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Pain in the throne

Cristal Ann Laquindanum


TMC ER Rotation

History of Present Illness

Few hours PTC,

Dysuria
Urgency
Frequency
Low back pain
No hematuria
No hypogastric pain
No suprapubic pain
No fever

No consult
No medications

Review of Systems

No vaginal discharge
No vaginal irritation
No cough/ cold
No fever
No loose stools
No chest pain
No dizziness
No palpitations

Past Medical History

UTI (early this year)


Treated, resolved

No past surgeries and hospitalizations


No hypertension, diabetes, asthma
Allergies to Amoxicillin

Family History

Unremarkable family history

Personal Social History

Non-smoker, non-alcohol drinker


Housewife

OB-Gyne History

LMP: Feb 11 (day 5 of menstruation)


3-5 day duration, 28-30 day interval of
menstruation
G0

PHYSICAL EXAMINATION

Vitals
64.5 kg 168 cm
(BMI: 22.9, normal weight)
BP: 110/70
PR: 60 beats/min
RR: 18 breaths/min
Temp: 36.8 C

HEENNT
Anicteric sclerae
Pink conjunctivae
No TPC, No CLAD
Neck veins not dilated
Dry lips, moist buccal mucosa
Nonhyperemic pharynx

Chest/Lungs
Symmetrical chest expansion
Resonant on percussion
Equal tactile and vocal fremiti
No retractions
No rales
No wheezes

Heart
Adynamic precordium
No heaves or thrills
Apex beat is at 5th ICS MCL
Normal rate, regular rhythm
No murmurs

Abdomen
Flat, soft abdomen
No tenderness
No organomegaly
No masses
Normoactive bowel sounds

Urinary
No CVA tenderness

Extremities
Full pulses
No edema, no cyanosis
Good turgor
No rashes, no lesions
Equally distributed hair
No clubbing
CRT <2sec

31 female
Painful urination
Acute presentation of:

Dysuria
Urgency
Frequency
Low back pain
No hematuria
No hypogastric pain
No suprapubic pain
No fever

Afebrile
Soft, non-tender abdomen
No CVA tenderness
Sexual history?

Previous history of UTI

Salient Features

CLINICAL IMPRESSION
Urinary Tract Infection

Clinically, acute uncomplicated cystitis is suspected in


non-pregnant women, 18-64 years old, presenting with
dysuria, frequency, or gross hematuria, with or without
back pain. Risk factors for complicated urinary tract
infection must be absent.

Acute uncomplicated cystitis


The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

The most common


agents are the gramnegative bacilli.

Etiology

Escherichia coli
Proteus
Klebsiella
Enterobacter
Serratia
Pseudomonas

Gram-positive cocci
play a lesser role in
UTIs.

Etiology

Staphylococcus
saprophyticus
Enterococci
Staphylococcus
aureus

urinary tract should be viewed as a single anatomic unit


bacteria gain access to the bladder via the urethra
alteration of the normal vaginal flora by antibiotics, other
genital infections, or contraceptives (especially
spermicide)
Loss of the normally dominant H2O2-producing
lactobacilli in the vaginal flora facilitate colonization by
E. coli.

Pathogenesis

Why females?
proximity to the anus, its short length (~4 cm), and its
termination beneath the labia
Found in 2-8% of pregnant women
decreased ureteral tone, decreased ureteral peristalsis, and
temporary incompetence of the vesicoureteral valves

How about males?


Uncommon; entertain a possibility of heterosexual or
homosexual rectal intercourse
urethral obstruction due to prostatic hypertrophy

Pathogenesis

Obstruction?
Any impediment to the free flow of urine (tumor, stricture,
stone, or prostatic hypertrophy) results in hydronephrosis

Dysfunction?
Interference with bladder enervation, as in spinal cord
injury, tabes dorsalis, multiple sclerosis, diabetes, and other
diseases

Reflux?
common among children with anatomic abnormalities of the
urinary tract as well as among children with anatomically
normal but infected urinary tracts

