Presentation on theme: "Mr. Noor Buchholz Consultant Urological Surgeon & Director Endourology and Stone Services."— Presentation transcript:
Mr. Noor Buchholz Consultant Urological Surgeon & Director Endourology and Stone Services
33 year old female Dysuria, frequency, cloudy urine No fever, no kidney pain No Hx of similar episodes
Wait for urine culture? Imaging? Refer to urology? Immediate treatment?
Wait for urine culture? Imaging? Refer to urology? Immediate treatment? Dipstick sufficient
Wait for urine culture? Imaging? Refer to urology? Immediate treatment? Dipstick sufficient Not needed
Wait for urine culture? Imaging? Refer to urology? Immediate treatment? Dipstick sufficient Not needed No
Wait for urine culture? Imaging? Refer to urology? Immediate treatment? Dipstick sufficient Not needed No yes
AntibioticsDaily doseDuration of therapy Fosfomycin trometamol°3 g SD1 day Nitrofurantoin50 mg q6h7 days Nitrofurantoin macrocrystal100 mg bid5-7 days Pivmecillinam*400 mg bid3 days Pivmecillinam*200 mg bid7 days Alternatives Ciprofloxacin250 mg bid3 days Levofloxacin250 mg qd3 days Norfloxacin400 mg bid3 days Ofloxacin200 mg bid3 days Cefpodoxime proxetil100 mg bid3 days If local resistance pattern is known (E. coli resistance < 20%) Trimethoprim-sulphamethoxazole160/800mg bid3 days Trimethoprim200 mg bid5 days Table 3.1: Recommended antimicrobial therapy in acute uncomplicated cystitis in otherwise healthy premenopausal women
Patient has come back with cystitis x3 over 8 months Each time ABX worked well
Yes Urography, cystography, cystoscopy not routinely – perhaps US KUB Urine culture? Imaging? Refer to urology? Immediate treatment?
Yes Urography, cystography, cystoscopy not routinely – perhaps US KUB Not in the abscence of risk factors Urine culture? Imaging? Refer to urology? Prophylactic treatment?
Category of risk factorExamples of risk factors No known/associated RF- Healthy premenopausal women RF of recurrent UTI but no risk of severe outcome- Sexual behaviour and contraceptive devices - Hormonal deficiency in post menopause - Secretory type of certain blood groups - Controlled diabetes mellitus Extra-urogenital RF, with risk of more severe outcome- Pregnancy - Male gender - Badly controlled diabetes mellitus - Relevant immunosuppression* - Connective tissue diseases* -Prematurity, new-born Nephropathic disease, with risk of more severe outcome- Relevant renal insufficiency* -Polycystic nephropathy Urological RF, with risk or more severe outcome, which can be resolved during therapy - Ureteral obstruction (i.e. stone, stricture) - Transient short-term urinary tract catheter - Asymptomatic Bacteriuria** - Controlled neurogenic bladder dysfunction -Urological surgery Permanent urinary Catheter and non resolvable urological RF, with risk of more severe outcome - Long-term urinary tract catheter treatment - Non resolvable urinary obstruction - Badly controlled neurogenic bladder Table 2.1: Host risk factors in UTI (refer to urologist) RF = Risk Factor; * = not well defined; ** = usually in combination with other RF (i.e. pregnancy, urological internvention).
Yes Urography, cystography, cystoscopy not routinely – perhaps US KUB Not in the absence of risk factors optional Urine culture? Imaging? Refer to urology? Prophylactic treatment?
Drink > 2.5 liters/ day Acidification Cranberry/ Vitamin C 1 gram/ day Genital hygiene pH-neutral alkaline-free soaps Empty bladder +/- sex General advise
Regimens TMP-SMX* 40/200 mg once daily TMP-SMX 40/200 mg thrice weekly Trimethoprim 100 mg once daily Nitrofurantoin 50 mg once daily Nitrofurantoin 100 mg once daily Cefaclor 250 mg once daily Cephalexin 125 mg once daily Cephalexin 250 mg once daily Norfloxacin 200 mg once daily Ciprofloxacin 125 mg once daily Fosfomycin 3 g every 10 days Table 3.3: Continuous antimicrobial prophylaxis regimens for women with recurrent UTIs
Regimens TMP-SMX* 40/200 mg TMP-SMX 80/400 mg Nitrofurantoin 50 or 100 mg Cephalexin 250 mg Ciprofloxacin 125 mg Norfloxacin 200 mg Ofloxacin 100 mg Table 3.4: Postcoital antimicrobial prophylaxis regimens for women with recurrent UTIs “In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short-course regimen of an antimicrobial agent should be considered “
Behavioural and general advise as well as one- shot low-dose therapy worked well Patient presents 2 months pregnant worried about UTI’s and baby No acute signs of cystitis Asymptomatic bacteriuria ≥ 10 5 cfu/mL
Another urine culture? Imaging? Refer to urology? Treatment in the abscence of symptoms?
