Uncomplicated Urinary Tract Infection

Young female presents with acute onset dysuria, urinary frequency/urgency. Pt recently became sexually active for the first time. Denies change in urine appearance/odor. Denies chills, rigors, marked increase in fatigue. Denies h/o confirmed multidrug resistant UTI. Afebrile with no suprapubic tenderness on exam; no costovertebral angle tenderness.

• Urine dipstick positive for leukocyte esterase, nitrites

• Obtain urine pregnancy test, urine culture

• Pregnancy test negative: Start nitrofurantoin 100 mg BID x5 days and adjust antibiotic therapy pending culture

Notes

• Symptom interpretation

  • Change in urine color/smell is not specific for UTI and should not prompt further workup in the absence of other symptoms

  • Women who self-diagnose UTI have a 85% positive culture rate; this is more accurate than dipstick testing

• Dipstick interpretation

  • Leukocyte esterase: 75% sensitivity, 98% specificity

  • Nitrites: 30% sensitivity, 90% specificity

• Cranberry products are not effective in relieving symptoms

• Pregnancy considerations

  • Antibiotics

    • Fosfomycin 3 g as a single dose is safe in all three trimesters, but may have decreased efficacy compared to other first-line agents (IDSA 2018)

    • Nitrofurantoin is safe in the 2nd and 3rd trimesters

    • TMP-SMX is contraindicated

  • Perform test of cure 1 week after starting therapy

Acute, Complicated Urinary Tract Infection

Elderly male with h/o indwelling Foley catheter and repeat UTIs presents with new onset urinary frequency/urgency in the setting of increased debility. Caretaker reports recent chills, rigors, flank pain. Fever, altered mental status, abdominal/suprapubic tenderness, costovertebral angle tenderness on exam.

• Labs

  • Obtain CBC, BMP, urine/blood cultures

  • Dipstick positive for leukocyte esterase, nitrites

  • Urinalysis positive for pyuria, bacteria

• Consider abdominal/pelvic CT with and without contrast in the following scenarios:

  • Patient meets sepsis criteria

  • Symptoms do not improve after 72 hours of antibiotic therapy

• Admit for inpatient management if the patient meet any of the following criteria:

  • Debility and/or marked change in overall health status

  • Fever >38.4

  • Pt requires IV antibiotic therapy, e.g.

    • Inability to maintain PO hydration and/or tolerate PO therapy

    • Treatment with IV agent indicated (see below)

• Antibiotic therapy

  • Meropenem 1 g IV q8 hours x 10 days for any of the following:

    • History of infection with multidrug-resistant organism

    • Long term care facility resident or recent hospitalization

    • Treatment with broad spectrum beta-lactam, TMP-SMX or fluoroquinolone within the past week

  • Otherwise start ceftriaxone 1 g IV daily x 10 days; transition to cefdinir (Omnicef) 300 mg BID and complete course once pt can tolerate PO intake

• Adjust antibiotic therapy pending culture sensitivities

Notes

• Complicated UTI includes infections extending beyond the bladder, e.g. pyelonephritis

• Clinical definition: One of the following must apply

  • Fever + s/sx systemic illness, e.g. new onset debility, chills/rigors

  • Pyuria + one of the following

    • Flank pain/CVA tenderness or imaging indicating pyelonephritis

    • Fever and/or sepsis

• Dipstick interpretation

  • Leukocyte esterase: 75% sensitivity, 98% specificity

  • Nitrites: 30% sensitivity, 90% specificity

• Microbiology/urine culture

  • Most commonly associated bacterial pathogens are nitrite producing and include E. coli, Klebsiella, and Proteus species

  • Positive if >100,000 bacterial colony forming units present

• Diagnostic reference: Urinalysis Evidence Based Summary

Acute Pyelonephritis

Young F with h/o sexual intercourse with new male partner, recurrent UTIs, DM presents with urinary frequency/urgency, dysuria, N/V. Pt's mother has h/o recurrent UTIs. T>38 C, CVA tenderness, suprabupic pain on exam.

