S2 E096 Infectious Disorders of the Urinary Tract

Hello and welcome to season two, episode 96 of the Physician Assistant Exam Review Podcast. This week, we’re going to be covering infectious disorders of the urinary tract. I’m Brian Wallace, founder and creator here at Physician Assistant Exam Review. I think I’d be able to get that out after 10 years of saying it, where we teach core medical content and how to dominate school and ultimately pass the PANCE. Those aren’t the same things, right? I taught a lot more about dominating school and the PANCE and your job on the other podcast on the same feed called dominating medicine. So you can check that out.

I think we’re up to seven or eight episodes there. It’s really being, well received. I’m getting a lot of good feedback on that. So if you haven’t listened to those episodes, please go ahead and do that. I think you’ll get a lot out of it.

Now, this show has been around for a long time, but the way that it’s grown, the way that it gets people to listen to it is through word of mouth. I need you to share the show. If you find something valuable in today’s episode, I would be very grateful and so would your friends and the people in your class if you shared it with them. So that’s definitely something you can do to help me.

Now, this week we’re going to be covering infectious disorders of the, what are we talking about? The urinary tract. Fading a little here and I’ll talk a little bit more about that as we get to the end of this show, what’s going on there. But for now, we’re going to move through the urinary tract, talk about some infectious issues that happen, talk about their treatments, how you can separate them a little bit. And we will, we’re getting closer to the end of the genitourinary system. So I’m excited for that.

All right, let’s go ahead and move on to our priming questions. A gram-negative intracellular diplococci should make you think of what organism? A gram-negative intracellular diplococci should make you think of what organism? Costovertebral tenderness should make you think of what diagnosis? Costovertebral tenderness should make you think of what diagnosis? What’s the most common organism causing a UTI? What is the most common organism that causes a UTI?

What’s the most common organism that causes cystitis?

All right, UTIs aren’t as such on your blueprint, but I thought it was important that we cover them here. Urinary tract infection. This is, it’s similar to urethritis, right? It’s the urethra getting infected, but urethritis is more of a sexually transmitted disease. With urethritis, we’re talking about Neisseria gonorrhoeae and Chlamydia. With urinary tract infection, we’re really talking usually about E. coli. Could be other factors, but generally speaking, that’s what we’re talking about.

Risk factors for a UTI are females are more prone than males, and that’s just an anatomical issue, right? Female urethra is much shorter than a male’s, so it lends itself to, and it’s much closer to the anus, which then lends itself to the risk of infection. Diabetes increases the risk. Obesity increases the risk. And sexual activity is a major factor here. So in young sexually active females, urinary tract infections are related to, I think it was something as high as 70 to 90% of urinary tract infections. So something to keep aware of in the clinic.

If you have patients coming in with UTIs, you may want to counsel them about sexual activity as well.

All right, so clinical presentation here. Likely we’re all fairly familiar with this. It’s a burning with urination frequency, which is the feeling of needing to urinate without empty bladder. And one thing to understand is that this may present strangely in elderly patients. You can actually get a change in mental status from a urinary tract infection without other symptoms. So it’s a little odd, definitely something to be aware of there. Diagnosis, symptoms alone can be enough in a patient who you trust and know.

You can do urinalysis and cultures, of course, to get a definitive diagnosis. Treatment, you can get several different options. Keflex is one, fluoroquinolones, and Bactrim, but that’s obviously becoming a little bit less effective due to resistance. Then we get into more and more sexually transmitted diseases, urethritis. Causes here would be Neisseria gonorrhoeae and Chlamydia. Clinical presentation is purulent. Urethral discharge, that’s more like Neisseria.

Or clear urethral discharge, that’s more like Chlamydia. Painful voiding in frequency as well. Lab studies and physical exam findings here is a urethral swab. Doesn’t that sound pleasant? Treatment, antibiotics, ceftriaxone, azithromycin, or doxycycline are going to be your choices here. Cystitis is next. In men, if you get an adult male with cystitis, there may be some other pathology.

It’s something to look into. Cystitis is a bladder infection, right? Another possible or a possible cause here would be catheterization. So if we’re using a catheter in a patient, we want to do so sparingly to avoid a urinary tract infection and more importantly, something like cystitis. It’s one of the reasons why we actually have stopped almost entirely using catheters in people in surgery. We used to use them routinely. Every total knee got a catheter.

