Urinary tract infection

Urinary tract infection is the most common bacterial infection managed in general medical practice and accounts for 1-3% of consultations. Up to 50% women have a UTI at some time. In male UTI is uncommon. Most common presentation of UTI is acute urethritis and cystitis.

Spectrum of presentation:

1) Asymptomatic bacteriuria
2) Acute pyelonephritis
3) Symptomatic acute urethritis & cystitis
4) Acute prostatitis
5) Septicaemia

Common causes:

1) E. coli
2) Klebsiella
3) Proteus
4) Pseudomonus
5) Streptococci
6) Staphylococci epidermidis
7) In Hospitals- E. coli , Klebsiella and streptococci

Risk factors:

1) incomplete bladder emptying :

a) bladder outflow obstruction
b) neurological problems-
multiple sclerosis
diabetic neuropathy
c) gynaecological abnormalities-
uterine prolapse
d) vesico ureteric reflux

2) foreign body-

a) urethral catheter
b) ureteric stent

3)loss of host defence-

a) diabetes mellitus
b) atrophic urethritis and vaganitis in post menopausal women

Differential diagnosis:

1) urethritis
2) vaginitis

Clinical feature :

1) abrupt onset of frequency of micturation and urgency
2) dysuria
3) supra pubic pain during and after voiding
4) stranguary
5) urine may appear cloudy and have an unpleasant odur
6) microscopic or visible heamaturia
7) fever, rigor, vomitting

Investigations :

1) Dipstick examination - nitrite, leucocyte esterase and glucose
2) urine R/E - for pus cell and epithelial cell ( > 5-6)
3) urine culture (midstream urine)
4) CBC
5) Blood culture
6) USG
7) Serum urea ,electrolytes, creatinine
8) Cystoscopy

Management:

1) fluid intake at least 2 litre per day
2) regular complete emptying of bladder
3) good personal hygiene
4) emptying of bladder before and after sexual intercourse
5) if vesico ureteric reflux is present practice double micturation
6) antibiotics according to the report of urine culture

• ciprofloxacin - 500mg 12 hourly for 3 days
• trimethoprim - 200 mg 12 hourly for 3 days
• nitrofurontion - 50 mg 6 hourly for 3 days
• coamoxiclav - 500/ 125mg 8 hourly for 3 days

Seriously ill patient I/V cefuroxime -750 mg 8 hourly for 3-14 days
In pregnancy - penicillin and cephalosporins

Edited by ImAn NoOr

Hematuria

What is blood in urine (hematuria)?

Hematuria, or blood in the urine, can be either gross (visible) or microscopic (as defined by more than three to five red blood cells per high power field when viewed under magnification). Gross hematuria can vary widely in appearance, from light pink to deep red with clots. Despite the quantity of blood in the urine being different, the types of conditions that can cause the problem are the same, and the workup or evaluation that is needed is identical.

People with gross hematuria usually present to their doctor with this as a primary complaint. Microscopic hematuria, on the other hand, is most commonly detected as part of a periodic checkup by a primary-care physician.

What are the causes of blood in urine?

The causes of gross and microscopic hematuria are similar and may result from bleeding anywhere along the urinary tract. One cannot readily distinguish between blood originating in the kidneys, ureters (the tubes that transport urine from the kidneys to the bladder), bladder, or urethra. Any degree of blood in the urine should be fully evaluated by a physician, even if it resolves spontaneously.

Infection of the urine, stemming either from the kidneys or bladder, is a common cause of microscopic hematuria. Kidney and bladder stones can cause irritation and abrasion of the urinary tract, leading to microscopic or gross hematuria. Trauma affecting any of the components of the urinary tract or the prostate can lead to bloody urine. Hematuria can also be associated with renal (or kidney) disease, as well as hematologic disorders involving the body's clotting system. Medications that increase the risk of bleeding, such as aspirin, warfarin (Coumadin), or clopidogrel (Plavix), may also lead to bloody urine. Lastly, cancer anywhere along the urinary tract can present with hematuria.

How is blood in urine diagnosed?

The evaluation for blood in urine consists of taking a history, performing a physical examination, evaluating the urine under a microscope, and obtaining a culture of the urine. Lower urinary tract symptoms, such as urgency (feeling a strong need to urinate) and frequency (needing to urinate frequently), as well as the presence of fever and/or chills are suggestive of infection. Recent trauma, even if believed by the patient to have been inconsequential, should be considered as a potential cause. Abdominal and/or flank pain, especially if radiating to the inguinal or the genital area, may suggest kidney stones. All recent medications, including vitamins or herbal supplements, should be reviewed with the health-care provider. However, it is important to note that even if the patient has been taking a medication that is associated with bleeding, a full workup (as listed below) should still be undertaken.