• U/A showing +LE, microscopic pyuria/hematuria; reflex for culture

• Obtain BMP; consider ordering lipase, transaminase, beta-hCG

• [Pregnent: Admit to hospital and start CTX; transition to oral antibiotics x 10 days once afebrile. Suppressive therapy with daily low-dose nitrofurantoin s/p treatment course.]

• Negative urine pregnancy test; start levofloxacin 750 mg BID x 5 days

• Re-evaluate pt within 48-72hr

• Consider CT if pt's symptoms fail to improve or if symptoms recur s/p initial treatment

• Consider hospitalization if pt develops hemodynamic instability, metabolic derangement, severe flank/abdominal pain, toxic appearance, fever or is unable to tolerate PO liquids

Nephrolithiasis

Pt with h/o low fluid intake, congenital kidney deformity, primary hyperthyroidism, and DM/gout due to excess sweetened beverage consumption presents with acute onset, paroxysmal flank pain. Flank pain is unilateral and episodes of severe pain generally last 20-60 minutes. ROS positive for N/V, dysuria, and urinary urgency. Reports personal h/o malabsorptive bariatric surgery and family h/o nephrolithiasis. Severe, unilateral CVA tenderness on exam.

• Pregnancy test negative

• Microscopic hematuria on urinalysis

• Low-dose CT with contrast shows hydronephrosis, presence of stone

  • Stone <10 mm

    • Administer indomethacin 75 mg BID, tamsulosin 0.4 mg daily, and strain urine with voids

    • Consult urology if pt requires hospitalization or stone does not pass within 3 weeks in the outpatient setting

  • Stone >10 mm: Administer ketorolac 15 mg q6 hours and consult urology

• Pt advised to keep stone upon passage

• Send stone for analysis

Notes

• Kidney stone types

  • Calcium stones (80%)

    • Calcium oxalate: More common and increased risk with malabsorptive bariatric surgery, e.g. Roux-en-Y

    • Calcium phosphate: Less common than calcium oxalate

  • Struvite (magnesium ammonium phosphate)

  • Uric acid

  • Cysteine

• Differential diagnosis to consider

  • Ruptured aortic aneurysm

    • Microscopic hematuria may be present

    • Verify stable BPs to rule out diagnosis

  • Ectopic pregnancy

    • Rule out with pregnancy test

    • Consider pelvic ultrasound if pregnancy test is positive

  • Other gynecologic issues can also be ruled out with ultrasound, e.g.

    • Ruptured ovarian cyst

    • Ovarian torsion

Chronic Kidney Disease

Patient with history of obesity, HTN, and DM type 2 presents with decreased renal function for > 3 months. Decreased urine output, continued unhealthy diet, and progression of diabetic retinopathy on yearly ophthalmologic exam. Denies recent illness, flank pain, pruritic rash. Denies family history of renal disease. HTN with decreased visual acuity on exam. No JVD, M/R/G, abdominal bruit, flank pain, suprapubic tenderness, LE edema, joint swelling/tenderness, rash on exam. Dorsalis pedis pulse 2+ bilaterally.

• Labs

  • Obtain CBC, CMP, lipid panel, HbA1c, urinalysis, urine culture, morning spot urine albumin/creatinine ratio; GFR calculated using National Kidney Foundation (NKF) calculator <60 mL/min/1.73 m^2

  • Hgb indicates anemia: Obtain reticulocyte count, ferritin level, transferrin saturation, and vitamin B12/folate levels

  • No urine sediment or casts noted on microscopy

• Imaging

  • Obtain renal ultrasound with Doppler to rule out structural disease, decreased perfusion

  • Consider nerve conduction study if pt develops paresthesias or s/sx consistent with restless leg syndrome

• Blood pressure management per KDIGO for adults with and without DM

  • Hypertension and not pregnant: Start lisinopril 2.5 (GFR < 30) to 10 mg (GFR > 30) qd for renal protection and titrate to 40 mg daily with close monitoring of serum potassium and creatinine

