Core Conditions: Urology & Renal
Urinary Tract Infection
Definition Bacteriuria – bacteria in the urine. Asymptomatic or symptomatic
UTI – Diagnosis based on symptoms and signs
Lower UTI – bladder (Cystitis), prostate (prostatitis)
Upper UTI – Pyelonephritis = infection if kidney/renal pelvis
Epidemiology 10-20% annual incidence in women
10% of men and 20% of women >65 have asymptomatic bacteriuria
Risk Factors
• Bacterial inoculation
Sexual activity, urinary incontinence, faecal incontinence,
constipation
• Binding of pathogens
Spermicide use, Oestrogen, Menopause
• Urine flow
Dehydration, obstruction
• Bacterial Growth
DM, immunosuppression, obstruction, stones, catheter, renal
tract malformation, pregnancy
Aetiopathogenesis Typical organisms
Usually anaerobes and gram-negatives from bowel and vaginal flora
• E. coli (75-95% in the community, in hospital)
• Staphylococcus saprophyticus (5-10%)
• Proteus mirabilis
• Klebsiella pneumonia
Classification Uncomplicated – normal renal tract structure and function
Complicated – Structural/functional abnormality of genitourinary tract
Clinical Presentation Cystitis
• Frequency
• Dysuria
• Urgency
• Suprapubic pain
• Polyuria
• Haematuria
, Core Conditions: Urology & Renal
Prostatitis
• Pain: Rectum, perineum, scrotum, penis, bladder, bowel, back
• Fever
• Malaise
• Nausea
• Urinary symptoms
• Swollen or tender prostate on PR
Acute Pyelonephritis
• Fever
• Rigors
• Vomiting
• Loin pain/tenderness
• Costovertebral pain
On Examination
- Fever
- Abdominal or loin tenderness
- Check for distended bladder
- Enlarged prostate
Investigations 1. Dipstick
Negative dipstick reduces probability to <20%
Do not use in pregnant women
Limited data in men
2. MSU Culture
Use in pregnant women, men, children and if fail to respond Rx
3. Bloods
If systemically unwell
FBC, U&E, CRP, blood culture (+ve in 10-25% pyelonephritis)
4. Imaging
Consider USS and referral to urology for assessment
(cystoscopy, urodynamics, CT) in men with upper UTO, failure
to respond to treatment, recurrent UTI, pyelonephritis, unusual
organism, persistent haematuria
Differential Diagnosis Sterile Pyuria
WCC but no organism cultured on standard urine MC&S
• TB
Sterile pyuria, dysuria, frequency, suprapubic pain
Malaise, fever, night sweats, weight loss, haematuria
Diagnosis – microscopy with acid-fast staining of mane MSU
, Core Conditions: Urology & Renal
Management – Rifampicin & Isoniazid for 6/12 plus
pyrazinamide and ethambutol for 2/12
• Recently treated UTI
• Inadequately treated UTI
• Appendicitis, prostatitis, chlamydia
• Calculi
• Renal tract tumour
• Papillary necrosis
• Tubulointerstitial nephritis
• Chemical cystitis
• Polycystic kidney
• Recent catheter
• Pregnancy
• SLE
• Drugs (e.g., steroids)
Management Lower UTI
Non-pregnant women
Treat empirically if 3 typical symptoms present
1st line – Trimethoprim or Nitrofurantoin (3 days)
2nd line – Pivmecillinam, Fosfomycin 3g STAT
Send culture if - >65 years, haematuria
If haematuria – re-test urine after treatment. If persistent, consider
possible underlying cause (e.g., 2WW for uro/gynae cancer)
Pregnant Women
Symptomatic
Send culture.
1st line - Nitrofurantoin. 2nd line – Amoxicillin or Cefalexin
Asymptomatic
Based on routine urine culture at booking appointment
1st line – Nitrofurantoin (not close to term)
2nd line – Amoxicillin or Cefalexin
7-day course. Confirm eradication.
