PANCE Blueprint Genitourinary (5%)

Infectious Disorders (PEARLS)

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


Cystitis 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)
    • > 100 k 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 Epididymitis is characterized by dysuria, unilateral scrotal pain, and swelling

The pathogen is based on 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

  • Over 35- E. coli
    • Levofloxacin (Levaquin) 500 mg/day PO for 10 days OR
    • Ofloxacin 300 mg PO BID for 10 days
  • Under 35 – Gonorrhea and chlamydia
    • doxycycline 100mg PO BID for 10 days PLUS ceftriaxone 250 mg IM × 1
    • Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms
Orchitis Unilateral swollen testicle with erythema and shininess of the overlying skin

Orchitis is rarely seen without epididymitis unless the patient has mumps

  • 25 % are associated with MUMPS
  • Organism:
    • Over 35: E. coli
      • Treatment: Ciprofloxacin
    • Under 35:  Gonorrhea and chlamydia
      • Treatment: Ceftriaxone and doxycycline/azithromycin
Prostatitis 65-year-old man with groin pain who goes into septic shock after a rectal prostatic exam

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

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

Organism: E. coli

  • Urinalysis: Bacteria and WBC casts

Treatment:

  • Outpatient: ciprofloxacin/levofloxacin +/- ceftriaxone IM
  • Inpatient: Ciprofloxacin/levofloxacin or imipenem for more severe disease
Urethritis 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

  • Sexually active patients with symptoms are usually treated presumptively for STDs pending test results

Diagnosis: nucleic acid amplification test (NAAT) of first voided urine

Organisms:

  • N. gonorrhoeae (gram-negative diplococci)
    • Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infectionPLUSAzithromycin (1 gram in a single oral dose) for possible additional activity against N. gonorrhoeae and for treatment of potential chlamydia coinfection
    • Doxycycline (100 mg orally twice daily for seven days) is an alternate option for a second agent to administer with ceftriaxone
  • C. trachomatis
    • Azithromycin (1 gram single-dose therapy) with observed therapy
    • Doxycycline (100 mg orally twice daily for seven days) is an alternate option for a second agent to administer with ceftriaxone
    • Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection
Human sexuality (Prev Lesson)
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