: generally only involves the superficial mucosa of the bladder and high urinary concentrations of antibiotics are easily obtained and resolves quicker Upper: involvement of medullary tissue is a “deeper” infection and also b/c of kidney involvement it is more difficult to obtain high urine concentrations of abx CLINICAL FEATURES Infants: lethargy, vomiting, poor feeding, fever, irritability, diarrhea, FTT Children: abdominal pain, dysuria, frequency, fever Check urine in kids with very low threshold!! Fever is a poor indicator of severity of infection Lower: dysuria, frequency, urgency, hypogastric pain Upper: fever, anorexia, nausea, vomiting, back/flank pain Lower vs upper tract is actually not very accurate clinical distinction: one study showed that 3050% of women with only lower tract symptoms have involvement of kidneys URINE COLLECTION Catheter (or suprapubic aspiration) Neonates Infants Young children Elderly, debilitated especially women Bag specimen Only useful if -ve +ve needs to be followed by cath Do NOT send for culture (95% false +ve rate) Midstream Appropriate in older children and adults Best samples are from men Skin prep important to decrease contamination Debatable how good this is!! One study collected midstream urines on women with document proven sterile urine by cath specimen 50% of women grew bacterial colonies which ranges in numbers from 10^3 to 10^5 Evaluating contamination Bacteria present with moderate to high numbers of epithelial cells = contamination Bacteria presnet with no or few epithelial cells = clean Note that leukocytes are picked up from perineum thus leuks can be contamination related URINALYSIS Leukocyte esterase Enzyme found in wbc.s Nitrite Produced by nitrate reductase which is an enzyme found in gram -ve bacteria Microscopy Looking for wbc.s, bacteria, epithelial cells There are chamber counting methods but most are done by direct counting Direct counting affected by centrifugation, specimen handling, operator, etc NO specific level of pyuria is diagnostic of UTI Urine culture is the gold standard, not R/M See peds summary for specificity Wbc > 5/hpf Wbc > 10/hpf Bacteria Not 100% sensitive Not 100% specific See peds summary Bacteria by a catheter or suprapubic aspiration is much more specific than bacteria by midstream or bag specimen Gram Stain Helps differentiate leukocytes from epithelial cells and bacteria Gram stains more likely positive in coliforms vs staph Combinations Sensitivity/specificity varies with studies depending on what culture is defined as being positive (ranges from 10^2-10^6 CFU/ml) Urine Culture Definitive dx of UTI What is a positive culture? 10^5 CFU/ml is the traditional cutoff 10^5: 95% chance of infection 10^4: 50% chance of infection 10^5 number came from studies with upper tract infection! Study: 40% of symptomatic women with culture counts of bugs < 10^5 will yield bacteruria by suprapubic aspiration This is a consistent number in the literature where 30 - 50% of women with cystitis symptoms have -ve culture by the 10^5 CFU/ml criteria Thus some suggest that women with lower tract symptoms who grow a known UTI bug from a clean specimen with > 10^2 CFU/ml is a specific indicator of UTI Q: what are the Indications for urine culture (Box 94-1) Q: who are at high risk for bacteremia, complicated UTIs, resistent organisms (Box 94-2) SUSPICIOS HISTORY FOR NON-DIAGNOSTIC R/M (IND FOR CULTURE) Increased risk of complicated UTI and bacteremia Young: neonates, infants, children < 12yo Elderly Immunocompromised Longer duration (symptoms >5 days) Signs of an upper tract infection Signs of systemic toxicity (fever, tachycardia, sepsis) Significant comorbitidies (DM, sickel, cancer, debiliating dz, alcoholism) Urinary obstruction or reflux for any cause (including stone) Pregnant women Increased risk of unusual or resistant organims Recent catheterization or instrumentation Males Partially treated and treatment failures Patient taking antibiotics for other reason Recurrent renal infections Recently hospitalized IMAGING Majority do not require imaging Ultrasound R/o renal or perirenal abscess and obstructions that need to be drained: indicated in septic patients and those with fever > 72 hours of antimicrobial therapy Pediatrics to r/o structural renal anomalies All boys with first time UTI All girls under 4 yo with first time UTI VCUG Best test to look for reflux Less radiation than IVP Pediatric imaging Rationale? detect renal and ureteral abnormalities to prevent recurrent UTIs, renal scarring, renal failure, hypertension Which tests? ultrasound and VCUG When? within weeks as outpatient unless septic in ICU CT IV contrast CT abdomen is very good at looking for pyelonephritis, abscess, hydronephrosis, hydroureter, masses, alternative dx Generally not done as initial tests SPECIAL POPULATIONS Pregnancy 10% incidence Higher prematurity and fetal mobidity, preterm labor, anemia Pyelonephritis rates are much higher (20%) Compressive and hormonal precipitants to infection MUST treat asymptomatic bacteruria as complications are common Must pick safe antibiotics in pregnancy: cephalosprins, penicillins, nitrofurantoin, septra if used before third trimester Lower threshold for admission and iv abx Close follow up needed Diabetes and Sickle cell Increased risk of pyelonephritis, papillary necrosis, and perinephric abscesses Admit, iv abx Indwelling Catheters Do not treat asymptomatic bacteruria (promotes resistance) Remove catheter if possible for asymptomatic bacteruria Treatment includes antibiotics and replacing the catheter Note that chronic indwelling catheters are “special” catheters that have lower