  • Albumin-creatinine ratio

    • < 30 mg/24h: Treat to ≤ 140/90 mmHg

    • ≥ 30 mg/24h: Treat to ≤ 130/80 mmHg with at least one ACE-I or ARB

  • Monitor for postural hypotension

• Treatment per stage (KDIGO recommendations, see notes for shared decision making considerations)

  • All patient stage ≥ 3a (GFR < 60)

    • Obtain annual CBC (anemia) and baseline CMP, phosphorous, PTH

    • Serum bicarbonate < 22 mmol/L: Start oral bicarbonate supplementation

    • Elevated PTH: Obtain serum 25-hydroxyvitamin D and supplement to > 20 ng/mL

    • Administer pneumococcal 23 vaccination

    • Refer to nutrition to discuss caloric, protein, sodium, potassium, and phosphate intake

  • Stage 3b (GFR 30-44)

    • Obtain annual CMP, serum phosphate

    • Do not perform routine bone mineral density testing (risk for misleading results)

    • Maintain serum phosphate concentrations within normal range

  • Stage 4 (GFR 15-29)

    • Obtain CBC every 6 months

    • Immunize against hepatitis and confirm response with HBV Ab

    • Do not administer bisphosphonate therapy

    • Prepare for renal replacement therapy

  • Stage 5 (GFR < 15): Refer to nephrology for initiation of dialysis

• Medication

  • GFR < 60: Avoid sodium-phosphate bowel preparations

  • Uremic pruritus: Chronic condition common in advanced CKD. Trial of capsaicin cream and/or mirtazapine.

• Refer to nephrology for any of the following:

  • GFR <30 mL/min/1.73 m^2

  • Potassium levels persistently > 5.0 meq/L

  • Two of three early morning spot urine albumin/creatinine ratio > 300 mg/g and spot urine protein/creatinine ratio > 500 mg/g

  • Development of anemia of chronic disease

• Imaging with contrast: Hydrate before/after study and reevaluate GFR within 48-96 hours

Notes

Diagnosis

• Differential includes alternate etiologies that may be indicated by recent illness, urine sediment/casts on microscopy, etc.

  • Acute: AKI (Cr 1.5-1.9 x baseline or Cr increase > 0.3 mg/dL), UTI, nephrolithiasis

  • Chronic: Autoimmune disease, familial kidney disease

  • Acute or chronic: Medication use, intrinsic renal disease

• CKD diagnostic criteria: Must meet one of the following for > 3 months

  • GFR < 60 ml/min/1.73 m^2

  • Any marker of kidney damage: Albuminuria ≥ 30 mg/24 hours, electrolyte/urine sediment/structural/histologic abnormality, history of renal transplant

Determining Renal Function

• CKD categorized per GFR (see KDIGO chart, NKF calculator) and albuminuria

• Creatinine

  • Creatinine concentrations affected by muscle mass/protein intake and may be less reliable in frail/aging populations

  • If concern for Cr accuracy, consider cystatin C for confirmation (e.g. GFR 45-59 with no marker of kidney damage)

  • If GFR per Cr and cystatin C < 60, diagnosis is confirmed

• Albuminuria

  • Term “microalbuminuria” no longer recommended

  • Spot urine albumin/creatinine ratio (ACR)

    • Can be collected at any time

    • Confirm ACR ≥ 30 mg/g with early morning urine sample

    • Greater values indicate increased risk for progression to ESRD and death

  • Suspicion for false elevation due to multiple myeloma: Obtain urine kappa/lambda light chain assay (Bence-Jones protein)

• Cockcroft-Gault equation

  • Only used for medication adjustments

  • Calculation becomes increasingly important in elderly patients as GFR declines with age. For example, in two 70 kg male patients with Cr 1:

    • GFR in the 40 y/o = 44 mL/min

    • GFR in the 80 y/o = 26 mL/min

Dialysis Considerations

• Patients with CKD have variable illness trajectories

  • Dialysis inconsistently modifies symptoms (i.e. patient dependent)

  • Mortality is significantly affected by patient characteristics

    • Average annual mortality for hemodialysis patients is 20%

    • Dialysis may not prolong survival in the frail/elderly or those with significant comorbidities

• Calculators

  • 6 month mortality on hemodialysis

  • 3 year survival for elderly ESRD patients

  • Candidacy for home (peritoneal) dialysis

Benign Prostatic Hyperplasia (BPH)

Elderly male presents with chronic urinary frequency. Reports urgency, weak stream, straining, and nocturia. Denies fever, dysuria, gross hematuria, flank pain. No history of tobacco use, DM, prostate cancer, excessive caffeine intake, or sexual dysfunction. No h/o urologic surgery. Digital rectal exam reveals normal sphincter tone, enlarged prostate, and bladder distention.

