GI/GI Exam 2
10/18/2005 9:51:00 AM
Urinary Tract Infection
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Second most common infection in the US
Not much morbidity
Divide into upper and lower UTI
Lower is much more common
Upper includes kidney
Lower is bladder
Most commonly an older person problem
Over the age of 65 4-10%
Below this age is 1-4%
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Mainly an adult problem
Young group is pediatric females—diapers to toilet training
This is a hygiene problem
o Wearing diapers too long
o Wiping front to back or back to front
o Bubble baths—urethra has bacterostatic chemicals
80-90% have E. coli at the base of the problem
UTI's are ascending infections
Ratio of men to women is 1:10
Subcategories
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o Blockage of one ureter
o Catheter
5%/day risk of getting a UTI of a hospital stay
o Now at 1%
o Coated w/tephalon
o Less frequent changing of catheter
18-27 y/o women—sexually active
o Honeymoon cystitis
o Peri-urethral swelling
o Increase urethral outlet pressure
o Harder to urinate
o Urinary stasis
o Good medium for bacterial growth
Pregnant women
Diabetes Mellitus
o Reduced immune status
o Enhanced environment for bacteria—glucose in urine
Obstruction of any type
o Hypertrophy of prostate
o Floor of pelvis tightened—women
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How to
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o Surgery
o Stenosis of urethra
Obstruction leads to stasis
Hypertension
o Upper urinary tract—kidneys
o Form of renal failure
Neurogenic bladder
o Lost ability to contract bladder
decide if Lower or Upper
If common UTI, can be treated conservatively
Have to be more cautious w/upper
Upper UTI is sicker
o 102 to 104
o Shaking chills
o Unilateral flank pain (can be B/L)
o Casts
 Historical—what happened wks ago
 Bloody casts
o Epithelial cells (renal)
o Pt looks ill
o Urine labs are abnormal
o Very unusual for Dysuria
Lower
o Change in urinary output
o Burning pain w/urethritis
o Females do not have strong urethritis (pain is not prominent)
o Males are more likely to have pain and copious discharge
Fever is present is low grade
Cystitis—low grade
ESR slightly elevated if bladder, none w/urethritis
Urine labs abnormal
 Combination of bacterial and WBC
 Bacterial or WBC alone consider contamination
o Double catch for women
o Triple catch for men
o Blood may be in urine
o
o
o
o
Kidney and upper UTI




Medullary portion affected first
Can occur from ascension
Build up of urine from stenosis of ureter
Cortex affect primarily or only—can't talk about ascension
o Look at vascular tree
o Patchy infiltrate of infection
o Septicemia—look at both kidneys
o This is worse than medullary—environment is hostile due to
osmolarity
Investigate Pt.
 IVP and retro exam
 Include abdominal US
Tx
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


Only one's that look for spinal cause and susceptibility to infection
Don't know why have UTI but do
Hydrating the pt will help the pt—flush out the organisms
Cranberry juice