infection rates Lower threshold for iv therapy and admission b/c higher risk of bacteremia, unusual bugs and treatment failures DDX OF DYSURIA Lower and upper UTI Urethritis from STDS Vulvovaginitis Prostatis Chemical irritants Allergic inflammation Trauma DIAGNOSIS HISTORY PHYSICAL LABORATORY UTI (upper and lower) Feels internal Sudden onset Frequency, urgency, small volume voids Suprapubic tenderness Flank tenderness Fever Pyuria Hematuria Bacteruria Positive urine culture URETHRITIS FROM STDS Feels internal Gradual onset STD risk factors Frequency, urgency less common Vaginal discharge Vaginal or cervical discharge Vulvar lesions Pyuria No hematuria No bacteruria Urine Culture -ve Abnormal cervical smear STD culture +ve VULVOVAGINITI S Feels external Gradual onset Vaginal discharge Vaginal odor Vaginal discharge No pyuria No hematuria No bacteruria Urine Culture -ve Abnormal cervical smear Vaginal smear +/- positive TRAUMA, IRRITATION, Feels external None of above No pyruia DIAGNOSIS HISTORY IRRITATION, ALLERGY Gradual onset Trauma to area Creams or other irritants/allergens to area PHYSICAL LABORATORY No hematuria No bacteruria Culture -ve APPROACH TO DDX OF DYSURIA UTI is the MCC of dysuria but must think of urethritis and vaginitis Chlamydia may be present in up to 20% of women with dysuria STD risks, vaginal discharge, or wbc.s on urine without bacteria: should do pelvic and cervical cultures and or urine for chlamydia Vaginitis dysuria is often described as “external”; vaginitis will not cause frequency/dysuria If unsure of UTI vs STD, do urine C/S and cervical cultures TREATMENT General Duration Ecoli is the MC bug and resistance varies Resistance is increasing Ampicillin resistance is 30-45% Septra resistance is 15-30% Cranberry juice: one study showed that 300 ml of cranberry juice per day decreased the bacteriuria with pyuria in elderly women Controversial Shorter duration with lower tract, longer with upper tract Some studies have looked at single dose therapy; slightly lower cure rates Longer duration has no benefit for lower tract unless high risk or complicated Three days po therapy is indicated for uncomplicated lower UTI CMAJ study this year showed equal efficacy with less s/e Lower tract low risk: 3 days Lower tract higher risk: 7 days Upper tract; 10-14 days Antibiotic choices PO: septra, nitrofurantoin, keflex, ciprofloxacin, ofloxacin, amoxicillin IV: ceftriazone, ampicillin + gentamycin, ciprofloxacin, levofloxacin, etc Choice depends on low risk vs high risk and local resistance patterns, Hooton et al JAMA 1995: septra po X 3/7 was the most cost effective Amoxil: resistance is too high to use Ampicllin: resistance is too high to use Fluroquinolones should generally be reserved for complicated UTIs, recurrent, or resistant UTIs Nitrofurantoin Excellent urine concentration Cheap and effective Low serum levels thus low side-effects Consistent bacterial resistance - Doesn’t cover proteus and klebsiella as well as septra MacroBID is the macrocrystalline form which has less GI s/e MacroBID: 100 mg po bid X 3/7 - 7/7 (take with food to decrease GI side effects) - Excellent urine concentration Cheap and effective Covers klebsiella and proteus better than nitrofurantoin Has more GI side-effects than macrobid Trimethoprim: inhibits dihyrdofolate reductase thus decreases the production of folate (folate antagonist) Sulfamethoxazole: competes with PABA (para-aminobenzoic acid) which decreases the bacterias ability to produce folate Complications: steven’s - johnson syndrome, toxic epidermal necrolysis, fulminant hepatic failure, aseptic meningitis, aplastic anemia Don’t use in pregnancy (cleft palate, etc) Adults: septra DS one tab bid X 3/7 - 7/7 or regular septra two tabs bid Children: 0.5 ml/kg bid Septra Ciprofloxacin Gentamycin - Lower tract: 250 mg po bid X 3/7 - 7/7 Upper tract: 500 mg po bid X 7/7-10/7 Covers all uti bugs except only 75% coverage of enterococcus Note association with tendon rupture Can cause Cdiff, rashes, photosensitivity Do NOT use in kids (bones), pregnancy, or lactating women VERY concentrated in urine Ceftriaxone + gentamycin iv if septic Ceftriaxone covers most bug but gentamycin is very concentrated in the urine Also adds ENTEROCOCCUS coverage which ceftriaxone does not cover ANTIBIOTIC SELECTION IN LOWER TRACT UTIs Low Risk No high risk features Duration = 3 days Antibiotics Septra DS one tab bid X 3/7 MacroBID 100 mg po bid X 3/7 with food Ciprofloxacin 250 mg po bid X 3/7 Higher Risk Longer duration (>5 days) Significant comorbid illness (DM, sickle, cancer, debiliating dz, alcoholism) Urinary tract abnormalities Recent catheterization or instrumentation, or hospitalization Taking antibiotics for another reason Recurrent infection Males Antibiotics Septra DS one tab bid X 7/7 MacroBID 100 mg po bid X 7/7 with food Ciprofloxacin 500 mg po bid X 7/7 NB: go to ciprofloxacin for structural abnormalities or significant comorbidities Pregnancy (UTI or asymptomatic Bacturuiria) Duration = 7 days Antibiotics MacroBID 100 mg po bid X 7/7 Amoxil 250 mg po tid X 7/7 Keflex 500 mg po qid X 7/7 UPPER TRACT INFECTION PO therpay No indications for iv Duration = 10 - 14 days Antibiotics Septra DS one tab bid X 10/7 Ciprofloxacin 500 mg po bid X 10/7 IV therapy IV therapy until stable and afebrile X 24hrs Urosepsis Vomiting Immunosuppressed < 3months or elderly Pregnant Urinary structural abnormality or stone dz Antibiotics Ceftriaxone 1gm q 24hr (add gentamycin if septic) Ciprofloxacin 400 mg iv q 12hr Ampicillin 1gm q6hr + Gentamicin 1mg/kg q8hr Admission > HPTP Significant dehydration or ongoing vomiting Immunosuppressed < 3 months or elderly