PANCE Blueprint Genitourinary (5%)

Infectious Disorders (PEARLS)

The NCCPA™ PANCE Genitourinary Content Blueprint covers six types of infectious GU conditions

Cystitis
Patient will present as → a 34-year-old woman with a 3-day history of hematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain. On examination, she does not look ill. Her temperature is 37.5 ° C. Her abdomen is nontender. There is no CVA tenderness.

Infection of the bladder and is characterized by dysuria without urethral discharge. E. coli (most common)

  • Dysuria, urgency, frequency, hematuria, new-onset incontinence (in toilet-trained children). Abdominal or suprapubic pain
  • Absence of fever, chills, or flank pain. Change in urine color/odor
  • Urine dipstick: nitrite, leukocyte esterase
  • Urinalysis: pyuria, bacteriuria +/− hematuria +/− nitrites
  • Urine culture (gold standard)
    • > 100k CFU/mL (women)
    • > 1000 CFU/mL men or cath patients
    • → takes 24 h to obtain results

Treat with Nitrofurantoin (not over age 65), Bactrim, Fosfomycin

  • Ciprofloxacin- reserved for complicated cases
  • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTI in sexually active women

Lower UTI in pregnancy

  • Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days
  • Cephalexin (Keflex): 500 mg PO BID × 7 days

Interstitial cystitis: Symptoms relieved with voiding. Diagnosis of exclusion.

  • Hunner’s ulcer” on cystoscopy
Epididymitis
Patient will present as → a 25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF.

Epididymitis is characterized by dysuria, unilateral scrotal pain, and swelling

The pathogen is based on the patient's age and risk factors

  • men < 35 chlamydia and gonorrhea
  • men > 35 E.coli

+ Prehn's sign = relief with elevation is a classic sign

TX:

< 35 years, or suspected STD etiology

  • Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) plus doxycycline (100 mg orally twice a day for 10 days)
  • Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms.

≥ 35 years, with suspected enteric organism

  • Levofloxacin (Levaquin) 500 mg/day PO for 10 days OR
  • Trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative.
Orchitis
Patient will present as → a 31-year-old male complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema with erythema, and shininess of the overlying skin.

Unilateral swollen testicle with erythema and shininess of the overlying skin

  • Orchitis is caused by ascending bacterial infection from the urinary tract
  • Mumps is a common cause in kids
    • Orchitis develops in 20 to 25% of males with mumps; 80% of cases occur in patients less than 10 years old
  • Orchitis without epididymitis is very uncommon in adults
  • Testicular torsion should be ruled out in all cases of new-onset testicular pain

DX: Urinalysis with cultures will show pyuria and bacteriuria with cultures positive for suspected organisms

  • Ultrasound is useful if abscess or tumor is suspected or to rule out torsion

TX: bed rest, NSAIDS, scrotal support, ice, and antibiotics (if bacterial)

  • Over 35: E. coli
    • Treatment: Ciprofloxacin
  • Under 35: Gonorrhea and chlamydia
    • Treatment: Ceftriaxone and doxycycline/azithromycin
Prostatitis
Patient will present as → a 63-year-old man with a history of benign prostatic hyperplasia who reports 3-days of fever, chills, and pain with urination. He was recently catheterized during admission to the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria.

Sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria

DX:

Urinalysis will reveal pyuria (↑ WBC in acute) +/- hematuria

  • Urine cultures: positive in acute and negative in chronic prostatitis
  • Prostatic fluid/secretions may show leukocytosis (↑ WBCs) with a culture typically positive for E Coli
  • Ultrasound/CT scan/cystoscopy: For individuals with significant voiding dysfunction/suspected abscesses/neoplasms
  • Blood tests: CBC, blood cultures if clinical findings suggestive of bacteremia
    • Blood urea nitrogen, creatinine levels for individuals with urinary retention/obstruction
    • Serum prostate-specific antigen (PSA) may be elevated

TX:

  • Men < 35: Chlamydia and Gonorrhea - ceftriaxone and azithromycin (or Doxycycline)
  • E coli in men > 35 -  treat with fluoroquinolones or Bactrim x 1 month
  • Chronic prostatitis  - treat with fluoroquinolones or Bactrim x 6-12 weeks
  • If you suspect acute prostatitis do not massage the prostate this can lead to sepsis
Pyelonephritis
Patient will present as → a 32-year-old female presents with fever, chills, nausea, and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts. 

Irritative voiding + fever + flank Pain + nausea and vomiting + CVA tenderness

  • Organism: E. coli

DX: Urinalysis

  • Pyuria, hematuria, bacteriuria, and WBC casts (pathognomonic pyelonephritis) 
  • Leukocyte esterase, nitrites, hematuria
  • Culture and sensitivity needs to be done
  • If complicated pyelonephritis order a renal ultrasound may show hydronephrosis secondary to obstruction

TX:

An oral regimen is considered the best initial outpatient treatment (7 days of outpatient treatment is equivalent to longer treatment regimens)

  • Ciprofloxacin: 500 mg BID for 7 days
  • Ciprofloxacin XR: 1,000 mg/day for 7 days
  • Levofloxacin: 750 mg/day for 5 days
  • Cephalexin 500 mg PO QID  for 10-14 days

IV antibiotics are indicated for inpatients who are toxic or unable to tolerate oral antibiotics

  • Ceftriaxone 1 g IV once daily

Management of acute pyelonephritis in pregnant women includes hospital admission for parenteral antibiotics.

  • Empiric therapy includes IV/IM ceftriaxone
"The decision to hospitalize a patient is usually clear in the setting of critical illness or sepsis. Otherwise, general indications for inpatient management include persistently high fever (eg, >101°F/>38.4°C) or pain, marked debility, inability to maintain oral hydration or take oral medications, suspected urinary tract obstruction, and concerns regarding adherence to therapy."
Urethritis
Patient will present as → a 22-year-old heterosexual male who recently started having unprotected intercourse with his new girlfriend. He now reports a painful itching and burning sensation with urination and discomfort in the urethra. He says that sometimes in the morning it appears that the walls of the meatus are stuck together with evidence of dried secretions. On exam, there is no purulent discharge. The meatus does appear red. His girlfriend does not have any symptoms.

Urethritis is an infection of the urethra with bacteria (or with protozoa, viruses, or fungi) and occurs when organisms that gain access to it acutely or chronically colonize the numerous periurethral glands in the bulbous and pendulous portions of the male urethra and in the entire female urethra

  • Symptoms include painful, burning, or frequent urination, or a discharge from the urethra

DX

First-void or first-catch urine and sometimes urine culture

    • Positive leukocyte esterase on urine dipstick or having ≥ 10 WBC/HPF on microscopy is suggestive of urethritis
    • Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen
    • Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine
    • Nucleic acid amplification test allows for the specific identification of N. gonorrhoeae, C. trachomatis, M genitalium

TX:

  • The preferred regimen for gonococcal infections is a single intramuscular dose of ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg)
  • If testing results for C. trachomatis are not available at the time of treatment, presumptive therapy for chlamydia coinfection is also indicated. In such cases, doxycycline 100 mg twice daily for seven days
  • Consider replacing doxycycline with azithromycin 1 g PO if compliance in question or pregnancy
Human sexuality (Prev Lesson)
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