dysuria and common urinary tract disorders in family medicine

renin (RAAS), EPO (RBC production), vitamin D activation.

hormonal functions of the kidneys

Internal sphincter (smooth muscle, involuntary, sympathetic control).

External sphincter (skeletal muscle, voluntary control).

define the 2 sphincters of the urethra

cystitis, urethritis (bacterial, STI such as gonorrhea/chlamydia, viral HSV).

infectious causes of dysuria

interstitial cystitis, atrophic vaginitis.

inflammatory causes of dysuria

Stones.

Infection (cystitis, pyelonephritis).

Tumors (renal cell carcinoma, bladder cancer, prostate cancer).

Trauma.

Benign prostatic hyperplasia (BPH).

non-glomerular causes of hematuria

hypovolemia, hypotension, renal artery stenosis.

causes of pre-renal failure

Acute tubular necrosis (ischemia, nephrotoxins).

Glomerulonephritis.

Interstitial nephritis (drugs: NSAIDs, antibiotics).

causes of intrinsic renal failure

obstruction (stones, BPH, tumors).

causes of post-renal failure

diabetes, hypertension, chronic GN, polycystic kidney disease.

chronic causes of renal failure

Leukocyte esterase, nitrites

urine dipstick findings indicating infection

renal tubular disorders, hydration status.

urine dipstick findings with out of range pH and specific gravity indicate

dysmorphic: glomerular hematuria

uniform: non-glomerular hematuria

dysmorphic vs uniform RBCs in urine microscopy indicate

glomerulonephritis

RBC casts in urine indicate

pyelonephritis, interstitial nephritis.

WBC casts in urine indicate

acute tubular necrosis

granular/muddy casts in urine indiate

nonspecific finding or dehydration

hyaline casts in urine indcate

CT without contrast

gold standard imaging for stones

Evaluate masses, hematuria, staging of urologic cancers, trauma.

CT with contrast is indicated in evaluation for these urological conditions

Renal artery stenosis, vascular injury.

CT angio is indicated in evaluation of these urological conditions

Hydronephrosis → obstruction.

Cysts vs solid renal masses.

Renal size/echogenicity → chronic kidney disease.

Bladder volume, post-void residual.

what can you determine with a renal ultrasound?

May detect radiopaque stones (calcium oxalate, struvite).

Cannot detect uric acid or cystine stones.

Sometimes used in follow-up of known stones

limited uses of abdominal XR KUB

voiding cytsourethrography

Fluoroscopic study with contrast instilled into bladder, images taken during voiding.

Suspected vesicoureteral reflux (esp. pediatrics with recurrent UTIs).

Urethral obstruction, posterior urethral valves, bladder outlet obstruction.

indications for VCUG

UA with microscopy

first line work up for most urological complaints

cystitis

Ascending bacterial infection (most commonly E. coli) from urethra → bladder mucosa inflammation.

Bacterial adherence (fimbriae) + immune response → mucosal edema, pain, urgency, frequency.

describe the pathophys of cystitis

Dysuria, frequency, suprapubic pain, hematuria.

primary symptoms of cystitis

interstitial cystitis/bladder pain syndrome

Chronic, non-infectious bladder wall inflammation

-Defective glycosaminoglycan layer → ↑ bladder permeability.

-Mast cell activation → histamine release → pain, urgency.

-Neurogenic inflammation, hypersensitivity of bladder nerves.

pathophys theories of interstitial cystitis

interstitial cystitis

Chronic pelvic/bladder pain, worse with filling, relieved by voiding. Negative cultures.

pain worse with filling, relieved by voiding

very specific finding of interstitial cystitis

STIs: Chlamydia trachomatis, Neisseria gonorrhoeae; HSV, Mycoplasma

most common agents of urethritis

urethritis

symptoms: Dysuria, urethral discharge, sterile pyuria on UA (esp. chlamydia).

pyelonephritis

symptoms: Fever, flank pain, CVA tenderness, dysuria, WBC casts in UA.

Urethral syndrome

irritative urinary symptoms without proven infection

-Hormonal changes (atrophic urethritis in post-menopause).

-Pelvic floor dysfunction.

-Urethral hypersensitivity / local irritation (chemicals, trauma).

pathophys theories of urethral syndrome (non-infectious dysuria)

urethral syndrome

Dysuria, frequency, urgency, but negative cultures.

Low urine volume, dehydration.

Hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia.

Infection (struvite stones with urease-producing bacteria).

pathophys mechanisms of nephrolithiasis

Hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia.

different electroyte imbalances contributing to nephrolithiasis

hunner lesions

Ulcerations found in interstitial cystitis patients on cytoscopy

urethritis

dysuria + urethral discharge OR positive NAAT for STI pathogen.

nitrofurantoin (5 days), TMP-SMX (3 days), fosfomycin (single dose).

empiric antibiotics indicated for uncomplicated cystitis

Phenazopyridine

drug of choice for short-term dysuria relief in cystitis

bladder training, diet changes (avoid caffeine, acidic foods).

non-pharm treatment of interstitial cystitis

amitriptyline, pentosan polysulfate, antihistamines.

medication treatment for interstitial cystitis

lidocaine, heparin instillation.

intravesical treatment of interstitial cystitis

Gonorrhea: ceftriaxone IM + doxycycline (7 days) for chlamydia coverage.

Chlamydia: doxycycline (7 days) or azithromycin single dose.

HSV: acyclovir, valacyclovir.

Treat partners, abstain until completion

treatment of STI related urethritis

fluoroquinolone (cipro, levo) if local resistance

outpatient treatment of pyelonephritis

IV ceftriaxone, fluoroquinolone, or aminoglycoside.

inpatient treatment of pyelonephritis

Address irritants, pelvic floor PT.

Vaginal estrogen (post-menopausal women).

Sometimes low-dose antibiotics if chronic, but often supportive.

management of urethral syndrome

Stones

management of kidney stones depending on size

tamsulosin (alpha blocker)

pharm therapy that may aid in kidney stone passsage

stress, poor sleep

Socio-economic factors that can worsen interstitial cystitis symptoms

T10-L2

sympathetic innervation of kidneys/ureters

sympathetics T11-L2, parasympathetics S2-S4.

sympathetics and parasympathetics of the bladder

1" superior, lateral to umbilicus.

chapman point of kidney

periumbilical

chapman point of bladder

pubic ramus

chapman point of urethra

T12-L2 for kidney, L2 transverse process for bladder.

posterior chapman point for kidney and bladder