Treat and Prevent UTIs Without Drugs
An estimated 40 percent of women report having had a UTI at some point in their lives, and UTIs are the leading cause of gram-negative bacteremia. I. Acute uncomplicated cystitis in young women A. Sexually active young women have the highest risk for UTIs. Their propensity to develop UTIs is caused by a short urethra, delays in micturition, sexual activity, and the use of diaphragms and spermicides. B. Symptoms of cystitis include dysuria, urgency, and frequency without fever or back pain. Lower tract infections are most common in women in their childbearing years. Fever is absent. C. A microscopic bacterial count of 100 CFU mL of urine has a high positive predictive value for cystitis in symptomatic women. Ninety percent of uncomplicated cystitis episodes are caused by Escherichia coli, 10 to 20 percent are caused by coagulase-negative Staphylococcus saprophyticus and 5 percent are caused by other Enterobacteriaceae organisms or enterococci. Up to one-third of uropathogens are...
Abstract Green sulfur bacteria (GSB) are anaerobic photoautotrophs that oxidize sulfide, elemental sulfur, thiosulfate, ferrous iron, and hydrogen for growth. We present here an analysis of the distribution and evolution of enzymes involved in oxidation of sulfur compounds in GSB based on genome sequence data from 12 strains. Sulfide quinone reductase (SQR) is found in all strains. Chlorobium ferrooxidans, which cannot grow on sulfide but grows on Fe2+, has apparently lost all genes involved in oxidation of sulfur compounds other than sqr. Instead, this organism possesses genes involved in assimilatory sulfate reduction, a trait that is unusual in GSB. The dissimilatory sulfite reductase (Dsr) enzyme system, which appears to be involved in elemental sulfur utilization, is found in all sulfide-utilizing strains except Chloroherpeton thalassium. The absence of Dsr enzymes in this early diverging GSB, in combination with phylogenetic analyses, suggests that the Dsr system in GSB could be...
Up to 20 percent of young women with acute cystitis develop recurrent UTIs. During these recurrent episodes, the causative organism should be identified by urine culture. Multiple infections caused by the same organism require longer courses of antibiotics and possibly further diagnostic tests. Most recurrent UTIs in young women are uncomplicated infections caused by different organisms. Women who have more than three UTI recurrences within one year can be managed using one of three preventive strategies 2. Postcoital prophylaxis with one-half of a trimethoprim-sulfamethoxazole double-strength tablet (40 200 mg) if the UTIs have been clearly related to intercourse.
Urinary tract infections most commonly occur in older men with prostatic disease, outlet obstruction or urinary tract instrumentation. In men, a urine culture growing more than 1,000 CFU of a pathogen mL of urine is the best sign of a urinary tract infection, with a sensitivity and specificity of 97 percent. Men with urinary tract infections should receive seven days of antibiotic therapy (trimethoprim-sulfamethoxazole or a fluoroquinolone). B. Urologic evaluation should be performed routinely in adolescents and men with pyelonephritis or recurrent infections. When bacterial prostatitis is the source of a urinary tract infection, eradication usually requires antibiotic therapy for six to 12 weeks.
Maher et al.7 studied 15 women prospectively and found increases in mean voided volume (90-143mL), frequency decreased from 20 to 11, nocturia decreased from 6 to 2 times, and mean bladder pain decreased from 8.9 to 2.4 points on a scale of 1 to 10. Quality-of-life measures, namely, the UDI-6 (the short form of urogenital distress inventory) and SF-36 Health Survey also showed improved parameters during the stimulation period. Sacral neuromodulation shows promise for both the urgency frequency and pain components of interstitial cystitis.
This takes us to the crux of the current controversy. It is probably only reasonable to refer to scars where we have evidence that the kidney was normal prior to the infection and that the defect in parenchymal function has appeared following the infection. This is obviously not a common situation, because very few children with their first apparent urinary tract infection have had a previous DMSA scan. Therefore, when a defect is seen following an infection, we do not know whether we are dealing with a scar that has developed in a previously normal kidney or whether we actually are dealing with a kidney that had an underlying abnormality, which has predisposed that kidney to the infection. There is now considerable evidence that this latter scenario is often correct and that many of these children have an abnormal urinary tract associated with a dysplastic or dysmorphic kidney. The corollary of this is that the hypothesis, at the start of section, that treatment will lead to a...
Lower Urinary Tract Infection (treat for 3-7 days) -Enoxacin (Penetrex) 200-400 mg PO q12h 1h before or 2h after meals. -Cefpodoxime (Vantin) 100 mg PO bid. -Cephalexin (Keflex) 500 mg PO q6h. -Cefixime (Suprax) 200 mg PO q12h or 400 mg PO qd. -Cefazolin (Ancef) 1-2 gm IV q8h. Complicated or Catheter-Associated Urinary Tract Infection -Trimethoprim SMX single strength tab PO qhs. Candida Cystitis
Interstitial cystitis (IC) is a chronic, debilitating disease of the urinary bladder characterized by urinary frequency, nocturia, urgency, and frequently pain. It affects more females than males by a ratio of approximately 10 1.' Recently, the International Continence Society has developed a somewhat broader term for IC described as IC-painful bladder syndrome. This new term is defined as the complaint of suprapubic pain related to bladder filling, and is accompanied by other symptoms, such as increased daytime and nighttime frequency in the absence of proven urinary infection or other obvious pathology.2 The true prevalence of IC is not determined and it may be underestimated. In 1997, Jones and Nyberg3 estimated that up to one million patients had IC, many of them unable to cope with day-to-day activities. In Finland, Oravisto4 estimated the incidence as 18.6 out of 100000 in 1975. Another Finnish study in 2002 used a wider definition and found 450 out of 100000 had IC.5 There is...
Reductions in renal and hepatic function do not alter plasma drug concentrations, and ketoconazole is not removed by hemodialysis or peritoneal dialysis. Penetration into cerebrospinal fluid is negligible, so that ketoconazole is ineffective in the treatment of fungal meningitis. Since only small amounts of active drug appear in the urine, ketoconazole is not effective in the treatment of Candida cystitis.
Cystitis is a bacterial infection of the lining of the bladder affecting mainly women. It is usually caused by E. coli which travels from the anus through the urethra and into the bladder. Food allergies, vaginal yeast infections, chemical sensitivities, tissue abrasion from friction during intercourse, and a too large diaphragm may increase exposure to bacteria. Stress and oral contraceptives can lower resistance to infection. Symptoms of cystitis include burning pain upon urination, pain in the lower abdomen, pressure, frequent urge to urinate but unable to do so, strong urinary odor, fever, and low back pain. If infection is recurrent, see a physician as the disease could spread to the kidneys. Drink plenty of fluids. Urinate frequently, completely, and always after intercourse. Wipe the genital area from front to back, wear cotton underwear, and avoid scented products.
Delirium in this population, alone or superimposed on dementia, is described in Chapter8.5.1. The elderly are considerably more susceptible than younger adults. They may become delirious due to otherwise minor physical problems such as constipation or urinary tract infection, or to combinations thereof. Prescription of multiple medicines (including psychotropics, especially hypnotics), dehydration, and chronic medical conditions are frequently contributing factors. Those with pre-existing dementia are especially vulnerable to developing delirium indeed, an episode of delirium is frequently the first presentation of patients with dementia to medical services.
The 6-year-old girl described being sexually abused by a teenaged uncle over several months. He bribed her to keep the abuse secret. The most recent episode occurred about 1 week ago. Patient has had intermittent complaints of genital pain and dysuria but no history of bleeding or discharge. She has no current symptoms, and exam was normal. The uncle had a history of a prior incident with a young cousin that the family dealt with themselves.