Men
Cystitis
7-day course of Nitrofurantoin or Trimethoprim
Prostatitis
4-week course of fluroquinolone (e.g., Ciprofloxacin)
Catheterised Patients
All are bacteriuric. Send culture only if symptomatic
, Core Conditions: Urology & Renal
Presentation can be atypical
- Fever
- Flank/suprapubic pain
- Change in voiding pattern
- Vomiting
- Confusion
- Sepsis
Change long-term catheter before starting antibiotic
Acute Pyelonephritis
See notes on pyelonephritis
Complications • Pyelonephritis, renal and peri-renal abscess
• renal function
• Urosepsis
• Pregnancy – low birth weight and pre-term delivery
Urinary Tract Infection
Definition Bacteriuria – bacteria in the urine. Asymptomatic or symptomatic
UTI – Diagnosis based on symptoms and signs
Lower UTI – bladder (Cystitis), prostate (prostatitis)
Upper UTI – Pyelonephritis = infection if kidney/renal pelvis
Epidemiology 10-20% annual incidence in women
10% of men and 20% of women >65 have asymptomatic bacteriuria
Risk Factors
• Bacterial inoculation
Sexual activity, urinary incontinence, faecal incontinence,
constipation
• Binding of pathogens
Spermicide use, Oestrogen, Menopause
• Urine flow
Dehydration, obstruction
• Bacterial Growth
DM, immunosuppression, obstruction, stones, catheter, renal
tract malformation, pregnancy
Aetiopathogenesis Typical organisms
Usually anaerobes and gram-negatives from bowel and vaginal flora
• E. coli (75-95% in the community, in hospital)
• Staphylococcus saprophyticus (5-10%)
• Proteus mirabilis
• Klebsiella pneumonia
Classification Uncomplicated – normal renal tract structure and function
Complicated – Structural/functional abnormality of genitourinary tract
Clinical Presentation Cystitis
• Frequency
• Dysuria
• Urgency
• Suprapubic pain
• Polyuria
• Haematuria
, Core Conditions: Urology & Renal
Prostatitis
• Pain: Rectum, perineum, scrotum, penis, bladder, bowel, back
• Fever
• Malaise
• Nausea
• Urinary symptoms
• Swollen or tender prostate on PR
Acute Pyelonephritis
• Fever
• Rigors
• Vomiting
• Loin pain/tenderness
• Costovertebral pain
On Examination
- Fever
- Abdominal or loin tenderness
- Check for distended bladder
- Enlarged prostate
Investigations 1. Dipstick
Negative dipstick reduces probability to <20%
Do not use in pregnant women
Limited data in men
2. MSU Culture
Use in pregnant women, men, children and if fail to respond Rx
3. Bloods
If systemically unwell
FBC, U&E, CRP, blood culture (+ve in 10-25% pyelonephritis)
4. Imaging
Consider USS and referral to urology for assessment
(cystoscopy, urodynamics, CT) in men with upper UTO, failure
to respond to treatment, recurrent UTI, pyelonephritis, unusual
organism, persistent haematuria
Differential Diagnosis Sterile Pyuria
WCC but no organism cultured on standard urine MC&S
• TB
Sterile pyuria, dysuria, frequency, suprapubic pain
Malaise, fever, night sweats, weight loss, haematuria
Diagnosis – microscopy with acid-fast staining of mane MSU
, Core Conditions: Urology & Renal
Management – Rifampicin & Isoniazid for 6/12 plus
pyrazinamide and ethambutol for 2/12
• Recently treated UTI
• Inadequately treated UTI
• Appendicitis, prostatitis, chlamydia
• Calculi
• Renal tract tumour
• Papillary necrosis
• Tubulointerstitial nephritis
• Chemical cystitis
• Polycystic kidney
• Recent catheter
• Pregnancy
• SLE
• Drugs (e.g., steroids)
Management Lower UTI
Non-pregnant women
Treat empirically if 3 typical symptoms present
1st line – Trimethoprim or Nitrofurantoin (3 days)
2nd line – Pivmecillinam, Fosfomycin 3g STAT
Send culture if - >65 years, haematuria
If haematuria – re-test urine after treatment. If persistent, consider
possible underlying cause (e.g., 2WW for uro/gynae cancer)
Pregnant Women
Symptomatic
Send culture.
1st line - Nitrofurantoin. 2nd line – Amoxicillin or Cefalexin
Asymptomatic
Based on routine urine culture at booking appointment
1st line – Nitrofurantoin (not close to term)
2nd line – Amoxicillin or Cefalexin
7-day course. Confirm eradication.
Men
Cystitis
7-day course of Nitrofurantoin or Trimethoprim
Prostatitis
4-week course of fluroquinolone (e.g., Ciprofloxacin)
Catheterised Patients
All are bacteriuric. Send culture only if symptomatic
, Core Conditions: Urology & Renal
Presentation can be atypical
- Fever
- Flank/suprapubic pain
- Change in voiding pattern
- Vomiting
- Confusion
- Sepsis
Change long-term catheter before starting antibiotic
Acute Pyelonephritis
See notes on pyelonephritis
Complications • Pyelonephritis, renal and peri-renal abscess
• renal function
• Urosepsis
• Pregnancy – low birth weight and pre-term delivery
