“CHRONIC” URINARY TRACT INFECTIONS Helen J. Kuo, MD Idaho Urologic Institute

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“CHRONIC” URINARY
TRACT INFECTIONS
Helen J. Kuo, MD
Idaho Urologic Institute
August 22, 2013
CHRONIC URINARY TRACT
INFECTIONS
 Chronic is a poor term
 Definitions are important
 Concentrate on female UTI’s
 Basic aspects are straightforward
 Small subjects first
 Definitions
 Review predisposing factors
 Case studies
MALE UTI’S
 Acute Febrile Prostatitis




Fever, chills, dysuria, urgency, pyuria
Low threshold to admit, IV antibiotics, (amp & gent)
Oral antibiotics (flouroquinolone) for 30 days
F/U cultures and assess voiding pattern, post void residual
MALE UTI’S
 Chronic prostatitis
 Persistent symptoms and / or bacteriuria
 May require therapy for 2-3 months
 Usually arises from an inadequately treated initial syndrome with
ignored residual symptoms
 Recurrent febrile prostatitis requires imaging (CT) with or without
cystoscopy
 Periprostatic abscess, prostatic calculi, chronic retention, bladder
stones
PYELONEPHRITIS
 Many lower UTI’s over diagnosed as Pyelonephritis
 Fever, chills, flank pain, pyuria, bacteriuria, +/- lower urinary
tract symptoms
 Consider admission, especially with diabetes,
 10-14 days flouroquinolone
 F/U culture
 If recurrent, imaging with CTIVP
CHRONIC PYELONEPHRITIS
 Aspects of the urinary tract can retain infection chronically
 Presents with positive history of infections or indolently, +/flank pain
 Imaging shows shrunken, thinned renal tissue, usually unilateral
 Assess function
 Treat with long term antibiotics, assess for predisposing factors,
consider nephrectomy
DEFINITIONS
 Bacteriuria
 Symptomatic vs.. asymptomatic
 Usually one organism - uropathogen
 Polymicrobial: contamination vs. complicated origin
DEFINITIONS
 Pyuria





Implies an inflammatory response
> 10 WBC’s / HPF
Contamination
Infections other than uropathogens
Non-infectious causes (tumor)
DEFINITIONS
 Cystitis





Abrupt onset, dysuria, urgency, frequency
+/- fever
+/- mid low back pain
+/- hemorrhagic
Rare in males
CYSTITIS
 3-5 days TMP/SMZ DS bid, nitrofurantion 100mg tid,
flouroquinolone
 Better than single dose regimen
 Longer courses probably not necessary
DEFINITIONS
 Urethritis




Pyuria
Negative urine culture
Gradual onset
“central" pain
DEFINITIONS
 Vaginitis




No pyuria
Vaginal discharge
Pruritis
Sensitive on exam
DEFINITIONS
 Interstitial cystitis
 Diagnosis of exclusion
 Rare to make the diagnosis in one visit
 We should be slow to mention this in a differential in initial
discussions with patients
 Patients frequently cite an initial event
 Indolent vs.. acute onset
 Negative or variable cultures
INTERSTITIAL CYSTITIS
 Variable response to antibiotics
 Pain is a cornerstone of the diagnosis – not just irritative voiding
symptoms
 Urologic referral indicated
DEFINITIONS: UTI’S
 Isolated or first
 Unresolved
 Recurrent
 Re-infection
 Bacterial persistence or relapse
 Outpatient vs.. nosocomial (Catheter associated UTI – CAUTI)
BACTERIAL VIRULENCE FACTORS
 Uropathic E. Coli
 Adhesins
 Fimbrial (pili) or afimbrial
 Typified and extensively studied
BACTERIAL VIRULENCE FACTORS
 Vaginal lining cell receptivity




Increased after damage from UTI
Increased after menopause
Increased at different points in menstrual cycle
Genetic predisposition to increased vaginal tissue receptivity
UROTHELIAL CELL RECEPTIVITY
 UPEC receptivity
 Intracellular bacterial populations escape antibiotics with poor
tissue penetration
 Uropathogens create biofilm that resists antibiotic penetration
NATURAL DEFENSES OF THE
URINARY TRACT
 Normal Flora
 Continual irrigation
 Immune response (innate or cell-mediated and adaptive or
humoral)
 Urothelium (not a mucosa)
ALTERATIONS IN HOST DEFENSE
 Obstruction / retention








UPJ obstruction
Horseshoe kidney
Urolithiasis
Cystocele
Neurogenic retention
Hypotonic bladder
BPH question
TB history with scarring
ALTERATIONS IN HOST DEFENSE
 Vesico-ureteral reflux




Pediatric
Adult
High pressure
Presence of bacteria
ALTERATIONS IN HOST DEFENSE
 Diabetes Mellitus