Pregnant Structural abnormality or stone dz Social factors PEDIATRIC UTIs EPIDEMIOLOGY 3% of girls before 11yo 1% of boys before 11yo Neonates: more common in boys Infancts and children: more common in girls PATHOPHYSIOLOGY Ecoli is still the MC bug Proteus is more common in older boys Klebsiella is more common in neonates Neonates: blood borne source thus high frequency of sepsis Infants and children: urethral source CLINICAL FEATURES Neonates Poor feeding Vomiting Irritability Lethargy Hypothermia Fever Failure to thrive Sepsis Infants Poor feeding Vomiting/diarrhea (esp vomiting w/o diarrhea) Fever Strong - smelling urine Younger Children Abdominal pain Vomiting Strong - smelling urine Fever Enuresis Frequency, dysuria, urgency Older Children Fever Enuresis Frequency, dysuria, urgency CVA tenderness HOW TO COLLECT THE URINE Age < 3 months: cath and no questions > 3 years: clean catch hopefully Inbetween: cath, bag, suprapubic tap Indications for cath urine Age under 3 months Urosepsis Known structural urinary abnormaltiy Prior history of UTIs Recurrent or relapsing infections Positive bag specimen 3 months - 3 years: who to cath? Strong suspicion: go for cath because you will need it anyways Low suspicion: start with bag, stop if R/M is -ve (dip isn’t good enough in kids) Parental preference: discuss options of waiting, needing cath anyway Complicated history: abnormal anatomy, recurrent/relapse infection What is a positive microscopy? wbc > 5/hpf by cath wbc > 10/hpf by bag What is a positive culture? Bag cultures are useless Cath cultures > 10^??? INDICATIONS FOR ULTRASOUND AND VCUG See pediatric UTI practice parameter MANAGEMENT Age < 3 months Admit all IV ampicillin and gentamycin Alternative is cefotaxime Do not need to do LP: recent study showing that majority of csf where -ve and when they were +ve it was the same bug and did not change managment Age 3 - 6 months Management is controversial Some use admission and iv abx for all Some use outpatient iv therapy for all Some use outpatient po therpay for all Increasing use of outpatient management Follow up and social factors must be tight for outpatient therapy Outpatient therapy = suprax (cefixime) Indications for iv therapy Signs of toxicity Vomiting High risk for complications: structural urinary abnormalities Immunocompromised states Age > 6 months - 12 years Indications for iv therapy Urosepsis/toxicity Vomiting Immunosuppressed Urinary structural abnormality or stone dz Antibiotics for oral therapy 6mo - 2yrs: Suprax (cefixime) 8 mg/kg od (NOT BID) > 2 yrs: Septra 1ml/kg bid X 7-10 days UTI, PROSTATITIS, URETHRITIS IN MEN GENERAL UTI uncommon in abscence of instrumentation Lack of circumcision, anal sex, BPH are other risk factors Pneumaturia with gas forming organisms or vesicoenteric fisutlas is described Prostatitis should be on ddx: examine the prostate! Men should have a urine culture done b/c it is uncommon Similar treatment: septra, cipro, macrobid PEARLS of UTI in men Obstruction must be rule out as a cause Obstruction must be dealt with if there is a UTI (very high risk of sepsis): ? Does this mean urgent TURP for BPH with obstruction then UTI Have a lower threshold for urology referral in men to r/o obstruction Urethral catheterization is only indicated with urinary retension: the risk of causing an infection should deter catheterization simply for specimen collection Retention + UTI: abx for UTI and catheter to overcome retention PYELONEPHRITIS As above May present with gross hematuria High risk for gram -ve sepsis Urine culture should be done R/O obstruction if there is no clear precipitant (catheter): ultrasound, IVP Obstruction: BPH, prostatic ca, renal calculi, ureteral strictures, urethral strictures, other tumors Oral therapy: septra, cipro IV therapy: ceftriazone, cipro URETHRITIS Gonococcal (GU) Non-gonococcal (NGU): chlamydia, myocplasma, ureoplasma If you have GC you have chlamydia 50% of the time and vica versa so just treat for both! Gonococcal urethritis: almost all are symptomatic and majority will have discharge Chlamydial urethritis: 25% will have NO signs or symptoms Must consider on ddx of dysuria in men (probably more common than uti in right age group) Swab urethral discharge or pass swab 2 cm into urethra and swirl Gram stain of discharge can be diagnostic First day void for chlamydia and gonorrhea can be done Urine for Chlamydia: 15 ml of FIRST VOID into sterile container and take to lab Consider ureoplasma, HSV, trichomonas, candida if symptoms persist despite treatment Associations Gonorrhea: dermatitis, arthritis Chlamydia: reiter’s syndrome Proper collection of urethral samples Label specimens as urethral discharge (not just penis) Use the blue Genprobe kit Insert 2-4 cm and rotate When to do a charcoal swab? Persistent symptoms and/or treatment failure should have a charcoal swab sent for GC culture Mycoplasma/ureaplasma: submit a mycoplasma DUO transport media swab Treatment Azithromycin 1 mg po X 1 (chlamydia) + cefixime 400 mg po X 1 (GC) Doxycycline 100 mg po bid X 7/7 + ciprofloxacin 500 mg po X 1 PROSTATITIS Bugs are KEEPS Majority are Ecoli (80%) Remainder are proteus, enterococcus, klebsiella, pseudomonas (20%) Acute Bacterial Prostatitis Fever, chills, low back pain, perineal pain, pelvic pain, hypogastric pain, buttocks Dysuria, frequency, urgency, urinary retention Must be on DDX of any elderly male with dysuria Malaise, arthralgias, myalgias Exam: tender, swollen gland that is firm and warm May have spontaneous urethral exudate Do not massage as this increases bacteremia Cystitis occurs with prostatitis in majority thus urine culture will reveal