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 Afebrile
Urgency Soft, non-tender abdomen
Frequency No CVA tenderness
Low back pain
No hematuria
Sexual history?
No hypogastric pain
No suprapubic pain
No fever
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
 Escherichia coli
Proteus
The most common Klebsiella
agents are the gram-
negative bacilli. Enterobacter
Serratia
Pseudomonas

Etiology
 Staphylococcus
Gram-positive cocci saprophyticus
play a lesser role in Enterococci
UTIs. Staphylococcus
aureus

Etiology
 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, Generally develop rapidly
urgency, and suprapubic fever, shaking chills, nausea,
pain 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 pyuria (> 5 wbc/hpf of centrifuged
can be detected (102 to urine) on urinalysis and bacteriuria
104 bacteria per milliliter with counts of > 10,000 cfu of a
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 E.coli UTI
Gradual, >7 days of symptoms abrupt onset, <3 days of symptoms
no hematuria gross hematuria
no suprapubic pain suprapubic pain
history of UTIs

Clinical Presentation
Infectious Physical
Cervicitis Urethral strictures
Urethretis Tumor
Vulvovaginitis

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
Diagnostics
The Philippine Clinical Practice Guidelines on the Diagnosis and
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
Management of Urinary Tract Infections in Adults, 2004
 Light yellow
Turbid
pH 7.0
SG 1.015
Urinalysis 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