During filling, the normal bladder has a minimal change in intravesical pressure until capacity is reached. At low volumes, the elastic and viscoelastic properties are primarily responsible for compliance. Elasticity allows the constituents of the bladder wall to stretch without a significant increase in bladder wall tension. The viscoelasticity of the bladder causes stretch to induce an increase in tension, followed by a decay when filling stops. In the animal model, it has been shown that at a certain level of bladder disten-tion, spinal sympathetic reflexes facilitory to bladder storage, are evoked. This allows smooth muscle relaxation of the bladder by beta receptor stimulation (accommodation). Spinal sympathetic reflexes inhibit parasympathetic activity at the level of the parasympathetic ganglia during filling. Clinically, detrusor compliance may be altered by any processes that can damage the elastic tissues (chronic cystitis, radiation, ischemia, etc.) or neurologic...
Has there been any bleeding Bleeding may be present after trauma or associated with infection or congenital anomalies. Excess calcium excretion and renal stones cause dysuria as well as hematuria. F. What medication(s) does patient take Some medications (eg, cyclophosphamide) may cause irritation to the urethra and painful urination.
Inspect skin and perineum for evidence of rashes, redness, or irritation. Look for evidence of discharge. Perform pelvic exam in sexually active adolescent girls who present with dysuria and discharge to rule out vaginitis, cervicitis, and pelvic inflammatory disease.
Ultrasound and voiding cystourethrogram. See Chapter 91, Urinary Tract Infection, p. 427. Order ultrasound if congenital anomaly is suspected. Voiding film obtained during IV urography or retrograde urethrography is diagnostic of urethral strictures or stenosis. Diagnosis of posterior urethral valves is made by a voiding cystourethrogram.
A relative contraindication to injectable therapy is severe vaginal tissue atrophy as evident by mucosal prolapse and urethral caruncles. It is generally recommended that hormonal deficiency resulting in vaginal atrophy be treated with topical estrogens for several months before injection therapy to improve urethral compliance, tissue manipulation, and acceptance of the bulking agent, as well as the ability of the periurethral tissue to retain the injectable bulking agent long-term. Absolute contraindications to therapy with injectable bulking agents include significant urethral pathology such as a urethral diverticulum, an untreated urinary tract infection, and known hypersensi-tivity to injectable bulking agents, such as Contigen.
Perform a GU exam to evaluate for pelvic inflammatory disease in a sexually active febrile adolescent. Consider UTI in a febrile girl without other evidence of an infectious focus. Physical findings (eg, CVA tenderness) are less reliable in younger children. Male adolescents must be assessed for testicular tenderness of epididymitis.
CPT has been identified as the active constituent of an extract isolated from the Chinese Tree Camptotheca acuminata. Mechanism of action studies demonstrated that CPT stabilized co-valent adducts between genomic DNA and topoI. Early clinical studies with CPT observed anti-tumour activity in a variety of common solid tumours. However, a high rate of severe and unpredictable toxicities, including haemorhagic cystitis and gastrointestinal effects, were seen. This led to discontinuation of CPT's development.
What medication(s) does patient take Patient may have been receiving an antineoplastic agent, such as cyclophosphamide, which is associated with hemorrhagic cystitis or urinary tract tumors (very rare in children). G. Any symptoms of UTI The most common cause of hematuria in a child, UTI is usually associated with pain, urgency, and frequency. WBCs are also present in urine.
Treatment depends on etiology. Cause of hematuria is rarely an emergency except for gross hematuria (with or without clots), for which the cause could be trauma, severe coagulation abnormality, or cyclophosphamide-induced cystitis. A. UTI. Begin treatment before culture results are known if patient is ill with symptoms and there are 10 WBCs HPF (infection is very likely) or if evidence of sepsis or pyelonephritis is present (increased C-reactive protein, ESR, high WBC count with left shift). G. Hemorrhagic Cystitis. Consult urology colleagues. Treatment of a patient with hemorrhagic cystitis consists of saline irrigation, but primary treatment is prevention with hydration and mesna. VI. Problem Case Diagnosis. The 10-year-old patient had hemorrhagic cystitis. On further investigation, the inciting agent for the bladder injury was found to be cyclophosphamide therapy. VII. Teaching Pearl Question. What are clues that a UTI involves the kidney (upper tract infection)
All evidence statements for UTIs are level Ia. Prevention of UTI- Five SRs were identified which assessed interventions for the prevention of UTI.308-311 A review of five studies looking at the effects of cranberry extract in elderly patients, patients needing intermittent catheterisation, and women with recurrent UTI, found no reliable evidence of the effectiveness of cranberry juice and other cranberry products.309 A review of eight RCTs comparing the effectiveness of indwelling silver coated urinary catheters and uncoated indwelling urinary catheters found that silver alloy catheters were significantly more effective in preventing UTIs as measured by the presence of bacteriuria than uncoated catheters but these studies were confined to relatively short-term use of catheters (2-10 days).311 The results from three of the eight trials indicated that women benefited from the silver-coated urinary catheters more than men. The third review looked at risk factors for UTI and the effects...
More than 9 million women have pelvic pain, and their management entails more than 2.8 billion in direct and greater than 555 million in indirect costs.1 The prevalence of chronic pelvic pain (CPP) in women is approximately 3.8 . Chronic pelvic pain is a symptom, not a disease, and it rarely reflects a single pathologic process.Various pelvic floor structures and disorders may be the cause of CPP.The origin of pain may be or psychological. Therefore, systemic evaluation, and different and combined therapies are required for patients with CPP.Therapies include invasive and noninvasive modalities. Noninvasive therapies include behavioral therapy, nutrition, physical therapy, and acupunc-ture.Dietary modification might help,because certain types of food,such as acidic foods,caffeine, and alcohol are common triggers for interstitial cystitis and irritable bowel syndrome. Pain in the patients with these diseases might respond to an appropriate change in diet. Pharmacologic therapies...
Urinary tract infections (UTI) may manifest as acute pyelonephritis and systemic illness with high fever, pain around the graft site, and laboratory data indicative of leukocytosis and active urinary sediment. Alternatively, renal allograft recipients with UTIs can be asymptomatic and present without pyuria. Because of this, a high index of suspicion is required, and routine surveillance urine cultures are often performed after transplantation. In febrile patients, blood cultures are obtained.
N. gonorrhoeae and C. trachomatis are the two most common causes of sexually transmitted disease. Disease caused by N. gonorrhoeae, called gonorrhea, is associated with dysuria and urethral discharge in men and cer-vicovaginal discharge in women. N. gonorrhoeae can also cause pharyngitis and anorectal infections. C. trachomatis causes a nongonococcal urethritis and is asymptomatic in 50 -66 of men and women. N. gonorrhoeae and C. trachomatis are often found in coinfec-tions, so it is prudent to rule out both organisms when considering that one is present.61
The main goal of examination is to exclude identifiable causes that may be responsible for the patient's symptoms. Abdominal examination is usually normal in IC patients except for occasional suprapubic tenderness. On pelvic examination, identifiable diseases can be recognized or excluded. In female patients, lack of estrogen identified by inspection of atrophic mucosa, may contribute to vaginal pain, dyspareunia, and dysuria. Pelvic floor hypertonicity is suspected if the levator ani muscles are tight or tender to palpation. The urethra should be palpated to check for a mass, tenderness, or expression of pus, because this finding may indicate presence of urethral diverticulum.
