GU infections

Asymptomatic bacteriuria (ASB)

bacteria in the urine without symptoms (common incidental finding in 5% of females, only treat if preg)

acute cystitis

Symptomatic bladder infection

acute pyelonephritis

Symptomatic kidney infection

Uncomplicated UTI

Any GU infection without pregnancy, renal abnormalities, instrumentation, or surgery

Complicated UTI

GU infections WITH any pregnancy, renal abnormalities, instrumentation, or surgery

Relapsing UTI

Recurrent UTI within 2 weeks

Recurrent UTI

Separate, repeated episodes of infections

Catheter Associated UTI (CAUTI)

The most common healthcare-associated infection (40%) and the 2nd leading cause of bacteremia due to intermittent/indwelling urinary catheters, that can be asymptomatic or symptomatic

Dysuria, frequency, urgency, maybe suprapubic tenderness and lower back pain, hematuria, malodorous urine, nocturia/incontinence, AMS (elderly)

Symptoms of acute cystitis

Sex, vaginal contraceptives (diaphragm, spermicides), pregnancy, structural abnormalities (cystoceles), hygiene (thongs, pads, wiping, douching); BPH, lack of circumcision, STI

Risk factors for acute cystitis

E.Coli, (80-95%), Klebsiella, Proteus, Staph saprophyticus, group B strep, staph A (spread from blood or lymph)

*Common pathogens for acute cystitis (most are ascending - if a culture has 2+ bacteria its contaminated)

pyelonephritis, STIs, interstitial cystitis, stones, vaginal atrophy

*DDX of acute cystitis

Clinical, UA (+ leukocyte esterase, + nitrite, hematuria), Microscopy (pyuria (5-10+ WBCs), hematuria), urine cultures 🏆

*How do you diagnose acute cystitis

Nitrofurantoin, TMP-SMX, fosfomycin 🥇, FQs 🥈, cephalexin (recurrent), post-coital abx (honeymoon cystitis), phenazopyridine (analgesics - caution will secretions orange/yellow), AZO (mask symptoms)

Treatment plan for acute cystitis - f/o in 48-72 hrs, refer if recurrent or structural abnormality

Cranberry juice/pills, hydration, urinate before and after sex

Prevention plan for acute cystitis

duration of indwelling foley, improper technique, DM, renal disease

Risk factors for CAUTI

E.coli, any organism that is on a healthcare workers hands

Pathogens for CAUTI

Fever, suprapubic tenderness, CVAT, AMS, hypotension, sepsis

Signs and Symptoms of CAUTI

3rd CPH or FQ (-), Vanc (+)

*Treatment of CAUTIs - do NOT use urine from the bag, do an I and O

Interstitial Cystitis (chronic painful bladder/syndrome)

Chronic, debilitating bladder pain in the absence of other etiologies (more common in females) due to leaky/damaged bladder lining, nerves, autoimmune that leads to the loss protective glycosaminoglycan mucin (Hunner’s ulcer)

bladder pain, pressure/discomfort, increase with bladder fillings/standing, relieved with emptying, hematuria, urgency and frequency

Symptoms and signs for interstitial cystitis

UTI, herpes, vaginitis, endometriosis, urethritis, prostatitis, malignancy, bladder or urethral stone, urethral diverticulum, chemical/radiation, cystitis

DDX for interstitial cystitis - dx of exclusion

Labs are normal, cystoscopy - biopsy for ulceration/cancer, mast cells not required

Diagnosis of interstitial cystitis

educate the patient that there is no cure, treat other conditions, Hydrodistention (fluid and anesthesia), amitriptyline/antihistamine 🥇 for pain and sleep, Nifedipine (reduce bladder spasms), Pentosan Polysulfate (only FDA approved therapy), Dimethyl sulfoxide (DMSO - with heparin as anti-inflammatory, pain relief, muscle relaxant/protector), Intravesical bacilli BCG, CBT, PT (pelvic floor),

Treatment for interstitial cystitis

endoscopic cauterization/ablation of ulcers, Sacral nerve stimulation (TENs), urinary diversion w/wo cystectomy

Last resort treatments for interstitial cystitis - after 2 failed non-surgical intervention