Every total hip got a catheter. Almost every surgery got a catheter.

Now, anything that gets done in less than four hours typically does not get a catheter. If you’re doing GYN surgery, then you’re going to because you want to deflate the bladder and get it out of your way. And things that last long are going to require a catheter because they’re going to be getting IV fluids from anesthesia throughout the surgery. So after four or five hours, the bladder becomes full, so we have to empty it, right? But if it’s shorter than that, for the most part, we’re not using catheters anymore. And if we use them even more so, you’d like GYN cases, they come out at the end of surgery. They don’t stay in overnight like they used to.

Now, you could also have people who need them long term for other reasons.

Let’s say that you had a situation where, you know, the example I could come up with is a complication of surgery. If we’re doing a GYN case, let’s say we’re doing a hysterectomy, we’re taking out the uterus, and we accidentally get into the bladder. We make a incision into the bladder by mistake, and then we close it. It’s not a big deal, but that patient will have a catheter for a few weeks after having that bladder injury closed. So that’s how a patient has a long-term, or one reason a patient would have a long-term catheter, and then they can wind up with a cystitis, right? Causes here, E. coli is number one, enterococci is also on the list. Clinical presentation, hurts when I pee, so dysuria, frequency, urgency, and hematuria is possible.

Urinalysis and culture is how we’re going to determine this. Treatment, once again, similar to our UTIs, Keflex, fluoroquinolones, and Bactrim. Pyelonephritis is next. We’re just moving up here. So this is going from the urethra to the bladder to the kidney. An ascending urinary tract infection. E. coli is the most common cause.

So that’s one takeaway here, right? So we get, for UTI, we get E. coli. For cystitis, we get E. coli. And for pyelonephritis, we get E. coli, right? So it’s the same bug just traveling up through the genitourinary system. Clinical presentation for pyelonephritis, fever, radiating flank pain. That’s a good one.

Again, dysuria, abdominal pain, nausea and vomiting. Lab studies and physical exam findings. Costovertebral tenderness is a good one here, right? That’s what’s going to make pyelonephritis stand out from your other things is that cost of vertebral tenderness, radiating flank pain. You’re going to want to do a UA, where you may see pyuria, you may see white cell casts, that’s another term we haven’t used yet, you’re going to do a urine culture, an x-ray of the kidney, ureter and bladder, ultrasounds, and a CAT scan if necessary. Antibiotics based on urine cultures, but fluoroquinolones, cephalosporins, aminoglycosides, and again, Bactrim. Epididymitis, a little bit different, this is the most frequent cause of acute pain in the scrotum.

I did not know that. The most frequent cause of acute pain in the scrotum is epididymitis. And it’s associated with urethritis. So before we’re talking about UTIs of the E. coli ascending, now we’re talking about chlamydia and Neisseria and the direction that they move from the urethra to the epididymis. Causes, Chlamydia trachomatis, Neisseria gonorrhoeae, gram-negative rods. Clinical presentation, my scrotum hurts. Swollen scrotum, urethral discharge, pain with voiding, and fever.

So this is a pretty, this is very uncomfortable.

Let’s just put it that way. Lab studies and physical exam finding, Prehn sign is positive. Do you remember what Prehn sign is? I should have put that in the priming questions. Prehn sign, P-R-E-H-N. A positive: Elevating the scrotum provides pain relief. Elevating the scrotum provides pain relief.

I believe that also helps with a testicular torsion in some cases. CBC, it’s going to be necessary. Gram stain and culture of discharge. Gram negative intracellular diplococci equal Neisseria gonorrhoeae. No visible organisms, but lots of white blood cells would point you toward chlamydia. Urine culture and a UA. Treatment, antibiotics which cover Neisseria gonorrhoeae and chlamydia would make sense.

Treat sexual partners as well. So something like macrolides, like azithromycin, or cephalosporins like cefixime. Orchitis causes: chlamydia, gonorrhea, and the mumps virus. Clinical presentation, severe scrotal pain, scrotal swelling, and hematuria. Lab study and physical exam findings. A UA and a urine culture. Treatment, scrotal elevation, and ice and NSAIDs, opiates, because this is painful.