Sulfadiazine, for example, produces changes only on local gut bacterial flora and finds wide use in presurgical bowel sterilization. Other sulfonamides, such as sulfisoxazole, are rapidly absorbed and highly soluble, and they undergo rapid urinary excretion, mainly in the unaltered form. A third group are rapidly absorbed and slowly excreted and maintain adequate blood levels for up to 24 hours (e.g., sulfamethoxazole). These drugs are useful in treating chronic urinary infections. Finally, some sulfonamides (e.g., sulfacetamide and sulfadiazine silver salt ) are designed for topical use such as in infection of the eye and in burn patients.
Underlying illness, usually dementia. This is particularly the case when a subclinical urinary tract infection occurs in a demented patient. It is of clinical relevance because treatment of the urinary tract infection results in a great improvement in the patient's mental state. On routine assessment particular attention should therefore be paid in the history to evidence of sudden worsening of a stable or only slowly deteriorating condition, and to nocturnal disturbance especially with (usually visual) hallucinations. On examination of the patient herself the level of consciousness, awareness of the environment, attention, and concentration should be noted.
Unexpectedly high culturable diversity of halophilic SOB was detected in hypersaline habitats. Two moderately halophilic aerobic groups belong to the known genera in the Gammaproteobacteria, while extremely halophilic aerobes, moderately and extremely halophilic thiodenitrifyers and moderately halophilic thiocyanate-uti-lizing SOB all represent new lineages within the Gammaproteobacteria.
Our knowledge regarding the effect of local estrogen on urethral function and continence is limited and somewhat unclear. It is assumed that urethral mucosal changes mimic those occurring in the vagina during local estrogen therapy. Atrophic women with urinary urgency, frequency, and particularly nocturia - in the absence of cystitis or detrusor instability - will typically benefit from local estrogen therapy. Presumably, this is attributable to thickening of the urethral mucosa with resultant improved mucosal coaptation and thus improved sphincteric function. It has been demonstrated in vivo and in vitro that there is increased contraction of the periurethral smooth muscles with estrogen therapy. This is thought to be mediated through alpha-2-adrenoceptors. Both of these effects should positively impact continence. Some studies have shown improvement in urethral function on dynamic ure-thral profilometry during multichannel urodynamics, whereas others have not.6,7 The overall...
Trimethoprim and sulfamethoxazole act at different parts of the same pathway of synthesis of bacterial folate. Their long half-lives allow both to be given at 12-h intervals. Trimethoprim is active against most staphylococci, streptococci (not enterococci), Enterobacteriaceae, and Hemophilus species, but not Ps. aeruginosa or anaerobes. Trimethoprim can be used for urinary tract infection but in hospital-acquired infections susceptibility needs first to be demonstrated. Sulfamethoxazole adds little to trimethoprim for most infections, but trimethoprim-sulfamethoxazole is commonly used to treat Pneumocystis pneumonia in AIDS. Adverse effects are common at the high dose used (120 mg kg day intravenously in four divided doses) and are due mostly to the sulfonamide. Rash, nausea, vomiting, and diarrhea are common, and occasionally Stevens-Johnson syndrome occurs. Administration in pregnancy is contraindicated.
There is a 6 1 predominance of women over men 35 . All have been adults and the mean age is perimenopausal (46 years). Presenting symptoms include flank pain, haematuria or symptoms of urinary tract infection 25 are incidental findings. Histories of estrogen therapy are common. Surgery has been curative in all cases.
Figure 15 Cystitis. (A) Mild circumferential bladder wall thickening (arrows) is identified in this patient, who was later diagnosed as having cystitis. When bladder wall thickening is diffuse, it is most commonly due to inflammation rather than neoplasm. Conversely, focal bladder wall thickening is often due to cancer. (B) As with EU, the excretory-phase, coronal, volume-rendered 3-D image allows only for visualization of the bladder lumen, so that bladder wall thickening is not suspected. The bladder base is elevated due to prostatic enlargement. Abbreviation EU, excretory urography. Figure 15 Cystitis. (A) Mild circumferential bladder wall thickening (arrows) is identified in this patient, who was later diagnosed as having cystitis. When bladder wall thickening is diffuse, it is most commonly due to inflammation rather than neoplasm. Conversely, focal bladder wall thickening is often due to cancer. (B) As with EU, the excretory-phase, coronal, volume-rendered 3-D image allows only...
Urethral Stricture and Meatal Stenosis. Usually result from urethral trauma, either iatrogenic (catheterization or endoscopic procedures) or accidental (straddle injuries). Symptoms include decrease in force of the urine, bladder instability, hematuria, and dysuria. G. Posterior Urethral Valves. Most common cause of bladder outlet obstruction in boys. In the presence of a persistent valve, the prostatic urethra becomes dilated, vesicoureteral reflux may be present, and a small bladder with hypertrophied walls develops. Infants may present with poor voiding stream, bilateral flank masses, or UTI and dysuria.
Strictures at the anastomosis of the ureter to an ileal conduit urinary diversion or continent urinary pouch or conduit are almost always benign and reportedly occur in 4 to 30 of patients (149-151). One study that compared complications in the different forms of urinary diversion reported the incidence of ureteroenteric strictures in ileal conduits to be 6.5 , compared to 10.0 in the continent reservoir group and 13.6 in patients who underwent ureterosigmoidostomy (150). The predisposing factors are ischemic necrosis and subsequent fibrosis and stricture, due to excessive mobilization and skeletonization of the ureter. Preoperative radiation therapy appears to have a compounding effect. Extravasation at the anastomosis may progress to scarring and subsequently a stricture, and, rarely, recurrent tumor in the ureter may present with obstruction. Stenoses tend to be more prevalent on the left side, probably because of the necessity for high mobilization of the left ureter (to ensure a...
Urinary tract infections account for about 7 million visits to the doctor's office each year in the United States. Urinary infections can involve the urethra, the bladder, or the kidneys, alone or in combination. Any situation in which the urine does not flow naturally increases the chance of infection. After anaesthesia and major surgery, for example, the reflex ability to void urine is often inhibited for a time, and urine accumulates and distends the elastic bladder. Even being too busy to empty the full bladder may predispose to infection. Catheterization of the bladder is another common cause of infection. Most cases, however, occur in otherwise healthy young women without impaired urinary flow. Bacterial Cystitis The most common type of urinary infection involves the bladder and is called bacterial cystitis, meaning inflammation of the bladder. Bacterial cystitis is common among otherwise healthy women, and it is a common nosocomial infection.
Figure 16 (A) A 30-year-old male with urinary tract infection and incidental cyst with slightly thickened septa. Bosniak Category IIF cyst. (B) Coronal T2-weighted MR scan shows minimal septation and slight wall irregularity. (C) Ultrasound examination shows more septa with associated nodular thickening appearing significantly more complex than the CT or MR. Lesion has remained stable for over a year of follow-up imaging. Abbreviations CT, computed tomography MR, magnetic resonance. Figure 16 (A) A 30-year-old male with urinary tract infection and incidental cyst with slightly thickened septa. Bosniak Category IIF cyst. (B) Coronal T2-weighted MR scan shows minimal septation and slight wall irregularity. (C) Ultrasound examination shows more septa with associated nodular thickening appearing significantly more complex than the CT or MR. Lesion has remained stable for over a year of follow-up imaging. Abbreviations CT, computed tomography MR, magnetic resonance.