• Obtain urinalysis

• Life expectancy >10 years: Obtain PSA s/p shared decision making

• Post void residual showing >100 mL urine

• Moderate/severe symptoms and no plans for cataract surgery: Start tamsulosin 0.4 mg daily

• Pt encouraged to keep voiding diary between now and next appointment

• Pt counseled against using alternative therapies such as saw palmetto

Notes

• Differential diagnosis

  • Rule out common causes of neurogenic bladder, e.g. diabetes

  • Urinalysis

    • If normal, rules out UTI, nephrolithiasis, bladder cancer

    • Positive for hematuria in approximately 10% of cases

• Alpha blocker (e.g. tamsulosin) are contraindicated in patients undergoing cataract surgery due to risk for intraoperative floppy iris syndrome

• Referral for surgery (transurethral resection of the prostate) may be considered for the following:

  • Symptoms uncontrolled with medical therapy

  • Development of bladder calculi

  • Gross and/or microscopic hematuria

  • Recurrent urinary tract infections

  • Renal insufficiency 

Prostate Cancer

Pt <77 years old with family h/o prostate cancer presents with gradual onset unintentional weight loss, urinary frequency/hesitancy, hematuria, and bony back pain. Denies h/o HTN, chest pain, heart failure, MI, stroke, lung disease, GI ulcer, IBD, DM, depression. Lower extremity weakness and enlarged prostate with asymmetry/nodularity on DRE.

• CBC shows anemia

• PSA > 10 ng per L indicating intermediate risk or higher; repeat in 1 month for confirmation

• Consider monitoring with yearly DRE and PSA every 3 to 6 months

• Consider MRI for prostate visualization

• Consider referral for 12-core prostate biopsy (sensitivity 80%) to determine Gleason score and quantify disease risk

• Treatment per disease risk and Charlson comorbidity index

  • Low risk disease: Observation vs. active surveillance vs. brachytherapy

  • Intermediate risk: Treat as low vs. high risk s/p shared decision making

  • High risk prostate cancer: Consider treatment plan that may include

    • Androgen deprivation therapy with Lupron (leuprolide) depot 7.5 mg q monthly

    • External beam radiation therapy (EBRT) vs. radical prostatectomy

• Refer to urology

• Pt counseled about risks and benefits of observation vs. treatment

Notes

• Epidemiology

  • Affects 1 in 7 men

  • 1 in 39 affected men will die from the disease (3rd most common cause of cancer-related death in men)

• The reason for the debate about screening:

  • Treatment may not greatly change the course of the disease and will almost certainly result in undesirable adverse effects.

  • Patients who present with symptoms as described above (e.g. bony pain and LE weakness due to spinal cord compression) have metastatic disease and will likely not benefit from treatment.

• Disease risk

  • Determined using a Gleason score (requires biopsy) and PSA level

  • Gleason scores range from 2 to 10

  • PSA

    • 10 ng per L or greater indicates intermediate risk or higher

    • 20 ng per L or greater indicates high risk

• Adjusted life expectancy

  • Performed using Charlson Comorbidity Index with 1 point each for the following: HTN, chest pain, heart failure, MI, stroke, lung disease, GI ulcer, IBD, DM, depression

  • Do not treat very low or low risk patients if

    • 62+ years old with 3 or more comorbidities

    • 77+ years old with any comorbidities

• Observation/treatment modalities

  • PSA rise >0.75 ng/dL in one year is concerning

  • Brachytherapy: Implanted radioisotopes (fewer adverse effects)

  • EBRT: Precision radiation of prostate (risk for urinary incontinence, erectile dysfunction, scarring of urethra/GI tract)

  • Radical prostatectomy: Removal of prostate that limits disease progression (almost certain urinary incontinence, ED)

Urinary Tract Malignancy

Male hairdresser age >35 years with h/o chronic UTI, pelvic radiation, smoking, and NSAID analgesic abuse presents with asymptomatic hematuria. No pertinent positive on ROS. No abnormalities on physical exam.

