NR 507
Uncomplicated UTI
Protein +/_ Leukocyte Esterase + Nitrites +/_ RBCs +/_ WBCs +/> 5000/hpf Casts - None
Patient Education The NP should take advantage of the opportunity to educate patients on the prevention of UTIs while the patient is in the office. Some of the most basic information to convey to a patient is:
-Drink more water. -Although there are differences of opinions, cranberry juice and vitamin C can help to acidify the urine. -Urinate before and after sexual intercourse to remove bacteria from the urethral area. -Encourage the female to avoid holding urine for extended periods of time. -Avoid the use of hygiene sprays and spermicides because they alter the normal microbial flora to enhance the risk for infection. -Encourage the female to wipe from the front to the back after a bowel movement to avoid spreading bacteria to the urethra and -Encourages showers rather than bathing to avoid the spread of bacteria.
When there is vaginal discharge or itching involved, the NP may need to include
A genital exam as well to rule out or diagnose a sexually transmitted infection (STI).
On a digital rectal exam to assess the quality of the prostate, the NP would be concerned with which of the following findings? A soft-smooth prostate. A hard nodule. A rubber-like quality of the prostate. A lack of pain on palpation.
A hard nodule can indicate prostate cancer.
Which of the following is a risk factor for the development of a urinary tract infection (UTI)? A. Pregnancy B. Perimenopause C. Marathon running D. Frequent showering
A. Pregnancy is a risk factor the development of a UTI.
A common organism that causes a urinary tract infection include: A. Staphylococcus saprophyticus. B. Streptococcus pneumonia. C. Syncytial virus. D. Methicillin Resistant Staphylococcus Aureus (MRSA).
A. Staphylococcus saprophyticus is the only choice listed that commonly causes a UTI.
Upon examination of a urinalysis, the NP can highly suspect that the causative bacteria are gram negative because of the presence of: A. Nitrites. B. WBCs. C. RBCs. D. Casts.
A. The presence of nitrites indicates that the causative bacteria is gram-negative.
A 25 year- old female presents to the primary care office with urinary burning and frequency for the last 3 days. She denies any fever, chills, back pain. Her gynecological history is negative and reports no vaginal discharge. The only new information reported is that she recently had sexual intercourse with a new male partner. The NP obtains a urinalysis and determines that the urine contains leukocytes, RBCs, nitrites, and WBCs. No casts are identified. Based on symptom presentation and UA results, the patient can be diagnosed with: A. Upper UTI B. Cystitis C. Complicated UTI D. Pyelonephritis
B. The patient presents with a simple cystitis and treated appropriately. In addition, although the patient has a new sexual partner with risk for a STI, the patient reports no itching and/or vaginal discharge with odor. The NP would determine if a pelvic exam is indicated at that visit to rule out an STI.
A symptom of a lower urinary tract infection includes: A. Fever B. Urgency C. Flank pain D. Decreased Urination
B. Urgency is a symptom of lower tract UTI.
There is a significant risk for men with benign prostatic hyperplasia (BPH) to develop cellular mutations that lead to prostate cancer. True False
False. BPH does not lead to prostate cancer.
Blood Culture
If sepsis is suspected, a blood culture may be drawn to identify the causative organism or rule it out.
Pyelonephritis
Inflammation of kidneys
UTI Risk Factors
Pregnancy Women short ureter Decreased estrogen in post-menopausal women Sexual intercourse Use of spermicide Indwelling urinary catheterization
Complicated UTI
Protein +/_ Leukocyte Esterase + Nitrites +/_ RBCs + WBCs +/> 100,000/hpf Casts +
Urethritis
The infection occurs at the opening of the urethra
Organisms that Cause Urinary Tract Infections
The most common organisms that cause a UTI is Escherichia coli (E. Coli), Staphylococcus saprophyticus, Proteus Mirabilis, and Klebsiella. -E. coli causes approximately 80% of the cases of UTI because it is the most common organism contained in the fecal matter that is easily accessible from the anus to the urethra. -If nitrites are present, this indicates that the causative organism is gram negative. -A urine culture may also be performed to determine infection. A positive culture indicates that there are greater than 100,000 colony forming units/ml. - Dip Stick Test: Nitrites detect the presence of the Enterobacteriaceae (gram-negative bacteria) family that converts nitrates into nitrites. -Enterococcus are unable to produce nitrites. -The presence of nitrites is the most specific finding and has the highest positive predictive value. Leukocyte esterase, WBCs and even bacteria on microscopic exam are not specific and therefore, do not necessarily indicate infection.