Table 25.1 Bacterial Cystitis Bacterial cystitis is common in women, promoted by a relatively short urethra, use of a diaphragm, and sexual intercourse. Middle-aged men are prone to infection because enlargement of the prostate gland partially obstructs their urethra. Placement of a bladder catheter commonly results in infection Taking sufficient fluid to void urine at least four to five times daily, wiping from front to back. Single dose of antimicrobial medication with sexual intercourse may help prevent bacterial cystitis in women. Short-term antimicrobial therapy usually sufficient. Longer treatment for pyelonephritis
A group of criteria for determining the cause of an infectious disease by using molecular techniques has been incorporated into a new set of postulates called the Molecular Postulates. These newer techniques deal directly with the virulence factors of microorganisms. These factors are particularly relevant in diseases such as pneumonia and urinary tract infection, which can be caused by a variety of microorganisms. They also help explain how some microbes such as Streptococcus pyogenes can cause a number of different diseases.
A 55-year-old obese woman with adult-onset diabetes mellitus has been receiving amoxicillin for treatment of an acute exacerbation of chronic bronchitis. After a week of therapy, the patient develops dysuria and increased urinary frequency. Urinalysis shows 10 to 50 white blood cells per high-power field, and Gram stain of urine shows many budding yeasts. Which antifungal agent would be best in treating this patient for Candida cystitis
In some patients, bladder neoplasms merely produce linear areas of wall thickening that are detectable by CTU. Although bladder cancers usually produce focal bladder abnormalities and cystitis usually produces diffuse wall thickening, there is overlap. Each type of thickening can be caused by either benign or malignant disease. In the report by Caoili et al. (12), eight of ten patients with focal bladder wall Although bladder hematomas can have an appearance similar to that of bladder neoplasms (Fig. 14), they can occasionally be identified correctly when they have characteristic high attenuation (60-80 Hounsfield Units) on precontrast scans. Sometimes, the cause of hemorrhage (which is often a bladder neoplasm, cystitis, or upper-tract bleeding) can also be identified. Cystitis As mentioned above, cystitis frequently causes uniform diffuse bladder wall thickening (Fig. 15). In many instances, cystitis can be suggested on CTU (when such thickening is visualized) however, false...
Modern randomized clinical trial studies have been done investigating acupuncture for a variety of pelvic dysfunctions. However, there is still only a limited number of such studies. The largest number of trials concern the syndrome of interstitial cystitis.1-6 Then, there are generalized pelvic pain,7,8 pelvic myofascial trigger points,9,10 vulvody-nia,11 and review articles of pelvic pain listing acupuncture as a treatment modality.12-14 Regarding interstitial cystitis, significant reductions in frequency and incontinence have been demonstrated using acupuncture.1 Others have found a significant increase in cystometric capacity and symptomatic improvement in frequency, urgency, and dysuria.6
Functional BOO is a condition, that deserves further attention. Terms such as female aseptic dysuria, female prostatitis, abacterial cystitis, and, most often, the urethral syndrome have been used to describe this condition in the literature.16,17 Such variation in terms reflects both the common symptoms among these patients (recurrent episodes of urinary frequency, urgency, and dysuria without pelvic pain) and the lack of consensus over the etiology and pathophysiology of this condition. Some authors suggest that the urethral syndrome is probably the most frequent reason for urological consultation among Based on a review of the literature and our clinical observations, we have theorized that these patients have inflammation infection of the urethra (urethritis) with a subsequent functional hyperactivity of the smooth muscle components of the urethra. Such spasm of the smooth muscle of the bladder outlet may manifest in symptoms of frequency, urgency, and frequent cystitis. The spasm...
The tissues of the distal vagina and urethra are of similar embryonic origin, and both are sensitive to the trophic action of estrogens. Postmenopausal atrophy of these tissues may result in painful sexual intercourse, dysuria, and frequent genitourinary infections. Unlike the vasomotor complaints, these symptoms seldom improve if untreated. Treatment with a combination of minimally effective dosages of an estrogen and a progestin is recommended. Estrogen can be administered orally or in a topical preparation with equivalent efficacy. Progestins are given orally.
Nitrofurantoin is administered orally and is rapidly and almost completely absorbed from the small intestine only low levels of activity are achieved in serum because the drug is rapidly metabolized. Relatively high protein binding (about 70 ) also affects serum levels, reducing potential for systemic toxicity and alteration of intestinal flora. Relative tissue penetration is much lower than other antimicrobials for UTIs, and therefore, nitrofurantoin is not indicated in the therapy of infections such as pyelonephritis and renal cortical or per-inephric abscesses. Nitrofurantoin is rapidly excreted by glomerular filtration and tubular secretion to yield effective urinary levels. In moderate to severe renal dysfunction, toxic blood levels may occur while urinary levels may be inadequate. The drug is inactivated in the liver. The singular indication for nitrofurantoin is the treatment and long-term prophylaxis of lower UTIs caused by susceptible bacteria it is not used as a bacterial...
Acute uncomplicated urinary tract infections caused by E. coli and other pathogens generally respond promptly to one of the short-acting sulfonamides. Recurrent urinary tract infections (UTIs), when related to some structural abnormality in the tract, are frequently caused by sulfonamide-resistant bacteria.
The first-generation and oldest quinolones exhibit limited gram-negative activity. Nalidixic acid and cinoxacin do not achieve systemic antibacterial levels and are thus restricted to therapy of bladder infections caused by urinary pathogens, such as E. coli and Klebsiella and Proteus spp. Although they are bactericidal agents, their use is restricted by resistance.
The larvae penetrate skin that is in contact with contaminated water and then migrate through the lymphatics and blood vessels to the liver. After maturing, schistosomes migrate into the mesenteric or vesicular vein, where the adults mate and release eggs. The eggs secrete enzymes that enable them to pass through the wall of the intestine (Schistosoma mansoni and Schistosoma japonicum) or bladder (Schistosoma haematobium). In addition, some eggs may be carried to the liver or the lung by the circulation. Penetration of the skin is associated with petechial hemorrhage, some edema, and pruritus that disappears after about 4 days. Approximately 3 weeks after trematode penetration, patients complain of malaise, fever, and vague intestinal symptoms. With the laying of eggs, acute symptoms of general malaise, fever, urticaria, abdominal pain, and liver tenderness are reported. Diarrhea or dysentery is associated with infestations by S. mansoni and S. japonicum, whereas...
When did painful urination begin Trauma to the urinary tract must be ruled out if pain develops after an injury. Bicycle and straddle injuries commonly cause damage to the kidneys or urethra, leading to hematuria or dysuria, or both. Consider behavioral problems, including attention seeking, if symptoms occur only at a particular time of day (ie, during school). of dysuria. Dysuria associated with back pain is a common presentation of pyelonephritis. Renal stones in the pelvis, calyx, or ureter can cause abdominal or flank pain with radiation into the scrotum or vulva. Stones in the urethra or distal ureter cause dysuria. Stones in the bladder are not associated with pain. C. Are there associated complaints (eg, fever, drainage or discharge between urinations, abnormal urine odor or color, or changes in volume or frequency of urination) Fever, dark and foul-smelling urine, frequency, and urgency are all symptoms associated with UTIs. If patient is sexually active and experiencing...
Colovesical fistulas are more common in men, probably because of the male anatomy maintaining close proximity between the sigmoid colon and the bladder. This is contrary to the female anatomy, where the uterus forms a barrier between the bladder and the sigmoid colon, except in posthysterectomy patients. Colovesical fistulas are not a usual complication of diverticulitis,because most fistulas are at the dome of the bladder. Colovesical fistulas often present with symptoms of bladder irritability,dysuria,pneumaturia, fecaluria, and recurrent urinary tract infections.3 In addition to clinical signs and symptoms of an abnormal colovesical communication, complementary tests may be required to confirm the diagnosis (Table 13-3.1). Computerized tomography findings include air in the bladder, focal bladder wall and adjacent bowel wall thickening, and surrounding inflammation. A water-soluble enema may also identify the fistulous tract in addition to diverticular disease or tumor. Moreover, a...