Increased incidence of UTI’s in females
NO increased incidence in males
NO evidence that glycosuria is a factor
Renal papillary necrosis – may serve as a nidus of recurrent infection
and obstruction
ALTERATIONS IN HOST DEFENSE
 Constipation
 Urolithiasis
 Infrequent voiding – females should void every 2-3 hours during
the day
CASE STUDIES
 78 y/o female with 2 year history of approx. 6 cases of cystitis a
year
 Mild urgency over 2 years
 Normal voiding pattern except she has mild SUI, leaking into 1
pad per day, no constipation
 Gross hematuria 2 months ago.
 Last 2 urine cultures no growth
78 Y/O FEMALE
 Cultures have been intermittently positive for simple GNR’s
 Several cultures show no growth
 UA’s variable for bacteria, RBC’s, + nitrite
78 Y/O FEMALE – INITIAL IDEAS
 Vaginal estrogen
 Suppressive course of low dose antibiotic for 1-2 months
 Address SUI – change pads more frequently?
 Hematuria history trumps all
 CT IVP normal
 UA normal except 10 RBC’s / HPF
 Vaginal exam – senescent changes c/w age
78 Y/O FEMALE
 Cystoscopy shows erythematous, carpet like lesions on left and
posterior aspects of bladder wall
 Subsequent biopsy positive for carcinoma-in situ
78 Y/O FEMALE
 Asymptomatic bacteriuria
 CIS of bladder caused symptoms and hematuria
 Estrogen still a good idea
 Assess in f/u for improvement of SUI
CASE STUDIES
 35 y/o female with recurrent left pyelonephritis and episodes of
pink urine
 When symptoms arise, cultures positive for E. coli with or
without a Proteus sp. with consistent sensitivity profiles.
 UA’s show microhematuria, pyuria, bacteriuria
 CT shows left staghorn calculus, mild hydronephrosis, mild
parenchymal thinning
35 Y/O FEMALE
 Evaluate salvagability of kidney
 Consider DMSA renal scan to assess differential function
 Suppressive antibiotics around the time of percutaneous
nephrolithotomy vs.. nephrectomy
45 Y/O FEMALE
 Insulin dependent diabetes mellitus
 Obese at 300 lb.., hypertension
 6 UTI’s responding to 3 to 5 day courses of antibiotics from
different care facilities
 2 cultures with the same organism on each, 2 months apart
 + constipation, voids every 4 to 6 hours during the day
45 Y/O FEMALE
 Plan 2 months of nitrofurantion 100mg po qday
 Manage constipation
 Timed voiding q 2-3 hours during the day
 referral to a trusted PCP to manage diabetes, weight loss
program, consider bariatric surgery
45 Y/O FEMALE
 F/U visit 1 year later
 100 lb. weight loss, voids q 2-3 hours, 2 BM’s a day
 New job makes f/u visit for UTI’s difficult
 UTI’s less frequent, uncomplicated
 Culture shows a new organism
 Institute a self treatment program
45 Y/O FEMALE
 Septra DS 1 PO bid for 3 days when symptoms of UTI arise
 Dispense 30 pills for 5 treatment episodes
 Call if symptoms don’t respond
 f/u in 6 months
CASE STUDIES
 58 y/o male Kurdish immigrant
 Recurrent UTI’s treated 4 x in past year
 Mild flank pain on left occasionally
 Nocturia x 3, sensation of incomplete voiding. Slowed urine
stream over past 2 years
 Well documented tuberculosis 6 years ago
 2 documented cultures 2 months apart show E. coli with similar
sensitivities
 Bladder Scan PVR 300 ml
58 Y/O MALE
 Normal creatinine and PSA
 CT IVP shows scarred left UPJ and upper pole infundibulum with
hydrocalyx, mild hydronephrosis and perinephric stranding
 Cystoscopy shows trilobular impingement on prostatic urethra
with a 4.5cm prostatic urethral length
58 Y/O MALE
 Scarring pattern is a long term sequela of renal tuberculosis
 Consider long term antibiotic suppression, endopyelotomy, or
nephrectomy
 Medical therapy for BPH with 5-ARI and alpha blocker
CASE STUDIES
 64 y/o male with indwelling Foley catheter for past year
 Dense left hemiplegia from CVA 2 years ago
 Obese at 300lbs, very poor mobility as he requires a Hoyer lift,
Foley has caused pressure necrosis of distal ventral penis
 History of several UTI’s treated with antibiotics
 Recently hospitalized with C. difficile infection
64 Y/O MALE
 Communicative patient reports that UTI’s haven’t caused a fever
and only minimal symptoms
 Patient was sent for consideration for suprapubic tube
cystostomy
64 Y/O MALE
 Discuss with patient options when bladder drainage is a problem
 Consider




Indwelling Foley with change every 2 to 3 weeks
Suprapubic tube
Clean Intermittent Catheterization
Urinary diversion
64 Y/O MALE
 Decision: indwelling Foley catheter
 Change every 2-3 weeks
 Counsel family, patient and care staff on strategies for
appropriate wear
 Observe UA and culture with each catheter change
 Treat only for increased pain, increased bladder spasms or
febrile illness

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