bug; prostatic massage in the acute prostate is not warranted to express discharge Duration of treatment = 30 days Oral Rx: Septra DS one tab bid X 30 days or ciprofloxacin 500 mg po bid X 30 d IV Rx: Ampicillin 2 gm iv q6hr + Gentamycin 7 mg/kg q 24hr Consult urology if associated urinary retention Septra is concentrated in prostatic secretions Chronic Bacterial Prostatitis Frequency, dysuria, urgency +/- pelvic or abdo pain with a flare of chronic prost Fevers and chills are uncommon Examination of the prostate is usually unremarkable (non-tender) Relapsing UTI by same organism is the HALLMARK of chronic prostatitis Prostadynia Dx: prostatic massage produces secretions in first 10 ml urine with > 10 wbc/hpf Septra has good prostatic penetration and is actually concentrated in secretions Septra DS one tab bid X 4-12 weeks or cipro 500 bid X 30 days Prostate pain without evidence of infection No wbc.s in urine Prostate nontender RENAL CALCULI INTRODUCTION 95% have underlying specific pathophysiology and are not simply idiopathic All types of stones have a common pathogeneisis based on excessive supersaturation 3:1 male to female (except infection stones which are MC in female) Prevelence: 7% of men, 3% of women Majority (75%) occur b/w 20-50 yo; PEARL first onset “renal colic” in > 50yo is uncommon thus look for something else: AAA, cancer, renal infarct, etc Calcium stones are the MC stones in males, females, and children Recurrence is 50%; recurrence peak at 1-2yrs and 8-10yrs Risk factors for renal calculi Male, fhx, older Primary hyperparatyroidism Mil-alkali syndrome Sarcoidosis Crohn’s Laxative abues Recurrent UTI RTA type I TYPES OF STONES Calcium oxalate stones (75%) Struvite = Magnesium-ammonium-phosphate stones(15%) Uric acid stones (10%) Cystine stones (1%) CALCIUM OXALATE STONES Idiopathic Hypercalcuria MC (70% of all nephrolithiasis) in adults AND children Patients have hypercalcuria but NOT hypercalcemia (b/c of hormones) Treatment fluids (double or triple to be effective; keep urine white) thiazides are the most useful Rx (increases resorption of calcium; contraindicated in hyperparathyroidism) sodium cellulose phosphate orthophosphates allopurinol low calcium diet Primary Hyperparathyroidism MOST frequent single primary systemic disorder assoc w/ nephrolithiasis must R/O by serum calcium level (> 10mg/dL X or 12.6mmol/L X 3) 55% have nephrolithiasis treatment: removal of adenoma or subtotal parathyroidectomy for hyperplasia Idiopathic Calcium Lithiasis All labs normal; often have low urine volume Treatment: high fluid intake, low calcium diet, low oxalate diet, thiazides Excess oxalic acid: Small bowel disease: crohns, ulcerative colitis, radiation enteritis, jejunoileal bypass STRUVITE STONES Infection Stones Only stone more common in females 80% of all staghorn calculi are struvite Urease-induced b/c splitting of urea by urease is the source of MGNH4PO4H20 E. coli is NOT urease producing (KEPS) MCC are Proteus, Pseudomonas, Klebsiella, Staph aureus Infection can also produce soft, mucoid, radiolucent concretions called matrix concretions which may mineralize to form a staghorn calculus (big stone) Evaluation: blood and urine biochemistry, urine C/S, radiological evaluat Therapy: surgical removal is mainstay + medical Rx for infection URIC ACID STONES ONLY radiolucent stone (note -ve CT in suspected renal colic; could be radiolucent stone) Uric acid from diet (purines) and endogenous Predispositions (i) hyperuricosuria, (ii) acid urine (iii) decr urine volume Etiology: hyperurecemia, idopathic (MCC), diet Think of in people with GOUT! Treatment fluid intake of 2L/d low purine diet (meat, fish, poultry) alkalinization allopurinol (xanthine oxidase inhibitor, use if stones recurr or if 24hr uric acid excretion > 600mg./d) CYSTINE STONES Cystinuria autosomal recessive affecting aa transporters in kidney and GIT excessive excretion of COLA (cysteine, ornithine, lysine, arginine) usu presents in 2nd or 3rd decade but may present earlier stones are radiopaque urinary sediment shows hexagonal benzene crystals screen by cyanide-nitroprusside test (positive is a purple-red color) NOT as common as calcium stones in children treatment hydration usu effective alone alkalinization w/ bicarb and acetaozolamide D-penecillamine (many s/es: sensitiviey, blood cell disorders, VitB6 inhibition, etc, etc) .... works by increasing solubility in urine PATHOPHYSIOLOGY Ureteric obstruction, shifting of blood flow to opposite kidney, decreased GFR to effected kidney, peristalsis decreases Irreversible damage from complete obstruction does not occur until 1-2 weeks Irreversible damage can occur from incomplete obstruction but this is less common Passage determined by size < 5mm 90% spontaneously pass 5 - 8mm 15% spontaneously pass > 8 mm 5% spontaneously pass Five common locations of obstruction Renal calyx Ureteropelvic junction = UPJ (1cm pelvis narrows to 2-3 mm ureter) Pelvic brim (ureter crosses under the iliac vessels) Ureterovesicular junction = UVJ (most common location for impaction because the ureter enters the muscular coat of the bladder and is narrow) Vesicular orifice CLINICAL FEATURES Onset at night or early morning is classic Abrupt onset that reaches maximal intensity very quickly Flank and back pain that radiates to lower quadrant, inguinal region, testicle or labia May be constant or colicky (renal colic actually a misnomer as most have constant pain) Constant pain related to obstruction, hydronephrosis, capsular tension Unilateral, colicky pain related to ureteral spasm Frequency, urgency, dysuria occurs as the stone nears the bladder May be misdiagnosed as a UTI (note blood > wbcs, no bacteria, unilateral severe pain) Classically can’t sit still (peritonitis doesn’t want to move) Fever suggests alternative dx or renal colic + UTI Abdominal tenderness is minimal or absent EVALUATION Urine pH > 7.6 suggest urease splitting organisms present in urine. TRA is dx Urine proteinuria from blood leaking in Urine for crystals may show calcium oxalate, uric acid, etc R&M Hematuria sensitivity is 85% Degree of hematuria does not correlate with severity of obstruction Wbc.s can be present from blood Significant wbc.s should raise concern for infection (? What level) Bacteruria should suggest infection Culture should be done for possible infection Other lab tests CBC, urea, creatinine in all Recurrent stones Serum uric acid elevated in 50% of uric acid stone formers Serum calcium for PTH, sarcoidosis, Serum phosphorus will be up with PTH 24hr urine for calcium, phosphorus, uric acid if above do not demonstrate the cause of recurrent stones IMAGING KUB 50% sensitive and 70% specific NOT adequate for dx Only used as part of IVP Phlebolith: very round, may have lucent center Stones: irregularly shaped, no lucent center Calcified lymph nodes may also cause false +ves Sacrum makes stone identification very difficult IVP Sensitivity 95% Advantages: shows amount of hydro Contraindications: renal failure (Cr > 130), contrast allergy, multiple myeloma, pregnancy, dehydration Delayed nephrogram > 5 min after injection is most sensitive indicator Columnization: the ureter should not be seen in its entirety on a single film b/c it is a dynamic structure with normal peritalsis; with obstruction, peristalsis decreases and the volume in the ureter increases resulting in a column of dye Definitive dx = column of dye ending at a calculus The hyperosmolar nature of the contrast may actually assist the stone passage Ultrasound Good for hydronephrosis Not good for identifying stones Test of choice in pregnancy CT KUB Most sensitive test: 98%; 100 % specific (Chen J Emerg Med 1999;17: p299) Able to detect 1 mm stones and better documentation of size thus predicts course and which ones will pass Very good for alternative diagnoses: found in 10 - 35% in various series Can be done more rapidly: decreased time in ED has been shown Doesn’t cost much more ($600 vs $400) Who requires ED imaging? Controversial First presentations Uncertain dx New onset > 50 yo (uncommon) Who requires r/o AAA Syncope Age > 50 yo Vasculopaths Hypotension, tachycardia Abdominal mass No previous renal colic Which imaging test is better? Worster Ann Emerg Med Sept 2002 Fours studies met their inclusion criteria Liklihood ratio was better for CT than IVP (significant) NO RCT, generally small trials DIFFERENTIAL DIAGNOSIS OF PRESUMED RENAL COLIC AAA: mc misdx (EVER person > 40yo must r/o AAA); can have hematuria Ischemic gut Pyelonephritis Renal carcinoma Renal vein thrombosis Papillary necrosis Renal TB Renal infarct (will require infused scan!): Renal artery thrombosis (vasculopaths) Renal artery embolism (Afib, endocarditis, akinesis) Renal artery dissection (Ao dissection) Renal vein thrombosis (Hypercoag states, nephrotic syndromes) Renal artery aneurysm rupture Ovarian torsion Endometriosis Ovarian vein thrombosis Bowel obstruction Biliary colic Appendicitis (can have hematuria) PAIN MANAGEMENT IN RENAL COLIC NSAIDS NSAIDs are very effective in renal colic NSAIDs have been shown to be equally effective to opiods How do NSAIDS work in renal colic? Analgesic from PGE1 inhibition Decreases ureteral spasm Decrease renal capsular pressure secondary to decreased GFR by vasoconstriction of afferent vessel Every renal colic should get NSAID unless contraindicated Renal failure GI hemmorhage Peptic ulcer dz Asthma precipitated by NSAIDs Which NSAID? Ibuprofen 600 - 800 mg po Indocid 100 mg pr Toradol 10 - 30 mg iv (RR of GI bleed is 27 compared to other NSAIDS) Opiods Use in combination with NSAID Studies show combination > opiod alone Use alone if NSAID contraindicated Miscellaneous Fluid boluses: increase hydronephrosis, increase pain and decrease the passage of the stone (DOG study that showed stones pass through ureters better if there is dehydration vs overhydration) Buscopan has been used as an antispasmotic INDICATIONS FOR ADMISSION Absolute Persistent pain Persitent vomiting Obstruction + infection Urine extravasation Hypercalcemic crisis Solitary kidney or transplant with obstruction Relative High-grade obstruction Prior renal disease Size of obstructing stone > 6mm (definately if > 8mm) Prolonged symptoms UROLOGIC MANAGEMENT Which stones require intervention? 8/5 rule > 8mm in kidney requires intervention > 5mm in ureter urequires intervention ESWL = Lithotripsy Very useful for proximal stones 85% success rate with stones in kidney Upper ureteral stones can be pushed more proximally with the ureteroscope then blasted with the lithotripser Kidney stones < 2 cm Ureteral stones < 1 cm Scope removal Ureteroscopy or ureterorenoscopy Renal stones < 2 cm Percutaneous Nephrolithotomy Tract from the collecting system to the skin Used for stones to large for lithotripsy Renal stones > 2 cm Ureteral stones > 1 cm Open stone surgical removal Rarely used Indicated if structural abnormality that needs to be fixed or as last resort Stone + UTI = nephrostomy + stent + iv abx Acute renal failure = surgical mx High-Grade Obstruction No universal definition Generally means signficant hydronephrosis Does not need admission Urologic follow up: watch for 1-2 weeks No irreversible damage for 2-3 weeks DISCHARGE Discharge with percocet Rx RTED pain, fever, vomiting F/U with GP for calcium etc testing if