• Obtain BMP

• Urinalysis shows gross hematuria

• Obtain CT to evaluate upper urinary tract

• Imaging

  • Refer to urology for cystoscopy

  • Cystoscopy negative with risk factors for malignancy: Obtain CT abdomen/pelvis with and without contrast

• Lesions suspicious for malignancy on imaging: Refer to oncology

• Pt counseled about risks of smoking, analgesic abuse

Notes

• Epidemiology

  • Responsible for 5% of asymptomatic hematuria cases

  • Occupational exposure to benzenes or aromatic amines (e.g. hairdressers) increases risk

• May present with gross or microscopic hematuria

Urge Incontinence

Pt age >75 years with h/o cardiovascular disease, heart failure, alcoholism presents with new onset incontinence, urinary frequency, and nocturia. Episodes preceded by intense desire to urinate and pt often loses control of bladder en route to bathroom; this is followed by large volume urine loss. Mediations include diuretics. Minimal, delayed leakage following cough stress test.

• Variable volume loss noted on 3 day voiding diary

• Obtain urinalysis with reflex microscopy and urine culture

• Post void residual <50 mL

• Comorbid condition management

  • Vaginal atrophy present: Start intravaginal estrogen therapy

  • Pt advised to reduce alcohol consumption

• Initial therapy

  • Start 3 daily sets of 8 to 12 pelvic floor contractions sustained for 8 to 10 seconds each

  • Start bladder training with timed daily voids occuring at the shortest interval indicated on the 3 day voiding diary

    • Control urgency between voids with relaxation techniques, e.g. deep breathing

    • Increase interval between voids by 15 minutes following each day without incontinence

    • Goal: Timed voids every 3-4 hours

• Failure of initial therapy

  • Trial of mirabegron 25 mg once daily x8 weeks

  • Mirabegron not covered by insurance and no contraindication to anticholinergic therapy: Start one of the following

    • Oxybutynin immediate-release 5 mg TID

    • Trospium chloride (Sanctura) 20 mg BID

  • Consider referral to pelvic PT

  • Consider referral to urology

Notes

• Present in ~10% of women age 40-45 years

• Present in >30% of men and women age >75 years

• Potential etiologies

  • Detrusor instability: Detrusor overactivity or loss of inhibitory control of bladder contractions

  • Sensory: Urge to urinate caused by local irritation, inflammation, or infection

• Contraindications to anticholinergic

Stress Incontinence

40 year old F with h/o chronic cough, grand multiparity presents with chronic, small volume urine loss. Urine loss typically occurs when coughing, sneezing, jumping, lifting, or exercising. Episodes have even occured with minimal activity, e.g. rising from chair. Denies nocturia. Medications include alpha-adrenergic agonists and ACE inhibitor. Positive cough stress test on exam.

• Small volume leakage (<10 mL) on 3 day voiding diary

• Obtain urinalysis with reflex microscopy and urine culture

• Post-void residual <50 mL

• Initial therapy

  • Refer for pessary fitting

  • Consider referral to pelvic PT

  • Consider duloxetine 20 mg twice daily for 2 weeks then 40 mg BID in patients with comorbid depression

• Failure of initial therapy: Refer for surgical evaluation for mid-urethral sling placement

Notes

• Epidemiology

  • Present in 30% of women age >30 years

  • May occur in men s/p prostate surgery

• Etiology: Sphincter and/or pelvic floor weakness

• Cough stress test

  • Most reliable clinical assessment for stress incontinence

  • Positive if small volume leakage occurs with cough and stops once coughing terminates

  • Negative if no leakage occurs or if leakage occurs >5 seconds after coughing terminates

