Rosen & Barkin's 5-Minute Emergency Medicine Consult (744 page)

• Sepsis
  
• Inability to take oral antibiotics if needed
  
• Acute emergencies from primary GI disease or malignancies
  

• No evidence of sepsis
  
• Able to tolerate oral antibiotics if UTI present
  

Urogenital specialist (Urology or Gynecology) follow-up is required.

• Suspect a urinary tract fistula in the patient with the appropriate risk factors (usually a complicated recent pelvic surgery) and recurrent UTIs
  
• In the presence of urinary tract fistula, malignancy is always an important diagnostic consideration
  
• Urine leakage from the vagina may be confused with urinary incontinence
  

• Basler J. (2012, Jan 23). Enterovesical fistula. Retrieved from
  www.emedicine.com
  .
  
• Garely AD, Mann WJ Jr. (2012, Jul 30). Vesicovaginal, urethrovaginal, and ureterovaginal fistulas. Retrieved from
  www.uptodate.com
  .
  
• Katz VL. Urinary fistula. In:
  Comprehensive Gynecology.
  5th ed. St. Louis, MO: Mosby; 2007.
  
• Vasavada SP. (2011, Sep 14). Vesicovaginal and ureterovaginal fistula. Retrieved from
  www.emedicine.com
  .
  
• Wein AJ. Urinary tract fistula. In:
  Campbell-Walsh Urology
  . 9th ed. Philadelphia, PA: Saunders; 2007.
  

See Also (Topic, Algorithm, Electronic Media Element)

UTIs, Adult

CODES

• 596.1 Intestinovesical fistula
  
• 599.1 Urethral fistula
  
• 619.0 Urinary-genital tract fistula, female
  

BASICS

• Colonization of urine with uropathogens and invasion of genitourinary (GU) tract
  
• Defined as urinary symptoms with ≥10
  ²
  to 10
  ⁵
  CFU/mL of uropathogen and ≥10 WBC/mm
  ³
  
• Lifetime risk of UTI in women is >50%
  
• Uncomplicated cystitis:
  
  • Females aged 13–50
    
  • Symptoms <2–3 days
    
  • Not pregnant
    
  • Afebrile (temperature <38°C)
    
  • No flank pain
    
  • No costovertebral angle tenderness (CVAT)
    
  • Fewer than 4 UTIs in past year
    
  • No recent instrumentation or previous GU surgery
    
  • No functional/structural GU abnormality
    
  • Not immunocompromised
    
  • Neurologically intact
    
• Complicated cystitis:
  
  • Do not meet above criteria
    
  • Male gender
    
  • Patients with anatomic, functional, or metabolic abnormalities of GU tract
    
  • Postvoid residual urine
    
  • Catheters
    
  • Resistant pathogens
    
  • Recent antimicrobial use
    
• Uncomplicated pyelonephritis:
  
  • Renal parenchymal infection
    
  • Dysuria, frequency, urgency
    
  • Fever, chills, myalgias, nausea, vomiting
    
  • Flank, back, or abdominal pain
    
  • CVA tenderness
    
  • Leukocytosis (common)
    
• Complicated pyelonephritis:
  
  • Renal parenchymal infection
    
  • Temperature >40°C
    
  • Urosepsis with septic shock
    
  • Intractable nausea, vomiting
    
  • Diabetes, other immunosuppression
    
  • Pregnancy (especially latter half)
    
  • Concomitant obstruction or stone
    
  • Asymptomatic (occult)
    

• Mechanism:
  
  • Organisms colonize periurethral area and subsequently infect the GU tract.
    