The physical exam will focus on possible sources of hematuria. Bruising over the back or abdomen may indicate trauma. A digital rectal exam should be performed, as findings consistent with prostatitis (for example, tenderness on palpation of the prostate) or an enlarged prostate (suggestive of BPH or benign enlargement of the prostate gland) may be useful in making a diagnosis. A repeat urinalysis, as well as a urine culture, should be obtained. The presence of white blood cells on urinalysis is more consistent with a urinary tract infection. Protein, glucose, or sediment in the urine may indicate the presence of a disease of the kidneys. Blood tests are also important, as they will aid in assessing renal function and identifying any clotting abnormalities.

In addition to the basic history and physical exam, there are three additional components for any workup of hematuria: CT scan, urine cytology, and cystoscopy.

The CT scan is an imaging evaluation of the urinary tract. Prior to the procedure, the patient drinks an oral contrast agent and a dye is injected intravenously. The patient then goes through the CT scan machine and images are taken of the abdomen and pelvis. Another test that can be performed, the intravenous pyelogram (IVP), is also a type of X-ray evaluation of the urinary tract. In this procedure, a dye is injected into the veins, and this is filtered by the urinary tract. A series of X-rays are then taken over a 30-minute period to look for abnormalities. The CT scan is more commonly performed than the IVP to evaluate the urinary tract and should be considered the test of choice. Both of these studies are especially useful for evaluating the kidneys and ureters but not the bladder, prostate, or urethra. Therefore, a second examination called a cystoscopy is necessary. This is a simple 10-minute procedure wherein a thin, flexible cystoscope (or fiberoptic camera) is inserted via the urethra into the bladder in order to directly visualize any lesions or sources of bleeding. This is usually done with local anesthetic jelly injected into the urethra. Finally, urine cytology involves giving a urine sample to be analyzed by a pathologist for the presence of cancerous or abnormal-appearing cells.

How is blood in urine treated?

Treatments for hematuria vary widely and depend wholly upon the reason for the bleeding. It is important to note that there is often no source found for the hematuria. This should not be a source of major concern, however, since an appropriate workup effectively rules out the most serious causes of hematuria (for example, cancer). In cases where a workup is negative and the cause of the hematuria remains unknown, observation with repeat urinalyses is a reasonable option. A blood test to check kidney function and a blood-pressure check should be done as well. Men over 50 should discuss with their doctor the yearly prostate-specific antigen (PSA) blood test to screen for prostate cancer.

Further discussion of the treatment for hematuria would depend upon the results of the previously mentioned workup and the exact cause for the hematuria. The urologist who performs this examination would direct any further treatment or workup that would be necessary.

Blood in Urine (Hematuria) At A Glance

• Blood in urine can sometimes be visible only with a microscope.
• Evaluating blood in urine requires consideration of the entire urinary tract.
• Tests used for the diagnosis of blood in urine include a CT scan, cystoscopy, and urine cytology.
• Management of blood in the urine depends upon the underlying cause.

kidney stone

What is a kidney stone?

A kidney stone is a hard, crystalline mineral material formed within the kidney or urinary tract. Kidney stones are a common cause of blood in the urine and often severe pain in the abdomen, flank, or groin. Kidney stones are sometimes called renal calculi. One in every 20 people develops a kidney stone at some point in their life.

The condition of having kidney stones is termed nephrolithiasis. Having stones at any location in the urinary tract is referred to as urolithiasis.

What causes kidney stones?

Kidney stones form when there is a decrease in urine volume and/or an excess of stone-forming substances in the urine. The most common type of kidney stone contains calcium in combination with either oxalate or phosphate. Other chemical compounds that can form stones in the urinary tract include uric acid and the amino acid cystine.

Dehydration from reduced fluid intake or strenuous exercise without adequate fluid replacement increases the risk of kidney stones. Obstruction to the flow of urine can also lead to stone formation. Kidney stones can also result from infection in the urinary tract; these are known as struvite or infection stones.

Men are especially likely to develop kidney stones, and Caucasians are more often affected than blacks. The prevalence of kidney stones begins to rise when men reach their 40s, and it continues to climb into their 70s. People who have already had more than one kidney stone are prone to develop more stones. A family history of kidney stones is also a risk factor for developing kidney stones.

