on 17-Apr-2016 (Sun)

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Question

What alterations occur after Complete lesions above sacral spinal cord and below sympathetic outflow (T6-L1 vertebral)?
(incontinence)

Answer

◦ neurogenic detrusor overactivity (b/c reflex arc intact)
◦ Absent sensation below lesion
◦ Smooth sphincter synergia
◦ Striated sphincter dyssynergia (b/c striated msc not coordinated)

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Question

What alterations occur after Lesions above T6 vertebral?

Answer

◦ neurogenic detrusor overactivity
◦ Absent sensation below lesion
◦ Smooth sphincter dyssynergia (brain not talking to sympa's below lesion)
◦ Striated sphincter dyssynergia
◦ Autonomic hyperreflexia

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Question

What alterations occur after Conus medullaris and cauda equina injuries?

Answer

◦ Interruption of local reflex arc
◦ Detrusor areflexia (possible long term decreased compliance)
◦ Loss of voluntary sphincter control

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Question

What is autonomic dysreflexia?

Answer

Syndrome characterized by:
◦ sweating, flushing above the level of the lesion
◦ severe hypertension, bradycardia (or tachycardia)
◦ May have seizures, intra-cranial bleed

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Question

Autonomic dysreflexia is secondary to exaggerated sympathetic outflow in response to stimuli below the SC lesion.
It occurs with SC injury above [what level] only.

Answer

T6

NB: stimuli = bladder distention, rectal manipulation, fracture, cystoscopy, etc

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Question

What is the immediate rx for autonomic dysreflexia?

Answer

◦ Empty distended bladder ASAP
◦ Treat UTI with antibiotics

NB: may need to rx HTN w/ nifedipine

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Question

What are the long-term rx goals for autonomic dysreflexia?

Answer

1. Facilitate urine storage
2. Maintain low bladder pressure (to preserve renal function and continence)
--antimuscarinics, botox, surgery
3. Promote complete bladder emptying
--clean intermittent catheterization
--decrease outlet resistance (med/surg) - sphincterotomy, botox into sphincter, urethral stents
4. Yearly imaging, cystoscopy and urodynamics as needed

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Question

Emphysematous pyelonephritis is a [...]

Answer

surgical emergency

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Question

What is the pathogenesis of emphysematous pyelonephritis?

Answer

--ascending spread from urethra to bladder

• e.coli is the most comon UTI organism (uses adhesins & fimbriae)
• gi tract bacteria​

​--hematoenous spread

• bacteria in blood gets into urine via kidneys (s.aureus, candida) - if s.aureus in urine, make sure not in blood

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Question

What can result from bacteriuria?

Answer

bacteriuria -> asx bacteriuria
-- most resolve
--some go on to have acute cystitis -> pyelonephritis (ascension into kidneys) or resolution

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Question

What are protective factors to pyelonephritis?

Answer

--innate immunity (TLR4)
--high urinary urea + low pH
--urinary tract epithelium-derived proteins
--urinary flow + micturition

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Question

What are features of asymptomatic bacteriuria?

Answer

--bacteria in the urine (≥10^5 cfu/mL) -> w/ less virulence factors than bacteria causing systemic infections
--may/may not have pyuria
--common (especially in older ppl)

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Question

What are complications of asymptomatic bacteriuria?

Answer

--increased likelihood to develop symptomatic UTI within 1 week
--short-term relief with abx but likely to recur
--no increased risk for mortality without rx - so don't rx asx UTI

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Question

When is it important to screen for asx bacteriuria and why?

Answer

**in pregnant women & before urologic procedures** - asx UTI can be harmful in these conditions

Pregnant women
--high risk of pyelonephritis
--high risk of premature & LBW babies
--abx decreases both risks
--so screen early, rx for 3-7d, and re-screen intermittently throughout

Urologic procedures
--when mucosal bleeding likely b/c increased risk of bacteremia
--decreased risk with abx pre-procedure
--discontinue abx post-procedure

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Question

What are features of uncomplicated cystitis?