• Pelvic floor exercises: 3 daily sets of 8 to 12 pelvic floor contractions sustained for 8 to 10 seconds each

• Do NOT refer for urodynamic testing 

Overflow Incontinence

Elderly M pt with h/o BPH, DM, multiple sclerosis and alcoholism presents with chronic incontinence. Reports inability to empty bladder, dribbling, hesitancy, and urine loss without sensation of fullness/pressure in lower abdomen. Medications include calcium channel blockers, opioids, muscle relaxants, antidepressants, antiparkinsonian agents, sedatives, and anticholinergics. Bladder distention, peripheral neuropathy, decreased sphincter tone, and enlarged prostate on exam; no leakage noted on cough stress test.

• No consistent pattern noted in 3 day voiding diary

• Obtain urinalysis with reflex microscopy and urine culture

• BMP shows increased serum creatinine

• Post void residual >200 mL

• Treatment in men

  • Pt avoid to lose weight and perform daily pelvic floor muscle exercises

  • Start tamsulosin (Flomax) 0.4 mg daily and increase to 0.8 mg daily after 4 weeks

  • Concern for prostate cancer or failure of initial treatment: Refer to urology

• Pt advised to decrease alcohol intake and adhere to prescribed DM regimen

Notes

• Leakage is caused by bladder overdistention

• DM and alcoholism

  • Resulting peripheral neuropathy can lead to overflow incontinence

  • May be indicated by peripheral neuropathy or decreased anal sphincter tone on exam

Functional Incontinence

Elderly pt with h/o cognitive impairment due to CVA/dementia and decreased mobility due to arthritis presents with chronic incontinence. Caregiver reports variable urine leakage, difficulty transporting patient to and from bathroom. Medications include COX-2 selective NSAIDs, sedative-hypnotics, and thiazolidinediones. Negative cough stress test.

• MOCA <26

• <50 mL on post-void residual

• Caregiver counseled that incontinence is most likely related to delayed transport time to toilet and not a physiologic mechanism

Uremia

Pt with h/o ESRD presents with BUN >60 mg/dL. Reports confusion, fatigue, anorexia, vision loss, chest pain, N/V, erectile dysfunction, decreased libido, pruritus, LE numbness/tingling, seizures. Medications include diuretics, NSAID, ACE inhibitor, macrolide antibiotic. Fever, orthostatic hypotension, PERRLA, dry mucous membranes, pleuritic chest pain, pericardial friction rub on exam.

• Obtain CBC, CMP, PT/PTT/INR, ABG, urinalysis with microscopy

• Albumin:creatinine ratio >300 mg/g

• RBC casts on urine microscopy

• EKG shows no diffuse ST or T-wave elevations

• Treatment

  • Administer 1L bolus NS and re-evaluate volume status

  • Stop diuretics, NSAID, ACE inhibitors; transition to alternative antibiotic regimen

  • Pt actively bleeding; consider desmopressin, cryoprecipitate, estrogen, and/or dialysis to improve platelet function

  • Place hemodialysis catheter and initiate emergent hemodialysis

  • Pt will require long-term renal replacement therapy; discuss hemodialysis versus peritoneal dialysis

• Consults

  • Consult surgery about placement of AV fistula vs. peritoneal dialysis catheter pending pt preference

  • Consult nephrology

• Pt educated about s/sx of uremia

Notes

• Hypovolemia is a common cause of transient declines in kidney function

• Decreased glomerular filtration: NSAIDs prevent afferent arteriole dilation and ACE inhibitors prevent efferent arteriole constriction

• Aminoglycoside (e.g. gentamicin, tobramycin, neomycin) toxicity may precipitate uremia

• Uremia impairs platelet function and increases bleeding risk

• Uremic pericarditis presents as fever, pleuritic chest pain, friction rub. Unlike other pericarditis etiologies, there is no ST or T-wave elevation on EKG.

• AV fistulas are used for hemodialysis 2-5x per week and require at least 1 month to mature

• Uremic neuropathy is characterized by LE numbness/burning and may be a contraindication to initiating dialysis

• Severe uremia may cause transient cortical blindness