o Not b/c acidifier
o A component that makes it difficult for the bacteria to grab
onto the wall
o Reduced bacterial adhesions
We do not know for sure how much to drink
Recommend 4-8oz glasses per day—Dr. Kuhn got results w/this
If this is going to work, it will tend to work quickly
If this does not work, look at the water that they are drinking
Recommend steamed, distilled water
Prostatitis
 Bacterial acute
o Young men significantly
o Instrumentation—catheter
o Has more Sx that are more recognizable
o May be the first time that they have difficulty urination
o May see discharge which is reliable
o Burning sensation
o Rectal/digital exam—enlargement of gland
o Typical that it hurts during the exam and noticeably enlarged
o Positive cup 3 test (more so than chronic)
o Fever, blood,  WBC
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o Ascending UTI
Bacterial chronic
o Older men
o Idiopathic
o Recurrent UTI
Misc.—non-bacterial
o Viral
o Meds that irritate gland
o Less discharge
o Less burning
o Long standing Sx
o More workup is required
Rectal/digital exam
o Size
o Texture
o Shape
o DO NOT MASSAGE THE GLAND
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This introduces the bacteria deeper into the gland
where the body can not deal w/it as well
Urethritis
 E. coli origin
 Ascending route
 Anytime aggravate urethra
 2 categories
o Gonococcal
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Epidemic
Sx for men are worse
 Burning urination
 Copious discharge
 Have urgency and frequency
Women
 Some discharge
 Not a lot of burning
Complications
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Endocarditis
Meningitis
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Synovial inflammation—synovitis—arthralgia as
complication
Severity of the infection does not correlate to the
complications
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Dx
Tx
 Penicillin
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o Non-gonococcal
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Chlamydia
Less discharge
Same differences of Sx of men and women
Penicillin does work
Sulfa drugs
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Burning on urination
Men have more prominent complaints
 More tissue to have aggravated
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Bacteria and WBC
Urgency due to bladder outlet
E. coli
o Sx
Exam 2
10/18/2005 9:51:00 AM
Urinary Incontinence- Involuntary loss of urine
Incidence:
 More than 12 million Americans
 In women (approx. 38%)
 40% of hospitalized elderly persons
 50% of nursing home residents
 a leading cause of nursing home admissions
Cost $$:
 Over $1 billion in sales/year
 Psychological costs
o Embarrassment and social inhibition
o Depression, impaired nutrition in elderly
Causes:
 Myth: normal and expected age-related change
 Age-related physiological changes in the lower urinary tract or
chronic illness may predispose to urinary incontinence
o Changes consist of: decrease bladder capacity, flow rate,
ability to postpone voiding, nocturnal fluid excretion, and
prostate size.
Anatomy
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Detrusor muscle and two sphincters
Detrusor muscle innervations
o Pelvic nerve via PSNS (cholinergic receptor- Ach
neurotransmitter)
Bladder neck and proximal urethra
o SNS (alpha-adrenergic receptor- nor-epinephrine
neurotransmitter)
Base of the urethra (skeletal muscle- voluntary)
o Pudendal nerve (Ach neurotransmitter)
Function
 Storing urine
o Relaxation of detrusor muscle
o Contraction of sphincters
o Intravesicular pressure is less than urethral pressure
 Voiding urine:
o Detrusor muscle contracts and sphincter relax
o Intravesicular pressure is greater that urethral pressure
Causes of Reversible Incontinence
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Acute illness with:
o Confusion or disorientation
o Immobility
o Lethargy
 Urinary tract infection
 Fecal impaction
 Use of certain drugs
Classification of Persistent Incontinence
 Persistent incontinence may result from untreated illness or arise
insidiously
 5 basic classifications
o
o
o
o
o
stress
urge
overflow
functional
mixed
Stress Incontinence- loss of small amounts of urine during coughing,
laughing, or other activities which increase intra-abdominal pressure
 Due to weak pelvic floor and urethral muscles
 Predominantly found in women
Urge Incontinence- leakage of large amounts of urine precipitate by
involuntary bladder contractions. Inability to delay voiding once a
sensations of bladder fullness is perceived.
 Due to various GU and CNS conditions that cause hyper-reflexia of
bladder contractions
o Urethritis, cystitis, stones, stroke, spinal cord injury, MS,
Parkinson’s Alzheimer’s, tumors
*low volume voider, a patient that empties the bladder frequently, she
decreases the amount being able to be held.
Overflow Incontinence- constant dribbling of small amounts of urine also
known as: paradoxical incontinence, Neurogenic incontinence.
 Due to over-distention of the bladder
 Causes include:
o Anatomic obstruction
o Hypocontractile bladder
o Use of certain medications
Functional Incontinence- involuntary loss of urine resulting from the inability
to use a toilet
 Due to physical, psychological, or environmental factors
 Occurs despite normal urinary tract infection.
Mixed Incontinence- combinations of the four previous categories
 Most common combination- stress and urge incontinence
 Identifying presence of greater than 1 type important for treatment
options.
Patient Evaluation
 Primary goal: identify reversible factors contributing to incontinence
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History:
o Symptoms (frequency, volume, Dysuria, urgency)
o Active and past medical conditions
o Environmental factors and medications
Urobehavioral diary
o Self-monitoring and feedback
Physical exam
o Neurologic, abdominal, pelvic, rectal
Lab
o Serum electrolyte, BUN, glucose
o Urinalysis (hematuria, Pyuria, bacteriuria, glycosuria) and
culture
Spinal exam
Urodynamic evaluation (co-management)
o Sonography, catheterization, cystography
Treatment Goals in Elderly
 Maintain existing continence
 Improve socialization
 Decrease embarrassment
 Preserve renal function
 Avoid catheterization and the need for absorbent undergarments
Conservative Treatment Options
 Biofeedback Methods
o Monitoring pelvic floor muscle. And contraction of external
urethral sphincter through reinforcement with visual and
auditory signals
o 25% success rate
o requires expensive equipment
Aggressive Treatment
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Collagen injections
Nip and Tuck
Exam 2
10/18/2005 9:51:00 AM
10/17/05
Nocturnal Enuresis- wetting the bed at night
 Common problem in children
 4% of people have incontinence up until age 60
Causes:
 Psychosocial- divorce, terminal illness,
 Regression- regress into a younger mental state due to stress
 UTI- #1 on differential
Breneman- study that followed children growing up with NE, they found that
66% of cases could be eliminated from food allergies
 Most common allergen is cow’s milk
Esperanea & Gerard
 Dairy products are allergens that trigger enuresis, some citrus
products and decrease threshold in sphincter muscles.
Etiologies for Enuresis
 Children seem to be late walkers (possibly from skeletal muscle
immaturity)
 Seem to be on the smaller side of the height and weight charts
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Are not good at school
Are very deep sleepers, so if they don’t wake up, they just pee
Most destructive aspect is punishment/reward from parents
Exam 2
10/18/2005 9:51:00 AM
Carcinoma to GU System
#1 primary is prostate
 70, 000/year and climbing
 32,000 deaths/yr
 Lab studies—PSA
 Change in urinary habits
 can be prevented by surgical removal, and early detection (the
more invasive, more expensive surgeries ten to have a better
outcome)
Patient History

