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 A 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

Oral regimen is considered 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 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
  • 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
    • 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


  • N. gonorrhoeae (gram-negative diplococci)
    • Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection PLUS Azithromycin (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 alternative 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 alternative option for a second agent to administer with ceftriaxone
    • Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection
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