Women are at a higher risk for the development of a UTI because of having a shorter urethra. True False
True, women have a shorter urethra that puts them at higher risk for developing a UTI.
The peripheral zone of the prostate is the largest zone. True False
True. Anatomically, the peripheral zone is the largest one.
The urinalysis of a patient with a complicated UTI will show WBCs and casts: True False
True. Casts are present in a complicated UTI.
The purpose of straining in BPH is to overcome the obstruction encountered during urination. True False
True. The individual strains to overcome the obstruction in order to release the urine.
Complicate vs. Uncomplicated UTI
UTI may be classified as complicated or uncomplicated in terms of its severity: Complicated UTI, there is decreased renal function and an abnormal urinary tract -The more intervention required, the more complicated the infection -Exception would be during pregnancy due to the ureteral dilation that occurs that increases the risk for pyelonephritis. Even though she may be asymptomatic, treatment would be initiated to prevent damage to the fetus in utero. -Complicated UTI (pyelonephritis) will require intravenous (IV antibiotics) until the patient is afebrile, followed by a course of oral antibiotics. Overall, the course of antibiotics for a complicated infection is longer than in an individual that has an uncomplicated infection. Uncomplicated UTI indicates that the urinary tract and renal function is normal -An uncomplicated, symptomatic UTI (cystitis) will typically require a 3-7 days course of appropriate antibiotic therapy.
Diagnostic UTI
Urine dipstick Urinalysis - used to diagnose a UTI Urine Culture & Sensitivity
Urologist
-Referral to a urologist is necessary if the individual does not respond to antibiotic treatment or if there are recurrent UTIs, specifically 3 or more in one year -Because upper UTI is uncommon in males, they should be referred to a urologist. -The presence of hematuria would warrant a referral to the urologist to determine the presence of significant renal disease
Urine Dipstick
-Urine Dipstick can be observed for the presence of leukocyte esterase and nitrites. -A urine dipstick can be performed to identify hematuria, proteinuria, and the presence of nitrites. The presence of nitrites i.s highly specific for bacterial infection -Note that an individual can have a negative urine dipstick but still present with signs and symptoms of a UTI. If this is the case, then the NP can send the urine for a culture and sensitivity (C&S) test and microscopy.
.S. is an 80 -year-old patient who resides in a local nursing home. He recently became confused and then fell while ambulating to the bathroom three days ago. Because of his confusion and fall, he was transferred to the acute care facility for evaluation and treatment. Lab work revealed that the patient was very dehydrated with hypernatremia identified and appropriate intravenous fluids started. Cystitis was also identified from the urinalysis. He was also noted to have red and excoriated skin between the buttocks and inner thighs due to urinary frequency and dribbling. To help with skin healing and to prevent further urine leakage, an indwelling catheter was inserted. Two days after the catheter was placed, the patient spiked a fever of 102 degrees Fahrenheit associated with shaking chills. An intense, foul odor was noted in the urine. On examination of the flank area, the patient yelled out when touched. A urine culture was obtained and came back positive for nitrites and RBCs. Urine microscopy revealed >100,000 WBC/hpf and casts. Based on the information provided in the case, the patient can most likely be diagnosed with: A. Pyelonephritis B. Urinary obstruction C. Glomerulonephritis D. Simple UTI Identify the major risk factor J.S. has that is associated with pyelonephritis: A. Flank pain B. Fever C. Dehydration D. Indwelling Foley catheter
A. This patient would be diagnosed with pyelonephritis. D. The major risk factor for the development of pyelonephritis in this patient is the indwelling Foley catheter. Flank pain, dehydration and fever are symptoms rather than risk factors.