Other potential genes involved in virulence or environmental adaptation include a putative N-actylmannosamine-6-phosphate epimerase (EF0066), which is part of the N-acetylmannosamine utilization pathway, often found in oropharyngeal pathogens 125 . In addition, a large cell-wall-associated protein is present (EF0109), with a predicted size of 207kDa. This large protein may have a role in colonization or virulence through adhesion or immune evasion, but its role is at present unknown. 4 Gordon, K. A. and R. N. Jones. 2003. Susceptibility patterns of orally administered antimicrobials among urinary tract infection pathogens from hospitalized patients in North America comparison report to Europe and Latin America. Results from the SENTRY Antimicrobial Surveillance Program (2000). Diagn. Microbiol. Infect. Dis. 45 295-301. C. Waters and G. Dunny. 2004. Entero-coccal aggregation substance and binding substance are not major contributors to urinary tract colonization by Enterococcus...
Wound complications and urinary infections are the most common surgical complications after retropubic col-posuspension. Direct surgical injury to the urinary tract occurs relatively infrequently. Bladder lacerations occur in approximately 1 of patients the risk increases in women who have had previous bladder neck suspension. Accidental placement of sutures into the bladder during the Burch colposuspension or paravaginal repair, resulting in vesical stone formation, painful voiding, recurrent cystitis, or fistula can occur but is rare. Ureteral obstruction occurs rarely (0 -1.2 ) after Burch colposuspension and results from ureteral stretching or kinking after elevation of the vagina and bladder base. No cases of transected ureters have been reported. The incidence of voiding difficulties after colposuspen-sion varies widely, although patients rarely have urinary retention after 30 days. In my hands, the mean number of days to complete voiding after open Burch procedure is 7 days.12...
Clinical care in spinal cord injury has advanced to provide individuals who have sustained spinal cord injury with a nearly normal life span by minimizing the leading causes of death bladder infections and respiratory infections. While these advances have caused a dramatic reduction of morbidity and mortality, advances leading to functional restoration of the individual have been considerably less progressive. In point, conventional restoration of upper extremity function still utilizes orthoses or, more recently (since the mid-1960s), tendon transfers. Conventional mobility is focused on the wheelchair or standard orthotics, with some advancement in reciprocal gait orthoses. Conventional bladder management employs external collection devices or indwelling catheters, and defecation uses suppositories with the accompanying hours of time for bowel management. The evolving dissemination of neural prostheses is dramatically changing this environment. Neural prostheses are devices that...
There are a number of potential mechanisms for the higher level of chronic inflammation and hence oxidant stress, observed in the elderly than in younger subjects. The first of these is that the elderly are experiencing a higher level of asymptomatic bacteriuria. This possibility was studied in 40 consecutive patients (age 70-91 years) admitted to hospital for functional disability. Patients were examined for the presence or absence of bacteria in urine. Twenty subjects had positive urine culture and 20 sex- and age-matched subjects had negative urine culture. Patients with asymptomatic bacteriuria had significantly increased levels of circulating tumor necrosis factor receptors (sTNFR-I) and a higher number of neu-trophils in the blood compared with the group without bacteriuria. Thus, the study provides some support for the hypothesis that asymptomatic urinary infections are associated with low-grade inflammatory activity in frail, elderly subjects (30).
Autonomic neuropathy is prevalent and may manifest as gastropathy, cystopathy, and orthostatic hypotension. The extent of diabetic autonomic neuropathy is commonly underestimated. Neurogenic bladder dysfunction is an important consideration in patients receiving a bladder-drained pancreas-alone transplant or an SPK transplant. Inability to sense bladder fullness and empty the bladder predisposes to urine reflux and high post void residuals. This may adversely affect renal allograft function, increase the incidence of bladder infections and pyelonephritis, and predispose to graft pancreatitis. The combination of orthostatic hypotension and recumbent hypertension results from dysregulation of vascular tone. This has implications for blood pressure control posttransplant, especially in patients with bladder drained pancreas transplants that are predisposed to volume depletion. Therefore, careful re-assessment of posttransplant antihypertensive medication requirement is important. Sensory...
Close monitoring of fluid status, electrolytes and blood sugar is necessary in the ischemic stroke patient. Normovolemia and euglycemia is the goal, since hyperglycemia is associated with increased morbidity and mortality after stroke 14 . Maintenance of normo- or hypothermia provides brain protection, since hyperthermia can worsen outcome in cerebral ischemia 15 . Fever after a stroke is a common occurrence. Acetaminophen and cooling blankets help in reducing acute increases in temperature. An infectious source for the fever should always be sought and treated with appropriate anti-microbial agents. Fever in the chronic phase of stroke is usually the result of aspiration pneumonia or urinary tract infection 16 .
TMP-SMX (Septra, Bactrim) is used in the treatment of genitourinary, GI, and respiratory tract infections caused by susceptible bacteria. E. coli, enterococci, P. mirabilis, some indole-positive strains of Proteus spp., and Klebsiella pneumoniae are usually sensitive to this combination therapy for both chronic and recurrent UTIs. Trimethoprim is present in vaginal secretions in high enough levels to be active against many of the organisms found in the introital area that are often responsible for recurrent UTIs. In some patients with recurrent UTIs, most notably women of childbearing age, the long-term use of one tablet taken at night is an effective form of chemoprophylaxis. The drug is approved for use by the U. S. Food and Drug Administration (FDA) for treating UTIs in both children and adults.
When the OCAs are used for these purposes, they are administered at much lower doses than when used for cholecystography. At the higher doses, the major adverse effects of these compounds are acute renal failure, thrombocytopenia, and athrombocytosis possible minor adverse reactions include diarrhea, nausea, vomiting, and dysuria.
Perineal approaches include fistulotomy, cutting setons, conversion to perineal laceration with layered closure, and sphincteroplasty. The use of fistulotomy and cutting setons is mentioned only to be condemned because of the high risk of postoperative incontinence from sphincter damage. Conversion of the fistula to a perineal laceration with layered closure is more often used although not widespread because of the inherent division of the sphincter and the unknown rate of subsequent incontinence (Figure 12-2.3). For this technique, the patient is placed in the prone position after antibiotic and mechanical bowel preparation. The bridge of skin and muscle distal to the fistula are divided and the fistula tract is excised. The rectal mucosa is closed and the levators and the external anal sphincter are mobilized and reapproximated. The perineal body is reconstructed and the vaginal mucosa closed. This technique has been evaluated in small studies and demonstrates close to a 100 success...
All CPTs undergo a rapid, reversible, pH-dependent, nonenzymatic hydrolysis of the lactone ring to generate the less-active open-ring hydroxy carboxylate in aqueous solutions. The latter species predominate at physiologic or alkaline pH. This finding is clinically relevant because the low pH in the bladder favors the active closed lactone ring species that can cause severe hemorrhagic cystitis. Among the CPT analogues, irinotecan is structurally unique in that it lacks direct activity per se. It is a prodrug that must undergo cleavage of its bulky dipiperidino side chain by a carboxylesterase-converting enzyme to produce the metabolite SN-38 for biologic activity.
B, D, A Chemotherapy is commonly associated with renal injury. High-dose methotrexate is associated with renal tubular injury. Cisplatin may cause tubular necrosis cyclophosphamide and ifosfamide are both associated with hemorrhagic cystitis. L-Asparagi-nase is not associated with renal injury. (Rogers, MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition pp. 1452,1453 table 42.18.)