A number of different medical conditions can lead to an increased risk for developing kidney stones:

* Gout results in an increased amount of uric acid in the urine and can lead to the formation of uric acid stones.


* Hypercalciuria (high calcium in the urine), another inherited condition, causes stones in more than half of cases. In this condition, too much calcium is absorbed from food and excreted into the urine, where it may form calcium phosphate or calcium oxalate stones.


* Other conditions associated with an increased risk of kidney stones include hyperparathyroidism, kidney diseases such as renal tubular acidosis, and some inherited metabolic conditions including cystinuria and hyperoxaluria. Chronic diseases such as diabetes and high blood pressure (hypertension) are also associated with an increased risk of developing kidney stones.


* People with inflammatory bowel disease or who have had an intestinal bypass or ostomy surgery are also more likely to develop kidney stones.


* Some medications also raise the risk of kidney stones. These medications include some diuretics, calcium-containing antacids, and the protease inhibitor indinavir (Crixivan), a drug used to treat HIV infection.

What are kidney stones symptoms?

While some kidney stones may not produce symptoms (known as "silent" stones), people who have kidney stones often report the sudden onset of excruciating, cramping pain in their low back and/or side, groin, or abdomen. Changes in body position do not relieve this pain. The pain typically waxes and wanes in severity, characteristic of colicky pain (the pain is sometimes referred to as renal colic). It may be so severe that it is often accompanied by nausea and vomiting. Kidney stones also characteristically cause blood in the urine. If infection is present in the urinary tract along with the stones, there may be fever and chills. Sometimes, symptoms such as difficulty urinating, urinary urgency, penile pain, or testicular pain may occur due to kidney stones.


How are kidney stones diagnosed?

The diagnosis of kidney stones is suspected by the typical pattern of symptoms when other possible causes of the abdominal or flank pain are excluded. Imaging tests are usually done to confirm the diagnosis. A helical CT scan without contrast material is the most common test to detect stones or obstruction within the urinary tract. Formerly, an intravenous pyelogram (IVP; an X-ray of the abdomen along with the administration of contrast dye into the bloodstream) was the test most commonly used to detect urinary tract stones, but this test has a greater risk of complications, takes longer, and involves higher radiation exposure than the non-contrasted helical CT scan. Helical CT scans have been shown to be a significantly more effective diagnostic tool than the IVP in the diagnosis of kidney or urinary tract stones.

In pregnant women or those who should avoid radiation exposure, an ultrasound examination may be done to help establish the diagnosis.

What is the treatment for kidney stones?

Most kidney stones eventually pass through the urinary tract on their own within 48 hours, with ample fluid intake. Pain medications are used for symptom relief. When over-the-counter medications are not sufficient for pain control, narcotics may be prescribed. Intravenous pain medications can be given when nausea and vomiting are present.

There are several factors which influence the ability to pass a stone. These include the size of the person, prior stone passage, prostate enlargement, pregnancy, and the size of the stone. A 4 mm stone has an 80% chance of passage while a 5 mm stone has a 20% chance. Stones larger than 9 mm-10 mm rarely pass without specific treatment.

Some medications have been used to increase the passage rates of kidney stones. These include calcium channel blockers such as nifedipine (Adalat, Procardia, Afeditab, Nifediac) and alpha blockers such as tamsulosin (Flomax). These drugs may be prescribed to some people who have stones that do not rapidly pass through the urinary tract.

For kidney stones that do not pass on their own, a procedure called lithotripsy is often used. In this procedure, shock waves are used to break up a large stone into smaller pieces that can then pass through the urinary system.

Surgical techniques have also been developed to remove kidney stones when other treatment methods are not effective. This may be done through a small incision in the skin (percutaneous nephrolithotomy) or through an instrument known as an ureteroscope passed through the urethra and bladder up into the ureter.

How can kidney stones be prevented?

Rather than having to undergo treatment, it is best to avoid kidney stones in the first place when possible. It can be especially helpful to drink more water, since low fluid intake and dehydration are major risk factors for kidney stone formation.

Depending on the cause of the kidney stones and an individual's medical history, dietary changes or medications are sometimes recommended to decrease the likelihood of developing further kidney stones. If one has passed a stone, it can be particularly helpful to have it analyzed in a laboratory to determine the precise type of stone so specific prevention measures can be considered.