recurrent stone dz F/U with urology if not passed in 4 weeks Increase fluids, low calcium, low oxalate (nuts, chocolate, rhubarb, beets, dark veggies) Thiazide diuretics for hypercalcuria Allopurinal for uric acid Who needs to strain the urine? Uncertain diagnosis Recurrent stones: take to GP for testing Some say all b/c urology referral indicated if not passed in 4 weeks VESICULAR STONES Can form in the bladder but usually are formed in kidney MC in elderly men with indwelling catheters or UTIs with urease-splitting organisms Other risks: bladder neck obstruction from BPH, neurogenic bladder, vesical diverticular, irradiation, shistosomiasis Presentation = dysuria and hematuria sudden interruption of a vesical stone is very suggestive (intermittent blockage by stone) Physical examination is normal THE ACUTE SCROTUM INTRODUCTION Medical emergency Pain, mass, swelling, aching Review anatomy: normal testis lies in vertical axis with a slight forward tilt Epididymis is above the superior pole in the posterolateral position PHYSICAL EXAMINATION Testicular size, mass, tenderness, discoloration Epididymis: size, tenderness Cremasteric reflex: stroke or pinch of inner thigh should cause elevation of testicle > 0.5 cm DIFFERENTIAL DIAGNOSIS Testicular torsion Appendix testes torsion Orchitis Testicular tumor Testicular trauma Epididymitis Varicocele Hydrocele Spermatocele Hernia: cannot get “above” mass TESTICULAR TORSION Introduction 1:4000 people 50% will lose the testicle Two peaks of incidence: < 1 year and puberty Can occur at any age Very common in undescended testicles: inguinal mass + empty hemiscrotum Pathophysiology Bell-Clapper deformity: the tunica vaginalis completely covers the testicle and attaches higher up on the spermatic cord thus the testis “dangles” in the scrotum and is moblile (normally only partly covers testicle - posterosuperior) Obstruction of venous return then vein thrombosis Increased pressure of spermatic cord then arterial compromise Testicular infarction necrosis, edema, swelling Salvage rate 80-100% if pain duration < 6hrs Pain > 24hrs has very low salvage rate Clinical Features Sudden onset of scrotal and testicular pain is classic Prior history of pain in 40% that spontaneously resolved Associated with nausea and vomiting Common after exertion or during sleep Absence of urinary symptoms is the general rule Swollen, tender, firm hemiscrotum Reactive hydroceles are common Absence of cremasteric reflex (presense of reflex is 98% sensitive) High-riding transverse lie testes (not reliable) Prehn’s sign: elevation of the testicle relieves the pain of epididymitis (this sign is UNRELIABLE) PEDS: may have predominant abdo pain Every abdo pain needs Diagnosis their NADS examined Urinalysis: wbc.s suggests epididymitis Color flow Doppler: sensitivity 85-90%, specificity 100% Radioisotope scanning: 85-90% sensitive, 95% specific Management Manual detorsion = OPEN THE BOOK This is only a temporizing maneuver until the OR Use analgesia +/- PSA to detort the testicle Open book will not always be the right direction; stop if it seems to get worse Do not do cord blocks Immediate urology referral and OR TORSION OF APPENDAGES Several vestigial appendages exist in the normal scrotum There are testicular appendages and epididymal appendages Most commonly seen in 3-13yo Symptoms usually less severe than the testicular torsion History of previous episodes is uncommon No vomiting, fever, dysuria, or penile discharge Blue dot sign of the torsed, echymotic appendage Reactive hydroceles are very common and may obscure the torsed appendage Urinalysis without pyruria or bacteruria Color flow doppler shows a normal testis Mx: rest, analgesia, ice, scrotal elevation Resolution expected in 7-10days Surgical excision is reserved for refractory cases EPIDIDYMITIS Introduction MC misdiagnosis with testicular torsion Usually occurs in adult men Average age is 25yo Rare in prepubertal kids Pathophysiology Retrograde ascent of urethral and bladder pathogens Inflammation begins in the vas deferens and descends down to the epididymis Early presenation may show inguinal pain with inflammation of the groin Inflammation and edema of the epididymis The testis may or may not become inflammed (orchitis) Bacteria in men > 35yo = Ecoli, Pseudomonas (KEEPS) Bacteria in men < 35yo = Chlamydia, Gonorrhea, Syphillus Underlying urologic pathology common in older men Majority of STD epididymitis will NOT have urethral discharge complaint Syphillus: may be more common than recognized; usually only diagnosed when syphillus is evident elsewhere Other: TB, amiodarone induced PEDS Adolescents: GC, chlamydia Prepubesent: KEEPS Clinical features Gradual onset over hours to days Reaches maximal intensity over hours, not suddenly KID COULD Febrile, low grade (38) PRESENT WITH UTI symptoms commonly preceed FEVER ONLY Very sensitive/tender scrotum General edema, eythema are NOT present in early epididymitis Cremasteric reflex present Epididymis swollen, tender after 4hours Spermatic cord may be edematous as well Prehen’s sign = relief with elevation of the testicle on that side Diagnosis Urinalysis with wbc.s and bacteria only in 50%! Bacteria will not be seen on microscopy if GC or chlamydia is the cause Culture of urethral discharge if present Pyuria, fever, bacteruria dysuria COULD STILL BE A TORSION Color flow doppler or nuc med scan indicated in majority Studies will show normal or increased testicular flow Managment Presumed STD bugs: younger, risk factors Azithromycin 1 gm po X 1 + Cefixime 400 mg po X 1 ??????? Doxycycline 100 mg po bid X 10 days (takes longer to eradicate from the epididymis than