Answer

--bladder inf
--no urinary tract abnormalities
--dysuria, frequency, urgency
--positive WBC & nitrites
--bacteriuria

NB: mimics are
--urethritis (STIs)
--prostatitis
--chem irritation
--painful bladder syndrome/interstitial cystitis

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Question

What are rx of uncomplicated cystitis?

Answer

narrow spectrum abx, short course = proven efficacy
--nitrofurantoin -> 100mg PO BIDx5d
or
--trimethoprim/sulfamethoxazole (TMP-SMX, Septra) -> 160/800mg = 1ds tab BIDx3d

• caveat: only if local resistance rates for e.coli are <20%

Alternatives
--ciprofloxacin -> 500mg PO BIDx3d (used to rx many things so don't want resistance)
or
--amoxicillin-clavulanic acid -> β lactams have decreased efficacy in UTI

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Question

What is the rx of recurrent acute uncomplicated cystitis?

Answer

behavioural modification
--no spermicide, post-coital voiding, wipe front to back

abx prophylaxis
--if ≥3 UTI in 12 mo, ≥1 confirmed by positive culture
--post-coital/daily bedtime dose
--nitrofurantoin, TMP-SMX, cephalexin -> has complications so discuss w/ pt
--can self-dx & rx if pt is comfortable

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Question

What are the s&s of acute uncomplicated pyelonephritis?

Answer

--flank/abdo/pelvic pain
--N +/- V
--+/- dysuria
--frequency
--urgency
--fever
--CVA tenderness
--sepsis possible w/ adv infection (increased inflm around kidneys)

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Question

What is acute complicated pyelonephritis?

Answer

complicated = perinephric abscesses, emphysematous pyelonephritis, papillary necrosis

uncomplicated = healthy, pre-menopausal, non-pregnant women

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Question

What is the outpatient rx for acute uncomplicated pyelonephritis?

Answer

outpatient if: low fever, no dehydration, no concerns re: compliance or f/u

--fluoroquinolone (Ciprofloxacin 500 mg PO BID x 7 days); Only if < 10% E. coli resistance locally
--Trimethoprim/sulfamethoxazole (1 DS tab PO BID x 14d if susceptibilities are known)
--if β lactam, 1st dose IV (b/c decreased effectiveness), then 14 day course

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Question

What is the inpatient rx for acute uncomplicated pyelonephritis?

Answer

Most patients require initial IV therapy
--– Transition to oral therapy when clinically improved and able to tolerate oral meds and fluids

All require 14 days
--Fluoroquinolone IV
--Ampicillin + gentamicin
--3rd generation cephalosporin IV
--β‐lactam / β‐lactamase inhibitor IV

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Question

What are features of catheter-associated UTI?

Answer

--d/t indwelling/intermittent catheters
--no other source of infection
--s&s of UTI
--≥10^3 cfu/mL bacteria
--no pyuria, odour, colour

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Question

Signs and Symptoms of Catheter‐associated UTI

Answer

• New or increased fever, rigors, change in mental status, malaise, or lethargy
– No alternate cause
• Flank pain, CVA tenderness, acute hematuria
• Urgency, frequency, suprapubic pain if catheter recently removed
• In patients with spinal cord injury: increased spasticity and autonomic dysreflexia

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Question

What are the principles of therapy in catheter-associated UTI?

Answer

The most effective treatment is prevention
1. Place catheters only when needed
2. Discontinue ASAP
3. Consider automatic D/C times and MD reminders

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Question

What are Treatment Recommendations for catheter-assc UTI?

Answer

• Urine cultures before ABx to guide therapy
• Change urinary catheter if in situ ≥ 2 weeks
– Cultures from new catheter as well
• Treatment based on culture results
• Duration:
– 7 days if prompt response to therapy
– 10‐14 days if delayed resolution of symptoms