Another urine culture? Imaging? Refer to urology? Treatment in the abscence of symptoms? in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 10 5 cfu/mL of the same bacterial species on quantitative culture
Another urine culture? Imaging? Refer to urology? Treatment in the abscence of symptoms? in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 10 5 cfu/mL of the same bacterial species on quantitative culture US KUB to exclude hydronephrosis – avoid Xray where possible
Another urine culture? Imaging? Refer to urology? Treatment in the absence of symptoms? in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 10 5 cfu/mL of the same bacterial species on quantitative culture US KUB If risk factors present (pregnancy can be regarded as a risk factor!) Asymptomatic bacteriuria detected in pregnancy should be eradicated with antimicrobial therapy
AntibioticsDuration of therapyComments Nitrofurantoin (Macrobid®) 100 mgq12 h, 3-5 daysAvoid in G6PD G6PD: glucose-6- phosphate dehydrogenasedeficiency Amoxicillin 500 mgq8 h, 3-5 daysIncreasing resistance Co-amoxicillin/clavulanate 500 mgq12 h, 3-5 days Cephalexin (Keflex®) 500 mgq8 h, 3-5 daysIncreasing resistance Fosfomycin 3 gSingle dose Trimethoprim-sulfamethoxazoleq12 h, 3-5 daysAvoid trimethoprim in first trimester/term and sulfamethoxazole in third trimester/term Table 3.5: Treatment regimens for asymptomatic bacteriuria and cystitis in pregnancy G6PD = glucose-6-phosphate dehydrogenase
Figure 2.1: Traditional and improved classification of UTI as proposed by the EAU European Section of Infection in Urology (ESIU)
45 year old male No symptoms On health check microhaematuria
Refer immediately to urology? Further imaging? Risk factors for Ca?
Refer immediately to urology? Dipstick haematuria is a misnomer! false-positive by hemoglobinuria, myoglobinuria, concentrated urine, menstrual blood, rigorous exercise Always confirm by formal MSU – then refer
Conclusions The incidence of muscle-invasive disease has not changed for 5 years. Active and passive tobacco smoking continues to be the main risk factor, while exposure-related incidence is decreasing. The increased risk of developing bladder cancer in patients submitted to external beam radiation therapy, brachytherapy or a combination of external beam radiation therapy and brachytherapy must be taken into account during patient follow-up. As bladder cancer requires time to develop, patients treated with radiation at a young age are at the greatest risk and should be followed up closely. The estimated male-to-female ratio for bladder cancer is 3.8:1.0. Women are more likely to be diagnosed with primary muscle-invasive disease than men. Currently, treatment decisions cannot be based on molecular markers.
Imaging? Further imaging? Refer urology? Follow up? Treatment needed? If symptomatic and/ or complex cyst
Bosniak categoryFeaturesWork-up IA simple benign cyst with a hairline-thin wall that does not contain septa, calcification, or solid components. It measures water density and does not enhance with contrast material. Benign IIA benign cyst that may contain a few hairline-thin septa. Fine calcification may be present in the wall or septa. Uniformly high- attenuation lesions of < 3 cm, which are sharply marginated and do not enhance. Benign IIFThese cysts might contain more hairline-thin septa. Minimal enhancement of a hairline-thin septum or wall can be seen. There may be minimal thickening of the septa or wall. The cyst may contain calcification that might be nodular and thick, but there is no contrast enhancement. There are no enhancing soft-tissue elements. This category also includes totally intrarenal, non-enhancing, high- attenuation renal lesions of > 3 cm. These lesions are generally well- marginated. Follow-up. A small proportion are malignant. IIIThese lesions are indeterminate cystic masses that have thickened irregular walls or septa in which enhancement can be seen. Surgery or follow- up. Malignant in > 50% lesions. IVThese lesions are clearly malignant cystic lesions that contain enhancing soft-tissue components. Surgical therapy recommended. Mostly malignant tumour. Table 4: The Bosniak classification of renal cysts
55 year old male Routine check-up PSA 5.8 No LUTS No family Hx of prostate cancer