General measures for preventing urinary infections include taking enough fluid to ensure voiding at least four or five times daily, voiding immediately after sexual intercourse, and wiping from front to back after defecation to minimize fecal contamination of the vagina and urethra. Preventing recurrent infections may require taking a dose of antibacterial medication immediately before or after sexual intercourse, or taking daily a small dose of an antibiotic that is concentrated in the urine. Treatment of cystitis is usually easily carried out with a few days of an antimicrobial medication to which the causative bacterium is susceptible. Pyelonephritis usually requires prolonged treatment and often hospitalization. The main features of bacterial cystitis are presented in table
PCN is often performed to allow the closure of a ureteral fistula, ureteral leak, or a dehiscent urinary tract anastomosis. In most cases, PCN drainage alone is unsuccessful in totally diverting the urine, and either ureteral stenting or ureteral occlusion (the latter in patients with intractable vesicovaginal fistulas) is additionally required. In Farrell and Hicks' large series of patients (6), urinary fistulae were the most common nonobstructive indication for PCN placement (although this series did not include patients undergoing PCN for removal of stones). Urinary diversion by PCN alone has been used with some success to treat patients with intractable hemorrhagic cystitis (68).
Between 1985 and 1991, Ps. aeruginosa was the fourth most common nosocomial isolate in the United States, accounting for 10 per cent of nosocomial infections. Hospital-wide, it is the leading cause of nosocomial pneumonia (17 per cent), the third most common cause of urinary tract infections (12 per cent), and the fifth most common cause of surgical wound infection (8 per cent). It is the most common isolate in the ICU (13 per cent), where it is the leading cause of pneumonia (18 per cent), the fourth most common cause of urinary tract infections (12 per cent), and the third most common cause of wound infections (11 per cent). Other ICU infections caused by Ps. aeruginosa include meningitis, brain abscess, eye infection, hematogenous bone and joint infection (osteomyelitis), urinary tract infection, and gastrointestinal infection. Central nervous infections can arise from direct extension (e.g. paranasal sinusitis, where Ps. aeruginosa is the most common nosocomial isolate),...
Duration, characteristics, and severity of the incontinence, precipitating factors and reversible causes should be assessed. Dysuria, urgency, pelvic pain, dyspareunia, constipation, fecal incontinence, pelvic prolapse, or abnormal vaginal discharge should be sought. A history of diabetes, thyroid disease, spinal cord injury, cerebral vascular accidents, urethral sphincter B. Estrogen status should be determined because hypoestrogenism can contribute to recurrent cystitis, detrusor instability, and stress incontinence. Patients should be questioned about recurrent urinary tract infections, kidney stones, bladder pain, or hematuria.
Hospital-wide nosocomial pneumonia has become more common than surgical wound infection, and is numerically second only to urinary tract infection. The majority of nosocomial pneumonias develop in ICU settings. The overall mortality approximates 35 per cent and may be as high as 50 per cent in tertiary care centers. The mortality of nosocomial pneumonia is related to the type of organism and the concomitant presence of bacteremia (the overall incidence is about 10 per cent, but mortality increases threefold in cases complicated by bacteremia). Mortality from pneumonia caused by Gram-negative organisms (most commonly Pseudomonas,
Urethral dilatation has been used for many years as a treatment for recurrent cystitis, pelvic or bladder and ure-thral pain, and for nonspecific voiding dysfunction including bladder emptying dysfunction in women. Although frequently used to treat urethral syndrome or primary bladder neck obstruction in the female, this procedure often results in only temporary symptomatic relief and over time it may result in bladder outlet obstruction secondary to transmural urethral stenosis or stricture formation. The obstruction is caused by periurethral fibrosis and scarring of the urethral wall that results from multiple episodes of postdilatation bleeding or extravasation of urine into the periurethral tissues. This may result in rigidity of the urethral wall and narrowing of the urethral lumen.
UTIs are associated with WBCs in urine and a positive culture calculi produce hematuria. (Presence of a few WBCs or RBCs is also consistent with appendicitis adjacent to ureter or bladder.) Urine sediment is often abnormal in Henoch-Schonlein purpura.
To minimize graft thrombosis, prudent selection of donor pancreas grafts, short cold ischemia times, and meticulous surgical technique are necessary. Regarding the latter, it may be helpful to utilize the distal cava proximal common iliac vein or the common iliac vein after ligation and division of the hypogastrics. Patients are often given anti-platelet agents and or he-parin during the perioperative period to minimize the occurrence of vascular thrombosis. The quality of the pancreas graft, the age of the donor, and the cold ischemia time also influence graft thrombosis rates. Approximately 3-5 of pancreas grafts will need to be removed because of portal venous thrombosis. Arterial thrombosis is less common and is usually associated with anastomosis to atherosclerotic vessels. Bladder-drained pancreas transplantation is a safer procedure than enteric-drained pancreas transplantation with respect to avoiding the possibility of an intra-abdominal abscess....
Dementia in the elderly roughly doubles the risk of urinary incontinence. (35* To minimize incontinence, toilets should be easily identifiable and readily accessible. Clothing may need attention to ensure that it is easy to remove. If urinary incontinence is present then reversible causes, such as urinary tract infection, constipation, and medication (such as diuretics or drugs with anticholinergic side-effects causing urinary retention and overflow) should be excluded.
Acute uncomplicated pyelonephritis presents with a mild cystitis-like illness and accompanying flank pain fever, chills, nausea, vomiting, leukocytosis and abdominal pain or a serious gram-negative bacteremia. The microbiologic features of acute uncomplicated pyelonephritis are the same as cystitis, except that S. saprophyticus is a rare cause.
This may be due to infection preceding the stroke (consider endocarditis and encephalitis), the stroke itself, or, most commonly, a complication such as a chest or urinary infection or venous thromboembolism. Obviously the underlying cause should be sought and treated but it is probably sensible to try to reduce the temperature using simple means (for example, antipyretic drugs) in any case since this is likely to make the patient more comfortable and there is a possibility, based on animal models and the observation that raised temperatures are associated with poor outcomes in patients,64-67 that a raised temperature may exacerbate any ischaemic cerebral damage.68 There are no published randomised trials of cooling therapy yet,69 for patients with either a raised or normal temperature, but there is at least one ongoing randomised study, COOL AID 1 (see www.strokecenter.org trials ), and there are published small open studies.70
Despite the widespread and long-term application of this implant for the treatment of SUI, treatment-related morbidity has been minimal. Reports of transient urinary retention ranges from 1 to 21 and is managed with intermittent catheterization or short-term catheter use. Urinary tract infection occurs in 1 to 25 of cases, and self-limited hematuria may occur in 2 of cases. Other reported but rare complications include periurethral abscess formation, de novo instability, and a reaction at the previously negative skin test site after a Contigen implant treatment.
Include cytomegalovirus (CMV), rubella, hepatitis A though G, herpesviruses (simplex, zoster, HHV 6), adenovirus, enteroviruses, Epstein-Barr virus (EBV), reovirus 3, parvovirus B19, HIV, bacterial sepsis, E coli UTI, cholangitis, syphilis, listeriosis, tuberculosis, toxoplasmosis. Most of these patients present with other signs of infection. Laboratory evaluation usually reveals evidence of hepatocellular injury with elevated ALT and AST in addition to cholestasis.