simple STD urethritis) Rosen: Ceftriaxone 250 mg im X 1 then doxycycline X 14 d MUST treat sexual partners Presumed coliform bugs: older, no STD risks Septra DS one tab po bid X 14 days Ciprofloxacin 500 mg po bid X 14 days is an alternativE PEDS (not suspecting STDs): Septra X 10 days if well; ceftriaxone or cefotaxime and HPTP or admission if sick Other Rest, Ice, Analgesics Urology referral especially older patients: many have BPH etc Counsel re complications: infertility, abscess, chronic ORCHITIS Introduction Acute infection or inflammation of the testis Rare without a preceeding epididymitis b/c testes is resistant to infection Less common than epididymitis or prostatitis Bacterial Pyogenic Orchitis Testicular spread from epididymitis Klebsiella, Ecoli, Pseudomonas, staph, strep Viral Orchitis MUMPS is the MCC = paramyxo virus Uncommon in prepubertal boys More common in pubertal boys (30%) Other: EVV, coxsachie, arbovirus, enterovirus, etc Clinical features Pyogenic: fever, marked pain, swelling of testicle, reactive hydrocele, very tender testicle, pyruia, leukocytosis Viral: testicular pain and swelling 5 days after onset of viral illness; seen 5 days after the onset of parotitis with the MUMPS; resolves in 5 days Urinalysis and urine culture should be obtained Doppler Flow Ultrasound if torsion is possible Managment Bacterial: Septra or cipro Viral: supportive, NSAID, ice TESTICULAR TUMORS MC cancer of young men Average age is 32yo Epididymitis is the MC misdiagnosis Increased incidence of tumors in undescended testis = cryptorchidism (both sides!!) Seminomas are the most common cause (embryonal cells, teratomas) Metastasis by lymphatic system Presents with scrotal swelling that isn’t classic for torsion or epididymitis Majority are not painful but may be described as “heaviness” Acute hemorrage into the tumor may produce sudden pain PEARL = positive beta HCG with certain testicular tumors Color Flow Doppler is the initial test of choice CXR for ? Mets Abdo CT for ? Mets Mx: admit, consult urology and oncology Prognosis is good with oorchiectomy and radiateion therapy VARICOCELE Collection of venous varicosities of the spermatic veins in the scrotum 15% of adolescent males Uncommon < 10 yo Left sided in 90% and can be bilateral Right sided: suspect IVC syndrome, IVC thrombosis Sudden onset left sided: renal cell carcinoma with obstruction of left renal vein Tender, swollen Swelling increases in upright position May have “bag of worm” appearance Ultrasound if any diagnostic concern Surgical correction if symptomatic or bilateral IDIOPATHIC SCROTAL EDEMA Common in kids mOst are unilateral No allergen is identified in most Painless scrotal swelling, may be pruritic Minimal tenderness Swelling may extend into groin No masses or systemic symptoms Resolves in days without treatment HYDROCELE Fluid in the tunica vaginalis Communicating = connection with peritoneum Most are right sided Painless swelling Transillumination Dopplar shows normal flow INGUINAL HERNIA Indirect = processus vaginalis does not obliterate and thus connection b/w scrotum and peritoneum Right sided more common Can lead to bowel obstruction Swelling, pain, erythema, bowel obstruction, ischemic gut all possible Ultrasound if diagnostic concern Sedation and attempted reduction Surgery consult if can’t reduce or ischemia suspected ACUTE URINARY RETENTION INTRODUCTION AUR = sudden inability to pass urine Common in elderly men 30% of men in the 70-80 range will experience Women: atonic, decompensated bladder from years of infrequent voiding Young: spinal cord diseases (MS, syringomyelia, etc) Psychogenic is rare and a dx of exclusion Drug induced is common: antihistamines, anticholinergics, alpha agonists especially Men: BPH is the MCC ETIOLOGY (think anatomically) Penis: phimosis, paraphimosis, stenosis, FB Urethra: tumor, stone, stenosis, stricture, etc Prostate: BPH, cancer Nerves: SC, syingomyelia, cauda equina Drugs: antihistamines, anticholinergics, alpha agonists, antispasmotics, opiates Psychogenic CLINICAL FEATURES Obstructive symptoms Hesitancy, straining Decreased size, caliber, force of urine stream, dribbling Interruption of urine stream and sensation of incomplete emptying Previous retention Irritative symptoms: Frequency, Urgency, Dysuria, Nocturia Prior hx of retention, urologic procedures, strictures, prostatectomy May have symtoms of UTI BPH or prostatic mass on exam inmen Palpable bladder Renal failure if severe Relative increase in BUN to Creatinine Urinalysis for UTI, also do culture IVP, ultrasound, CT not indicated in ED unless toxic or ddx unsure MANAGEMENT Urethral catheterization: 16-18 Fr catheter 18 Fr. Coude’ tip catheter: upward deflection in the distal 3 cm which allows it to pass over an elarged median lobe of the prostate and be directed toward the roof of the urethra Consult urology Suprapubic catheter placement: comercial kits or central lines Hematuria is common after decompression Hypotension can occur after decompression (vesicovascular reflex: decreased sympathetic tone) Gradual emptying is recommended but unproven thus some recommend rapid emptying Discharge with indwelling catheter and urologic follow up Those with retention and UTI need admission, iv antibiotics, urgent drainage HEMATURIA INTRODUCTION Asymptomatic hematuria occurs in 10% of men and 20% of women Gross hematuria is much more significant: 5Xs the rate of significant disease Every patient with microscopic hematuria should be told to get repeat urine by GP PATHOPHYSIOLOGY Lower tract: 60%, upper tract 40% Urologic cancer: 5% of microsocopic hematuria and 20% of gross hematuria if > 50yo Anticoagulation