PANCE Blueprint Genitourinary (4%)

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.

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Cystitis is an infection of the bladder

• Characterized by dysuria (painful urination) WITHOUT urethral discharge
  • frequent urination/urgency, +/- hematuria
  • Abdominal or suprapubic pain
  • New-onset incontinence (in toilet-trained children)
  • Absence of fever, chills, or flank pain
• The most common cause is E. coli (80%) - gram-negative - Klebsiella; Proteus; Enterobacter; Citrobacter
  • Gram-positive bacteria: Enterococcus; S. saprophyticus, second most common, esp. in young individuals who are biologically female, sexually active
• Common in women, in whom cases of uncomplicated cystitis are often preceded by sexual intercourse (honeymoon cystitis)
• In men, a bacterial infection of the bladder is usually complicated and usually results from ascending infection from the urethra or prostate or is secondary to urethral instrumentation
  • The most common cause of recurrent cystitis in men is chronic bacterial prostatitis

Urine dipstick ⇒ nitrite, leukocyte esterase (enzyme created by white blood cells)

• Urinalysis: pyuria (white blood cells in urine), bacteriuria, +/− hematuria, +/− nitrites
• Urine culture (gold standard)
  • > 100,000 CFU/mL (women)
  • > 1000 CFU/mL men or cath patients
  • → takes 24 h to obtain results
• Imaging studies are not required for most women with UTIs and are warranted only if pyelonephritis, recurrent infections, or concern for anatomic abnormalities

Uncomplicated UTI (adolescents and adults who are nonpregnant, non-diabetic, afebrile, immunocompetent, and without genitourinary anatomic abnormalities)

• Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim): 160/800 mg PO BID × 3 days, best where the resistance of E. coli strains <20%
• A 5-day course of nitrofurantoin is also first-line and is the choice if the patient is allergic to TMP-SMZ or local E. coli resistance to TMP-SMZ is >20%
• Fluoroquinolones (e.g., ciprofloxacin) are not first-line for uncomplicated cystitis because of adverse effects and resistance; reserve them for when other agents cannot be used or for more serious infections
• Fosfomycin (Monurol): 3 g PO single dose (expensive)

The urinary tract topical analgesic phenazopyridine (Pyridium) 100–200 mg TID produces rapid relief of symptoms and should be offered to patients with more than minor discomfort; it is available over the counter. This medication is not a substitute for definitive treatment. This medication also may alter urinalysis but not the urine culture.

Treatment of uncomplicated UTIs reduces morbidity, but the risk of recurrence stays the same

• All pregnant women with bacteriuria should be treated
• Asymptomatic bacteriuria is commonly seen in the geriatric population and no treatment is needed as long as the patient is not diabetic or has no structural abnormalities of the genitourinary tract.

Treatment update

"You'll see more emphasis on limiting the use of quinolones.  It's coming from more concerns about "collateral damage" leading to resistance...and warnings of tendon rupture, peripheral neuropathy, etc.  Watch for situations where you may want to bench quinolones.  Urinary tract infections. Use nitrofurantoin or trimethoprim/sulfamethoxazole (TMP/SMX) for most UNcomplicated UTIs. Nitrofurantoin used to be discouraged in renal insufficiency...but the new thinking is that it's safe and effective if CrCl > 30 mL/min.  Also consider a cephalosporin (cephalexin, etc) or Monurol(fosfomycin)...depending on the bug causing the UTI.  Save quinolones (ciprofloxacin, etc) for COMPLICATED UTIs when appropriate...such as patients with obstruction (kidney stones, etc) - Prescriber's Letter "

Lower UTI in pregnancy

• Nitrofurantoin is a preferred empiric choice (TMP-SMX is generally avoided in the first trimester). Cefpodoxime, amoxicillin-clavulanate, and fosfomycin are also appropriate options. Tailor therapy to the urine culture
  • Fluoroquinolones are NOT safe during pregnancy and are usually avoided in the treatment of children.
  • TMP-SMX use in pregnancy is NOT desirable (especially in 3rd trimester) but is appropriate in some circumstances

Postcoital UTI: low-dose nitrofurantoin (50 to 100 mg orally postcoitally or at bedtime) or cephalexin (250 to 500 mg orally postcoitally or at bedtime) may reduce the frequency of UTI in sexually active women

Complicated UTI (diabetes, febrile, immunocompromised patient, recurrent UTIs): Extend course to 7–10 days of treatment with antibiotic chosen based on culture results; may begin with fluoroquinolone, TMP-SMX, or cephalosporin while awaiting results (avoid using nitrofurantoin for complicated UTI)

Pediatric cystitis: 

• Cephalosporin x 14 days are the first-line oral agent in the treatment of UTI in children without genitourinary abnormalities
  • First-generation cephalosporin (Keflex 50-100 mg/kg BID) for low risk of renal involvement
  • Second-generation (cefuroxime) or third-gen (cefixime, cefdinir, ceftibuten) for those with a high likelihood of renal involvement