Sacral neuromodulation is indicated in urgency frequency, urge incontinence, mixed incontinence with a significant urge component, and unobstructed urinary retention. More recently, it is indicated for interstitial cystitis. The work-up includes a complete history and physical examination, urinalysis, urine culture, cytology, and voiding diary. Cystoscopy, urodynamics, and upper tract imaging are performed as indicated. These diagnostics serve three purposes 1) to identify an underlying disorder that should be treated by other means (calculus or carcinoma in situ), 2) to clarify the etiology of the lower urinary tract dysfunction, and 3) to serve as a baseline for later comparison.
Bladder hydrodistention has been used in the past to reduce the irritative symptoms of OAB, hypersensitivity of bladder afferent nerves, and the pain associated with bladder filling in interstitial cystitis patients. The exact mechanism of action for the perception of clinical benefit is unknown, as is the exact etiology(ies) for this condition however, mechanical damage and local ischemia of the suburothelial nerve plexus is thought to provide temporary
Spasticity is a common finding in those with MS. It is defined as velocity-dependent stiffness about a joint. The muscle stiffens the faster it is moved. Spasticity is not inherently a bad symptom. Many patients use lower-limb spasticity to generate gait or transfers. Sometimes, however, it can become very bothersome and needs significant attention. Noxious stimuli anywhere in the body will exacerbate spasticity. Thus, the first attempt at treatment revolves around eliminating pain in the body. This may be from a urinary tract infection or from a sore. After pain is treated, an exercise program is instituted. This usually concentrates on the stretching and range of motion exercises, but aerobic exercises can be effective also. Physical therapists may be involved in the initiation of the process. The actual exercising should be as independent as possible so that the person can do it easily on a regular basis.
Just how much residual urine to accept is somewhat dependent on the situation. The normal residual is zero to 20 cc. Less than 100 cc is clearly acceptable. In MS, it is not unusual to see a residual of 200 cc to 400 cc without much discomfort. It all depends on individual symptoms. If high pressures exist in the bladder (dyssynergic type), it is potentially possible to push urine up the ureters toward the kidneys, although, surprisingly, upper tract disease is quite rare in MS. If chronic infections have been present, an ultrasound of the kidneys and ureters is appropriate cystoscopy may be necessary to find bladder stones that result from chronic bladder infections.
Urinary tract infections (UTI) are the most commonly reported bacterial infection in the United State. E coli causes 90 of them, some of which are hospital acquired. Hospital acquired UTI are difficult to treat. Other UTI are caused by Pseudomonas aeruginosa, Serratia, and Enterobacter. A family of antibiotics called sulfonamides, that stops the growth of bacteria, is used to treat UTI. These include trimethoprim-sulfamethoxazole (TMP-SMX) and cephalasporins. Aztreonam and fluoroquinolones are used as urinary tract antiseptics. Phenazopyridine (Pyridium) is used to treat pain from a UTI.
While it is likely that disturbed bladder control is the commonest general cause of bladder symptoms, some bladder symptoms may be indicative of infection, and infection not only causes pyrexia (high temperature) and malaise but can also cause general exacerbation of all impairments, especially spasticity. Urinary tract infection (UTI) may also, rarely, cause pyelonephritis and septicaemia. The frequency of actual UTI is unknown and so, although the potential importance of urinary tract infection is great, its actual medical importance is unknown. This section will first cover the assessment and management of disturbed bladder control leading to urinary frequency, nocturia, urgency of micturition, and incontinence. Then the specific issues of UTI will be covered. Many of the issues are not specific to people with MS, being similar to those faced by other people with neurogenic bladder disturbance and so some recommendations are based on generic evidence. The main issues to be covered...
Choice of therapy for UTIs depends on specific antimicrobial susceptibilities of the bacteria isolated from urine and blood cultures. Fluoroquinolones are widely used in this population cephalosporins are alternative agents. Anaerobic organisms are rarely involved in these infections and are not routinely covered. For infections caused by coagulase-negative staphylococci or by ampicillin-resistant enterococci, vancomycin is the antimicrobial agent of choice. Length of treatment depends upon the severity of the infection, with two weeks or longer duration of therapy for pyelonephritis. Recurrent infections of the urinary tract prompt further investigation with imaging studies to exclude anatomic abnormalities and obstruction.
Surgical drainage or removal of infected vascular catheters or prostheses is the cornerstone of therapy for enterococcal infections involving a discrete focus, such as an abscess. Empirical therapy for Enterococcus in intra-abdominal, non-biliary, or non-urinary infections does not appear necessary in good-risk patients, nor is therapy necessary if Enterococcus is isolated from a good-risk patient who is untreated but doing well. However, specific antibacterial therapy against enterococci is warranted in many of the circumstances typified by the seriously ill patient. If the patient has had enterococci cultured previously during hospitalization or if the infection is nosocomial, particularly with previous gastrointestinal or genitourinary surgery or previous antibiotic therapy, a drug effective against enterococci should be included in the regimen for both proved and presumptive abdominal or pelvic infections, or for burn or surgical wound infections. This is particularly true in...
The use of trimethoprim sulfamethoxazole (TMP SMX) reduces the incidence of UTIs and blood stream infections after renal transplantation. Such an approach offers additional protection against opportunistic pathogens such as P carinii, Listeria monocytogenes, and Nocardia species. For sulfa-sensitive recipients, fluoroquinolones are alternative prophylaxis agents. Typically, prophylaxis is continued for six months after transplantation.
Patients can present with many symptoms. These symptoms include urgency, frequency, pelvic pain, pelvic pressure, bladder spasm, dyspareunia, dysuria, awakening at night with pain, and pain that persists for many days after intercourse. The location of pain includes the vaginal area, the lower abdomen, suprapubic area, groin, or low back. Many symptoms are aggravated by menstruation and most of the patients believe that sexual intercourse exacerbates their symptoms.
Recipients of renal allografts are at risk for UTIs with these organisms because of underlying medical conditions, such as diabetes mellitus, and the use of indwelling urinary drainage catheters. Pancreas-kidney recipients also are at additional risk because urinary pH changes associated with exocrine secretion drainage favor bladder colonization with Candida. Candida infections can present in multiple ways including intravascular catheter infections with sepsis and fever, intra-abdominal abscesses, urinary tract infections. Mediastinitis can complicate heart and lung transplantation.
The common embryologic origin of the vestibule, urethra, and bladder has suggested an etiologic association among chronic painful conditions involving these tissues. This may help explain the similarity in physical and histologic findings, prevalence rates, and treatment strategies for vulvar vestibulitis, trigonitis, urethritis, and interstitial cystitis.1,2 Interstitial cystitis is considered in a separate chapter.
The type of anti-incontinence procedure, material used, and the temporal relationship between the procedure and the development of lower urinary tract symptoms should be identified from the patient's history. Women with BOO present with a variety of urinary symptoms. As a reaction to the obstructive mechanism, the detrusor muscle can become overactive and unstable, resulting in frequency, urgency, and urge incontinence, or even progress to the phase of detrusor decompensation heralded by urinary retention and recurrent urinary tract infections or overflow incontinence. patients (93 ) presented with irritative symptoms of urgency and frequency. Twelve patients (80 ) presented with urine retention (complete and incomplete) and increased postvoid residual volume. Eight patients (53 ) had urge incontinence, and four (27 ) presented with recurrent urinary tract infections. Pain (suprapubic or during micturition) or dysuria and poor urine stream were also reported, but at a lower rate than...
The genitourinary system is one of the portals of entry for pathogens. Many antimicrobial medications are excreted in the urine in concentrations higher than in the blood. The flushing action of urination is a key defense mechanism against bladder infections. The fallopian tubes can provide a passageway for pathogens to enter the abdominal cavity. The uterine cervix is a common site of infection by sexually transmitted pathogens. Prostate enlargement predisposes men to urinary infection.