does not usually cause hematuria unless over anticoagulated Men > 60 yo: MCC is BPH “Worm-like” clots are highly suggestive of tumors ETIOLOGY Prerenal Renal Post Renal Factitious Coagulopathy Collagen vasc dz Sickle cell dz Glomerular (dysmorphic rbc.s, rbc casts, proteinuria > 2+) IgA nephropathy Glomeruloneprhitis Lupus neprhtis Vasculitis Non-Glomerular (normal round rbcs, no rbc casts or proteinuria) Renal cell ca Pyelonephritis PCDD Interstitial neprhitis Papillary necrosis Ureter: stone Bladder: Cysitis (infectious or inflammatory) or cancer Prostate: prostatitis, BPH Epididmis: epididymitis Urethra: urethritis, FB, factitious Vaginal bleeding Rectal bleeding Automanipulation Pigmentation (+ve dipstick but -ve microscopy) Myoglobinuria Hemoglobinuria Porphyria Foods: beets, berries, rhubarb Drugs: pyridium, qinine, rifampin CLINICAL FEATURES History Bleeding disorder Large thick clots with bladder origin Small stringy clots with kidney origin What part of the urine stream: initial is urethra; total is bladder or upper; terminal is bladder neck or prostatic urethra Pain: stone, infection, necrosis, glomerulonephritis Trauma UTI symptoms Sickle cell dz Cancer risks: older, smoker, weight loss, certain chemotherapeutics, occupational exposures to dyes and rubbers, pelvic irradiation Hematuria + erythematous skin rash + fever = IgA nephropathy Fhx deafness and renal dz = Alport nephritis Rash, arthritis, hematuria = LUPUS Hemopytis, hematiura, anemia = goodpastures ENT + Lung + kidney = Wegener’s granulomatosis Preceeding strep pharyngitis, impetigo = post strep GN Sickle cellers and diabetics get papillary necrosis Renal colic should be obvious Diagnostic strategies Dipstick is only positive if there has been lysis of rbcs or myoglobinuria Most urines with rbc.s will be positive on the dipstick but not all RBC casts suggest glomerular source Microscopic hematuria = > 3 rbc.s/hpf Exercise-Induced Hematuria Strenuous exercise Transient glomerular and post glomerular hematuria Can be from bladder microtrauma Needs cystoscopy if doesn’t resolve in 48hr DISPOSITION Hematuria without identifiable cause needs investigation Cystoscopy is the first test Ultrasound and CT are subsequent tests BLADDER CANCER B: ETIOLOGY 1. Chemical carcinogens from industrial exposure - textile workers, dye workers, tire and rubber workers, leather, bootblacks, painters, truck drivers, petroleum, hair dressers, chemical workers 2. Cigarette smoking - most important factor related to bladder CA - 40% of cases have direct relation - risk is 2X - conc of tryptophan metabolites in urine, and other carcinogens (nitrosamines) 3. Schistosoma hematobium: middle east and Asia 4.Chronic inflam of infection: stones, infection, catheter 5. Drugs: cyclophosphamide C: PATHOLOGY - 90% are Transitional Cell Carcinoma (TCC) - 5% are Squamous Cell Carcinoma (SCC) – usu related to chronic inflam (catheter,stone diver) - 2% are Adenocarcinomas DIAGNOSIS 1. Symptoms - hematuria – 85% diagnosed by investigation for hematuria *** painless, total, gross hematuria is classical presentation*** This is bladder CA until proven otherwise. - bladder irritability – frequency, urgency, dysuria 2. Diagnostic procedures - cystoscopy and transurethral resection (must be done) - urinary cytology (random, fresh specimen is best) - tumor must be in contact with urinary stream - tumor must be shed into the urine - the shed cells must be distinguished from normal urothelium 3. Radiology - IVP = excretory urethrogram - CT – limited use except for detecting mets -US – mets, hydronephros F: TREATMENT SUPERFICIAL = resection + intravesicular chemo or cystectomy INVASIVE CANCER = radical cystectomy with urinary diversion, chemo for mets MISCELLANEOUS UROLOGY TOPICS BENIGN PROSTATIC HYPERTROPHY Rx: alpha antagoinists to reduce prostate smooth muscle tone (terazocin) or 5 alpha-reductase inhibitors to redusce side (finasteride) Surgery: recurrent UTIS, refractory urinary retension, gross hematuria, renal failure PROSTATIC CANCER Non-curative therapy: > 72yo or < 15 years life expectancy Hormaonal therapy: orchiectomy, estrogens, LHRH analogs, antiandrogens Palliateive radiotherapy Curative theapy: < 72yo and > 15 year life expectancy Radical prostatectomy Radiation therapy Radiation beads Palliative Radiotherapy Painful bone mets Epidural spinal cord compression Pathological fractures Life-threatening hematuria Chemotherapy Generally for palliation RENAL TUMORS Benign Malignant Cysts: simple vs PCKD Benign paillomas Angiomyolipoma Renal cell carcinoma MC malignant kidney tumor in adults 2nd MC of renal mass (cysts are more common) Flank pain, hematuria, mass Majority actually present with hematuria and no mas Paraneoplastic syndromes are common: hormone related symptoms also common: polycythemia (erythropoeitin), hypertension (renin), hyperthyroid (TSH), hypercalcemia, cushings 30% have mets at time of dx Tx= nephrectomy Wilm’s tumor MC tumor in kids TORSION EPIDIDYMITIS TUMOR HYDROCELE TORSION EPIDIDYMITIS TUMOR HYDROCELE AGE < 1yo Pubesent Any 20-30yo Any Hx Sudden onset Maximal intensity at onset Unilateral Prior episode No dysuria etc Gradual onset Intensity builds over hours Unilateral or bilateral No prior episodes Urinary sx Gradual onset Minimal pain Gradual onset Minimal apin No urinary symptoms PE Sever tenderness No transillumination No fever Severe tenderness No transillumination Fever Minimal tendernss No fever No transillumination Transillumination URINE Urine normal Wbcs, bacteria Normal +ve Bhcg in some Normal U/S Decreased flow Normal or increased Mass Normal flow
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