#2 Bladder is next 37,000/yr
 3:2 males: females (females are increasing)
 Women are working in places that they did not use to
 Women are smoking more
 In males a triple catch urine specimen would be abnormal
 Tx. Options:
Mets to bladder
 Melanoma—GIGU
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An increase in acidphosphatase is an indicator that the mets has
left the prostate and moved elsewhere
#3 Testicular Carcinoma (rare)
 earliest sign is a mass (part of male physical examination)
 pain, which is from the mass blocking the secretory duct
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Kidneys
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¾ w/calcifications on lumbar films are malignant processes
o This includes diabetes mellitus
o Hematuria is the most consistent sign, and it is only present
50-60% of the time
o Flank pain, but by the time the flank pain shows up it is a
considerably large lesion.
o ¼ of all patients with renal cell carcinoma have evidence of
metastasis at the time of diagnosis. Typically it moves to the
lungs- repeat episodes of pneumonia.
Exam 2
10/18/2005 9:51:00 AM
Urinary Tract Infection









Second most common infection in the US
Not much morbidity
Divide into upper and lower UTI
Lower is much more common
Upper includes kidney
Lower is bladder
Most commonly an older person problem
Over the age of 65 4-10%
Below this age is 1-4%



Mainly an adult problem
Young group is pediatric females—diapers to toilet training
This is a hygiene problem
o Wearing diapers too long
o Wiping front to back or back to front
o Bubble baths—urethra has bacterostatic chemicals
80-90% have E. coli at the base of the problem
UTI's are ascending infections
Ration of men to women is 1:10
Subcategories









o Blockage of one ureter
o Catheter
5%/day risk of getting a UTI of a hospital stay
o Now at 1%
o Coated w/tephalon
o Less frequent changing of catheter
18-27 y/o women—sexually active
o Honeymoon cystitis
o Peri-urethral swelling
o Increase urethral outlet pressure
o Harder to urinate
o Urinary stasis
o Good medium for bacterial growth
Pregnant women
Diabetes Mellitus
o Reduced immune status
o Enhanced environment for bacteria—glucose in urine
Obstruction of any type
o Hypertrophy of prostate
o Floor of pelvis tightened—women



How to




o Surgery
o Stenosis of urethra
Obstruction leads to stasis
Hypertension
o Upper urinary tract—kidneys
o Form of renal failure
Neurogenic bladder
o Lost ability to contract bladder
decide if Lower or Upper
If common UTI, can be treated conservatively
Have to be more cautious w/upper
Upper UTI is sicker
o 102 to 104
o Shaking chills
o Unilateral flank pain (can be B/L)
o Casts
 Historical—what happened wks ago
 Bloody casts
o Epithelial cells (renal)
o Pt looks ill
o Urine labs are abnormal
o Very unusual for Dysuria
Lower
o Change in urinary output
o Burning pain w/urethritis
o Females do not have strong urethritis (pain is not prominent)
o Males are more likely to have pain and copious discharge
Fever is present is low grade
Cystitis—low grade
ESR slightly elevated if bladder, none w/urethritis
Urine labs abnormal
 Combination of bacterial and WBC
 Bacterial or WBC alone consider contamination
o Double catch for women
o Triple catch for men
o Blood may be in urine
o
o
o
o
Kidney and upper UTI




Medullary portion affected first
Can occur from ascension
Build up of urine from stenosis of ureter
Cortex affect primarily or only—can't talk about ascension
o Look at vascular tree
o Patchy infiltrate of infection
o Septicemia—look at both kidneys
o This is worse than medullary—environment is hostile due to
osmolality
Investigate Pt
 IVP and retro exam
 Include abdominal US
Tx




Only one's that look for spinal cause and susceptibility to infection
Don't know why have UTI but do
Hydrating the pt will help the pt—flush out the organisms
Cranberry juice





o Not b/c acidifier
o A component that makes it difficult for the bacteria to grab
onto the wall
o Reduced bacterial adhesions
We do not know for sure how much to drink
Recommend 4-8oz glasses per day—Dr. Kuhn got results w/this
If this is going to work, it will tend to work quickly
If this does not work, look at the water that they are drinking
Recommend steamed, distilled water