• Risk factors:
  
  • Population:
    
    • Newborn, prepubertal girls, young boys
      
    • Sexually active young woman
      
    • Postmenopausal woman, elderly males
      
  • Behavior:
    
    • Sexual intercourse, spermicides, diaphragms
      
• Elderly females/postmenopausal state
  
• Less efficient bladder emptying, bladder prolapse, alteration of bladder defenses
  
• Increased vaginal pH
  
• Contamination due to urinary or fecal incontinence (Enterobacteriaceae)
  
• Instrumentation:
  
  • Elderly males due to prostatic hypertrophy and instrumentation
    
• Organisms:
  
  • Escherichia coli
    (80–85%)
    
  • Staphylococcus saprophyticus
    (10%)
    
  • Other (10%): Klebsiella,
    Proteus mirabilis
    ,
    Enterobacter
    spp.,
    Pseudomonas aeruginosa
    , group D streptococci
    

DIAGNOSIS

• Lower tract infection: Cystitis:
  
  • Dysuria, frequency, urgency, hesitancy
    
  • Suprapubic pain
    
  • Hematuria
    
• Upper tract infection: Pyelonephritis:
  
  • Symptoms of cystitis:
    
    • Fever, chills
      
    • Flank pain and/or tenderness
      
    • Nausea, vomiting, anorexia
      
  • Leukocytosis
    
  • Up to 50% of patients with cystitis may actually have pyelonephritis:
    
    • Symptom duration >5 days, homelessness, and recent UTI are risk factors for upper tract infection
      
  • Elderly or frail patients:
    
    • Altered mental status
      
    • Anorexia
      
    • Decreased social interaction
      
    • Abdominal pain
      
    • Nocturia, incontinence
      
    • Syncope or dizziness
      

• Urinalysis (dipstick test, microscopy)
  
• Females: Rule out pregnancy, urethritis, vaginitis, pelvic inflammatory disease (PID)
  
• Males: Rule out urethritis, epididymitis, prostatitis; inquire about anal intercourse/HIV.
  
• Urologic evaluation in young healthy males with 1st UTI is
  not
  routinely recommended.
  

• Rapid Urine Screen:
  
  • Dipstick (leukocyte esterase + nitrite) most effective when urine contains 10
    ⁵
    CFU/mL
    
  • Lab specimen unnecessary if pyuria and bacteriuria confirmed by dipstick
    
  • Leukocyte esterase: Positive likelihood ratio (LR+) ∼5, negative likelihood ratio (LR−) ∼0.3
    
  • Nitrite: LR+ ∼30, LR− ∼0.5
    
• Urinalysis/microscopy:
  
  • Obtain if rapid urine screen is unavailable or negative in patients with presumed UTI.
    
  • 10 WBC/mm
    ³
    in clean catch midstream urine indicates infection.
    
  • Bacteria detected in unspun urine indicates >10
    ⁵
    CFU/mL. (LR+ ∼20, LR− ∼0.1)
    
• Indications for urine culture:
  
  • Complicated UTIs
    
  • Negative rapid urine screen or microscopy in patients with presumed UTI
    
  • Persistent signs and symptoms after 2–3 days of treatment
    
  • Recurrence (relapse vs. reinfection)
    
  • Recently hospitalized patients
    
  • Nosocomial infections
    
  • Pyelonephritis
    

• Asymptomatic bacteriuria (including positive cultures) occurs in 20% of women >65 yr, 50% of women >80 yr and generally should
  not
  be treated.
  
• Consider treating symptomatic geriatric patients for 5–10 days to decrease risk of recurrent or persistent bacteriuria.
  
• Fluoroquinolones may cause CNS side effects.
  

• Indicated for complicated upper tract disease (see Pyelonephritis)
  
• Helical CT, renal ultrasound, or IV pyelogram if concomitant stone or obstruction suspected
  

Patients with significant hematuria, recurrent UTI with same uropathogen, or symptoms of obstruction
need
urologic evaluation to identify structural or functional abnormality.

• Appendicitis
  
• Diverticulitis
  
• Epididymitis
  
• Nephrolithiasis
  
• PID/cervicitis
  
• Prostatitis
  
• Pyelonephritis
  
• Urethritis
  
• Vulvovaginitis
  

TREATMENT