Complicate vs. Uncomplicated UTI
Complicated -A UTI that extends beyond the bladder -Caused by structural or functional urinary tract abnormalities or untreated UTI -Infants and older adults affected -Associated with: indwelling catheters renal calculi Diabetes Pregnancy Uncomplicated -Occurs in the normal urinary tract -Responds well to a short course of antibiotic therapy -Simple cystitis in non-pregnant women without any urologic abnormalities
Which of the following is true regarding a complicated urinary tract infection? A. It is usually asymptomatic B. Bacteria is located mostly in the lower urinary tract C. Is associated with young adults D. Can be caused by a structural urinary tract disorder
D. A complicated UTI can be caused by a structural issue in the urinary tract.
The NP would know that the patient most likely has an uncomplicated UTI because: A. Flank pain is present but minimal. B. There is low-grade fever. C. The bacteria are contained within the bladder. D. The UTI responds well to a short course of antibiotic therapy.
D. An uncomplicated UTI responds to a short course of antibiotic therapy. The other choices are not typical of an uncomplicated UTI.
Which of the following can help to prevent a UTI? A. Use spermicides during sexual intercourse B. Taking more Vitamin D C. Douching to prevent the growth of bacteria D. Increase water consumption
D. Increase water consumption Water consumption prevents UTI as it keeps bacteria flushed out of the urinary tract.
The patient most often develops symptoms of BPH when: A. The bladder becomes obstructed. B. The patient's PSA becomes elevated. C. A nodule forms on the prostate. D. The prostatic urethra becomes obstructed.
D. The cause of symptoms of BPH relates to the constriction of the prostatic urethra obstruction that affects that passage of urine.
Cystitis
Denotes a bladder infection
Urine Culture & Sensitivity
Patient with cystitis will have a white blood cell (WBC) count of greater than 5000 high power field (hpf) and hematuria. Patient with pyelonephritis, the urine will present with WBC casts. The presence of casts in the urine indicates that the protein in the lumen of the kidney tubules has solidified, especially in the nephron. This indicates kidney disease rather than a lower UTI. Urine can also be examined microscopically to determine the presence of a lower or upper UTI. The following may be seen in urine examined under microscopy: - RBCs (red blood cells): greater than 3 RBCs/hpf is considered abnormal. Abnormal morphology of the RBC strongly suggests glomerular disease. RBCs are often present with a UTI (hematuria). -WBCs: greater than 5 WBCs/hpf is considered abnormal. These will be present in a UTI. -Bacteria: will be present -Crystals: these are microscopic solids composed of a small number of different ions and molecules. These are common in the urine and if they remain small, are not pathologic. -Casts: are long cylindrical structures formed in the renal tubules due to the precipitation of Tamm-Horsfall mucoprotein. It is the most abundant protein excreted by the urine. Casts form in concentrated and/or acidic urine. The most common casts are hyaline casts that only consist of Tamm-Horsfall protein without other constituents. They are non-specific and may be seen in dehydration. Muddy brown casts suggest acute tubular necrosis. Waxy casts are suggestive of acute and chronic renal failure. Fatty casts are suggestive of nephrotic syndrome; RBC casts suggest glomerulonephritis and WBC casts suggest interstitial inflammation.
A 21-year-old patient reports to the primary care clinic complaining of urinary urgency, frequency and burning. She also reports a small amount of vaginal discharge that contains an odor. It is likely that the NP will perform a vaginal exam at this visit. True False
True. Because of the vaginal discharge that contains an odor, the NP will most likely perform a vaginal exam to rule out an STD.
UTI Lower vs. Upper Tract Disorders
Upper Urinary Tract Disorder When bacteria ascend from the bladder (lower urinary organs) to the kidney. Classic triad: vomiting, flank pain and fever. Upper Urinary Tract Symptoms: All the symptoms associated with cystitis including Fever Flank pain Costovertebral angle (CVA) tenderness Nausea Vomiting Malaise Condtion of Upper UTI Pyelonephritis. Lower Urinary Tract Symptoms: Urgency Burning on urination Frequency Dysuria Suprapubic Pain Cloudy urine Odorous. Condition of Lower UTI Cystitis Urethritis