Next we have prostatitis. Two different types here. We have acute and chronic prostatitis. Acute can be caused by E. coli or pseudomonas, our two main bugs here. Chronic is more gram-negative or enterococcus. Gram-negative rods, I’m sorry. Presentation is with fever, pain with voiding, and perineal pain.

Lab studies and physical exam findings. So again, we’re going to get a UA. Urine culture. And in an acute phase, we have tenderness with rectal exam. In a chronic phase, we have a rectal exam, which may be normal or have a boggy prostate. Treatments, these patients may require hospitalization for IV antibiotics, and a catheterization may be necessary. So Bactrim for 6 to 12 weeks, fluoroquinolones for 6 to 12 weeks, cephalexin for 6 to 12 weeks, erythromycin for 6 to 12 weeks.

So this is a long time to get into that prostate.

All right, so that covers infectious issues. So again, we sort of have the story of two different infections. One’s a sexually transmitted issue with chlamydia and Neisseria, and one is an E. coli issue. And they sort of seem to travel in different directions, treated slightly differently, present slightly differently. Definitely know how to separate out these diseases. And then understand the different treatment regimes based on what the most likely causative agent is. And then how you would evaluate and diagnose them.

So that’s largely going to be with a UA. It’s going to help a lot. So if you have a patient coming in complaining of scrotal pain or urethral discharge or anything along those lines, a urinalysis and culture, whether that’s a urethral swab or how you’re going to do it, that’s really the mainstay of treatment. And understanding that is a big help.

All right. Our study tip for today. This one’s going to be very straightforward. Our study tip for today is going to be the difference between wanting and deciding. You can want to do better. You can want to increase your scores. You can want to gain medical knowledge.

You can want to be thinner. You can want to be stronger. You can want to be faster. But there’s also a point when you can decide to be those things. You decide that you’re going to be at the top of your class. You decide you’re going to lose weight. You decide you’re going to be faster and stronger.

It’s hard to decide all of those things at once, of course. But the point is, it’s that point of decision that’s the differentiator for most of us. The reason this comes up for me tonight is this podcast has to go out tomorrow. It’s Monday when I’m recording this, Monday night. And I know my OR schedule tomorrow is very busy. I’m going to be doing robotic surgery and I’m going to have a busy day and I’m not going to be able to get to record this episode. And a lot of times I will do it early, but sometimes I’ll do it on the Tuesday.

But I decided that this episode was going to be done. I didn’t want to get it done. And I did a ton of work today for the 33 Days to Pass the PANCE cohort that I’m working with. We had a great day. I put together a ton of information for them. I just got off a really good group call where we talked about a lot of different things. They asked a whole bunch of great questions.

It was a blast. But at this point, I’ve been working on Physician Assistant Exam Review material for, I’d say, probably about 12 hours. I did break to eat. I did break to go for a run. But we’re probably close to 12 hours. So anyway, the point being, I decided that this episode was going to be recorded today. When you decide that you’re going to get your work done, it gets done.

When you want to get it done, it might not. When you decide you’re going to work out, it gets done. Deciding to do something is a very important step in accomplishing it. Wanting to do it means it might get done. Deciding to do it means it will get done. I hope you see the difference and I hope you can use that.

All right, let’s wrap up today with our priming questions. Gram-negative intracellular diplococci should make you think of what organism? One we talked about a lot today, Neisseria gonorrhea. Costovertebral tenderness should make you think of what diagnosis? Pyelonephritis. And the most common organism which causes a UTI, E. coli, and then obviously the most common organism which causes cystitis is also E. coli. Right?

That totally should make sense. So what’s the most common organism that causes pyelonephritis? Also E. coli, right? We’re talking about the same idea.

All right. So short show today, like I said, I knew this was going to be some quick material. I also knew it was late when I’m recording this. So, my stories are limited today, which some of you may actually appreciate. So anyway, that’ll wrap us up for today. If you’d like to get every single episode of the show, go over to physicianassistantexamreview.com/podcast, and you can get every episode delivered straight to your phone through there. It’s a really nice way to handle it.

So in addition to that, go ahead and share the show. I really do appreciate that. That’s it. We’ll talk to you next week when we cover something completely different in dominating medicine.