Acute pyelonephritis

A infection of the renal parenchyma and collecting system

sepsis, shock, emphysematous pyelo, obstructive pyelo, abscess, chronic/scarring pyelo

Complications of Acute pyelonephritis

fever, chills, flank pain

Triad of Acute pyelonephritis

CBC with diff, UA, with microscopy and gram stain, Urine and blood culture prior to abx, KUB and CXR, non-contrast helical/spiral CT ( 🏆 imaging of choice), Renal U/S (if pregnant)

67 y/o female presents to the ED for flank pain. She also notes N/V/D. Vitals are as follows 146/94, 134 bpm, and 102.3 temp. On physical exam you note CVAT, rigors, and homegirl looks SICK. What diagnostics you want?

One time IV ceftriaxone, cipro, or gentamicin; PO cipro 500 mg, levofloxacin, TMP-SMX

67 y/o female presents to the ED for flank pain. She also notes N/V/D. Vitals are as follows 146/94, 134 bpm, and 102.3 temp. On physical exam you note CVAT, rigors, and homegirl looks SICK. Labs ares as follows leukocytosis w/ hella bands, LE+, nitrites +, pyuria with WBC cast, hematuria. What is your OUTPATIENT treatment?

No improvement in 48 hours, admit and repeat work up, cultures will guide therapy

When should homies with acute pyelonephritis being referred or admitted?

Broad spectrum IV Ampicillin + AMG/FQ/CPH or ampicillin + gentamicin/cipro/ceftriaxone - continue IV until 24 hours after the fever resolves then transition to oral for 14 days

67 y/o female presents to the ED for flank pain. She also notes N/V/D. Vitals are as follows 146/94, 134 bpm, and 102.3 temp. On physical exam you note CVAT, rigors, and homegirl looks SICK. Labs ares as follows leukocytosis w/ hella bands, LE+, nitrites +, pyuria with WBC cast, hematuria. What is your INPATIENT treatment?

Chlamydia, Gonorrhea, mycoplasma genitalium, trich, viral STIs, chemicals instrumentation

Patho for urethritis

history of STIs, multiple sexual partners, unprotected sex, MSMC

Risk factors for urethritis

pharyngitis, conjunctivitis, strictures, infertility, prostatitis, epididymitis, proctitis, disseminated infection, septic arthritis (esp. the knees)

Complications of urethritis

Purulent (gonorrhea) or watery (mycoplasma, trich, chlamydia, etc) discharge, dysuria, urinary frequency/urgency, discharge or stains on underwear

Signs and Symptoms for urethritis

Urethral discharge with 2+ WBC, UA with 10+ WBC, Urine culture/gram stain, NAAT 🏆 (specimens from urethra, cervix, vagina, or 1st void), wet prep (trich, clue cells, candida), culture with thayer martin, syphilis, HIV, HBV, HCV

Diagnostics for urethritis

Ceftriaxone + doxy (alt: azithromycin or levofloxacin); if treatment fails recheck NAAT, repeat treatment may use moxifloxacin for mycoplasma genitalium, test for cure in 3 months, refer for persistent or recurrent

Treatment plan for urethritis

STI education and counseling, abstain from sex for 7 days and their symptoms have resolved, and their partners was treated, treat all partners from the last 6 months, avoid high risk behaviors

Patient Education measures for urethritis

Orchitis

Inflammation of the testes that can lead to male infertility and testicular atrophy (the most common complications of mumps)

Mumps (most common), epididymitis, mumps, viral illness (coxsackie, EBV, varicella), Chlamydia and Gonorrhea (with young males), E.coli (with patients under 14 OR older than 35, anal intercourse)

Etiology for Orchitis

UA, culture, NAAT, gram stain, CBC w/diff, U/S (reactive hydrocele), color doppler U/S

21 y/o male presents to the Ed for sudden onset of unilateral testicular pain. He is sexually active and also reports dysuria, urgency, and frequency. On physical exam you note swollen parotid glands and testes. What diagnostics you want?