Anthocyanidins are red-blue pigments in plants, and they are especially high in fruits such as blueberries, bilberries, and other berries. Like many other flavon-oids, anthocyanidins exist in nature almost exclusively in their glycoside (anthocyanin) forms. Although the glycosides are found in many plants, the primary commercial source of anthocyanins is Vaccinium myrtillus (bilberry), in which they occur at about 3 percent.185 Bilberries are eaten as food and have also been used medicinally to treat scurvy, urinary infections, diarrhea (due to their astringent characteristics), and varicose veins, as well to improve night vision and treat other eye
Piperacillin and azlocillin are active against many Gram-negative species, including some Pseudomonas and Klebsiella species, but they are susceptible to b-lactamase. They are usually given in combination with an aminoglycoside. Piperacillin-tazobactam contains a b-lactamase inhibitor which allows it to be used as monotherapy. These agents are active against enterococci. They are used in intra-abdominal (e.g. biliary) infections, respiratory or urinary infections, and septicemia.
Ceftazidime is the most active agent against Pseudomonas aeruginosa but resistance can develop during treatment. It is active against the Enterobacteriacae but has poor activity against staphylococci and streptococci. It penetrates the lung well and is commonly used in the treatment of ventilator-associated pneumonia, provided that staphylococcal pneumonia is excluded. Some advise combination with an aminoglycoside in severe cases. It is used to treat febrile episodes in neutropenic patients and pseudomonal urinary infections.
The carbapenems are used when several antibiotics would otherwise have to be given. Bacteremia, severe respiratory or urinary infections, febrile neutropenic episodes, and abdominal sepsis are common indications. Pseudomonal infections are better treated with other agents. Nausea and vomiting are common and fits develop in 1 per cent of patients given imipenem. Patients allergic to penicillins may be allergic to carbapenems. Superinfection with resistant pseudomonads or fungi can develop.
Ciprofloxacin and ofloxacin are available for intravenous use. Their broad spectrum of activity, oral or intravenous administration, and safety have encouraged inappropriate use, and resistance is increasing, particularly in Ps. aeruginosa and MRSA. They inhibit bacterial DNA gyrase and are bactericidal. They are active against staphylococci and streptococci, but should not be used in preference to penicillins. Neisseria species, Hemophilus species, and a high proportion of the Enterobacteriaceae are susceptible. Pseudomonas species are moderately susceptible, but high doses are needed to inhibit pseudomonads in the lungs. Excretion is by the kidney. The quinolones are used to treat complicated urinary infections and prostatitis. Other agents should be used for community-acquired pneumonia. They are first-line agents in severe Salmonella and Shigella infections. Osteomyelitis and soft tissue infections caused by Gram-negative bacteria and gonorrhea are other
Most upper urinary tract infections in children originate from bacterial contamination of the perineum and lower urinary tract by uropathogenic fecal flora. Although vesicoureteral reflux is the most widely described mechanism for upward transport of bacteria from the bladder to the renal collecting systems and kidneys, it is not invariably present in patients who develop ascending pyelonephritis. Other, as yet uncharacterized, mechanisms for upward conveyance of bacteria clearly exist. Pyelonephritis secondary to hematogenous seeding of the kidney is, by comparison, quite rare in childhood and generally occurs only in the context of serious extra-urinary disease of the cardiovascular, gastrointestinal, or musculoskeletal system that predisposes to recurrent bacteremia. Frequently, it can be difficult to reliably differentiate between upper and lower urinary tract infections in children based upon clinical and laboratory parameters alone. The vast majority of upper urinary tract...
PCNs are often performed as an inpatient procedure. When performed on an outpatient basis, 12 to 25 of patients may require admission to the hospital after the procedure because of such complications as bleeding or sepsis (16). Patients who may not be suitable candidates for outpatient PCN include those with hypertension, untreated urinary tract infection, coagulopathy, and staghorn calculi (16,22). When obstruction is complicated by urosepsis or azotemia, the response to renal decompression is often immediate, with fever and flank pain improving in 24 to 48 hours after PCN drainage (38). When obstruction and infection are due to uret-eral calculi, retrograde ureteral catheterization and PCN are equally effective in relieving the obstruction and infection, with neither technique superior to the other in promoting rapid drainage or clinical defervescence (39). However, percutaneous manipulations themselves can precipitate septicemia (manifested as shaking chills and fever) in these...
Suspect when dysuria, pyuria, but no bacteriuria, is present. Treatment with azithromycin, 1 g in a single dose, or doxycycline, 100 mg twice daily for 7 days, is VII. Teaching Pearl Question. Is dysuria the most common presentation in patients with C trachomatis infection VIII. Teaching Pearl Answer. Although dysuria is a more common presenting feature of chlamydial infection in children, up to 50 of patients are asymptomatic. Girls often present with mucopurulent cervical discharge boys, with urethral discharge.
BK virus (BKV), JC virus (JCV), and simian virus 40 (SV-40) belong to the family of Papovaviridae. The three viruses are similar in structural and functional properties.64,65 Nucleotide sequence homology of the three viruses is 68 to 72 , and protein sequence homology is 76 to 90 in different regions of the viral genomes.64 Primary infection by BKV and JCV occurs in childhood and is usually unapparent. During primary infection, the virus spreads by viremia to several organs and establishes a latent infection in the kidneys. Reactivation from latency can be induced by immunologic impairment. BKV and JCV are ubiquitous in the human population worldwide, and seroprevalence in adults is 80 to 100 . Both viruses are probably transmitted by the respiratory and the orofecal route.4,66,67 BKV and JCV cause posttransplantation interstitial nephritis in renal transplant recipients and BKV causes hemorrhagic cystitis in bone marrow transplant patients.4,64-66 JCV is the etiologic agent of...
Chronic trigonitis is often preceded by recurrent, documented urinary tract infections and is thought to represent a deep tissue bacterial infection. A long course of antibiotics with good tissue penetration is indicated as first-line therapy. We use Vibramycin 100 mg twice a day for 21 days. If antimicrobial therapy is unsuccessful, the patient should be evaluated and treated for interstitial cystitis.
G.W. is a 9-month-old child admitted with a chronic urinary tract infection. G.W. weighs 22 lbs. Currently, G.W. has a temperature of 104aR. Among her medical orders are foley catheterization to straight drainage force fluids urine for culture and sensitivity Tylenol elixir q.i.d. p.r.n. for temp 101a or greater vital signs q 4h The recommended dosage of Sulfatrim for children with urinary tract infections is 8 mg kg trimethoprim and 40 mg kg sulfamethoxazole per 24 hours, given in two divided doses every 12 hours for 10 days. Use the following table as a guide for children two months of age or older.
Methenamine is primarily used for the long-term prophylactic or suppressive therapy of recurring UTIs. It is not a primary drug for therapy of acute infections. It should be used to maintain sterile urine after appropriate antimicrobial agents have been employed to eradicate the infection. Gastric distress (nausea and vomiting) is one of the most frequently reported adverse reactions. Bladder irritation (e.g., dysuria, polyuria, hematuria, and urgency) may occur. The mandelic salt can crystallize in urine if there is inadequate urine flow and should not be given to patients with renal failure. Patients with preexisting hepatic insufficiency may develop acute hepatic failure due to the small quantities of ammonia formed during methenamine hydrolysis. 2. Urinalysis of a 38-year-old woman with recurrent UTIs revealed pH 6.8,30 to 50 WBC per highpower field, and gram-negative bacilli identified as Proteus mirabilis. Which of the following produces a bacteriostatic urinary environment for...
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