Pathogenesis

Cystitis

Pyelonephritis

History

dysuria, frequency,
urgency, and suprapubic
pain

Generally develop rapidly


fever, shaking chills, nausea,
vomiting, and diarrhea
symptoms of cystitis may or may
not be present
Hematuria in acute phase

PE

tenderness of the urethra or Tachycardia, muscle tenderness,


the suprapubic area
CVA tenderness
grossly cloudy and
malodorous urine; bloody
in ~30% of cases

Laboratory

White cells and bacteria


can be detected (102 to

pyuria (> 5 wbc/hpf of centrifuged


urine) on urinalysis and bacteriuria
with counts of > 10,000 cfu of a
104 bacteria per milliliter
of urine no bacteria seen) uropathogen/ml on urine culture

Clinical Presentation

Urethritis
30% of women with acute dysuria, frequency, and pyuria
have midstream urine cultures that show either no growth or
insignificant bacterial growth
Distinguish between sexually-transmitted pathogens and
low count E.coli or staphylococcal infection
Chlamydial or gonococcal infection

Gradual, >7 days of symptoms


no hematuria
no suprapubic pain

E.coli UTI

abrupt onset, <3 days of symptoms


gross hematuria
suprapubic pain
history of UTIs

Clinical Presentation

Infectious

Physical

Cervicitis
Urethretis
Vulvovaginitis

Urethral strictures
Tumor

Differential diagnosis

In women who present


with additional
symptoms such as
vaginal discharge or
vaginal irritation, either
a standard urine
microscopy or dipstick
for LE and nitrites can
be done to confirm the
diagnosis

Pre-treatment urine
culture and sensitivity
is not recommended
Standard urine
microscopy and
dipstick leukocyte
esterase (LE) and nitrite
tests are not
prerequisites for
treatment

Diagnostics
The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

Urinalysis

Light yellow
Turbid
pH 7.0
SG 1.015
RBC +3 (39/hpf)
Protein +1
WBC +3 (260/hpf)
Epithelial 3/hpf
Casts 0/hpf
Bacteria 251/hpf

What was done?


The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

ANTIBIOTICS THAT CAN BE USED FOR ACUTE UNCOMPLICATED CYSTITIS

Therapy
The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

Levofloxacin 500mg OD x 7 days


Etoricoxib (Arcoxia) 12 mg PRN

What was given?


The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

Ampicillin and amoxicillin should not be used

Three-day therapy is the recommended duration of


treatment except for nitrofurantoin, which must be given
for 7 days.
Post-treatment urine culture not recommended

The Philippine Clinical Practice Guidelines on the Diagnosis and


Management of Urinary Tract Infections in Adults, 2004

Patients whose symptoms worsen or do not improve after


3 days should have a urine culture and the antibiotic
should be empirically changed, pending result of
sensitivity testing
Patients whose symptoms fail to resolve after the 7- day
treatment should be managed as a complicated urinary
tract infection

It didnt work! Now what?


The Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults, 2004

In patients with uncomplicated cystitis or pyelonephritis,


treatment ordinarily results in complete resolution of
symptoms
It rarely progresses to renal functional impairment and
chronic renal disease. Repeated upper tract infections
often represent relapse rather than reinfection
Repeated symptomatic UTIs in children and in adults
with obstructive uropathy, neurogenic bladder, structural
renal disease, or diabetes progress to chronic renal
disease with unusual frequency

Prognosis

Women who experience frequent symptomatic UTIs (>3


per year on average) are candidates for long-term
administration of low-dose antibiotics
Daily or thrice-weekly administration of a single dose of
TMP-SMX (80/400 mg), TMP alone (100 mg), or
nitrofurantoin (50 mg)
Norfloxacin and other fluoroquinolones

Men with chronic prostatitis; patients undergoing


prostatectomy, both during the operation and in the
postoperative period; and pregnant women with
asymptomatic bacteriuria

Who needs prophylaxis?

PUBLIC HEALTH

The Philippine Clinical Practice Guidelines on the


Diagnosis and Management of Urinary Tract Infections in
Adults, 2004
Harrisons Principles of Internal Medicine, 16th ed

References

Pain in the throne


Cristal Ann Laquindanum
TMC ER Rotation

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