Thug it out (Viral), ceftriaxone and doxy (azithromycin as an alt)

Treatment plan for Orchitis

Epididymitis (can occur with testes (epididymo-orchitis), if testes + spermatic cord (funiculitis))

*Inflammation/infection of the epididymis (usually unilateral and right sided) and the most common cause of scrotal pain in adult males

Retrograde infection spread from urethra/bladder to ejaculatory duct → vas deferens → epididymis; Amio

*Patho for Epididymitis

Unprotected sex, strenuous activity, prolonged bicycle/motorcycle/sitting; recent UTI, structural abnormally

*Risk factors for Epididymitis

orchitis, testicular torsion, incarcerated hernia, testicular abscess, fournier gangrene, torsion of testicular appendix, hydrocele, varicocele, hematocele, pyocele, spermatocele, testicular cancer (painless)

*DDX for Epididymitis

STIs

*If under 35 and anal intercourse with symptoms of epididymitis think →

UTIs, prostatitis, BPH, urologic disorders (E.coli)

*If over 35 with symptoms of epididymitis think →

Levofloxacin 500 mg x 10 days, Scrotal support (ice, elevation, analgesics, no heavy lifting/straining, rest)

56 y/o male presents to the ED for acute onset of unilateral pain and swelling of the scrotum that radiates to his abdomen and lower back. Vitals are stable with the exception of a 103.6 temp. On testicular exam you note swelling, induration, and erythematous skin, a reactive hydrocele, an intact cremasteric reflex and pain is relieved with elevation of the scrotum. What is your treatment plan?

Ceftriaxone + Levofloxacin

Treatment plan for suspected STIs with history of MSM

Fournier Gangrene

A rare but rapid, necrotizing infection of the subcutaneous tissue of the external genitalia and perineum (maybe the thighs, abdominal wall, chest)

Type 1 necrotizing fasciitis (polymicrobial) involving the epidermis, dermis, subcutaneous tissue, fascia, and muscles

Patho for Fournier Gangrene

Male, 50+, DM, immunocompromised, obesity, alcoholics, smokers, local minor/major trauma, SGLT-2s

Risk factors for Fournier Gangrene

Staph, strep, E.coli, Klebsiella, proteus, bacteroides

Pathogens for Fournier Gangrene

CBC with diff, CMP, Coags, CK, LDH (sepsis workup), CRP, ESR, blood cultures X2, CT (preferred for gas detect and determining the extent of spread), U/S (gas and abscesses), surgical exploration 🏆

34 y/o male presents to the ED for SEVERE 10/10 scrotal pain. He has a hx of DM and kidney transplant. Vitals are as follows 104.6 and 141 bpm. On physical exam you note erythematous plaques w/o sharp margins and edema. The skin is firm, indurate, and you note crepitus. What diagnostics do you want?

Aggressive surgical debridement of necrotic tissue, Abx to cover everything under the sun, IVIG (streptococcal toxic shock syndrome), aggressive fluids, albumin, vasopressors (levophed), PEP (close contact or water exposure - PCN 250 mg QID)

Treatment plan for Fournier Gangrene

over 60, clostridial infection, delayed surgery, streptococcal/toxic shock syndrome, serum creatinine 2.0+. WBCs over 30,000, infection extending into the abdomen

The prognosis of Fournier Gangrene worsens IF…

Balanitis

Inflammation of the glans penis

posthitis

Inflammation of the foreskin

balanoposthitis

Inflammation of the glans penis and the foreskin (common with DM)

inadequate hygiene, irritation, Candida/staph/strep colonization

Etiology of balanoposthitis/Balanitis/posthitis

uncontrolled DM, uncircumcised males, obesity, immunocompromised, corticosteroids, HRT, abx

Risk factors of balanoposthitis/Balanitis/posthitis

Clinical diagnosis - supported by KOH prep with clusters of budding yeast and pseudo-hyphae

28 y/o male presents to the ED for swelling of his penis. On physical exam you note superficial denuded, beefy-red areas with or without satellite lesions of whitish curd-like concretion on mucous membranes. What diagnostics you want?

Keep the area clean/dry, exposed to air, topical nystatin/clotrimazole, soak with dilute aluminum acetate for 15 min BID, Clinda/metro/fluconazole (if severe)

Treatment plan for balanoposthitis/Balanitis/posthitis

treatment failures, phimosis, paraphimosis

Complications of balanoposthitis/Balanitis/posthitis