ISK 2 (SISTEM GU)

Aditiawarman SMF/Bag Penyakit Dalam FK Unsoed/RS Margono Soekarjo Purwokerto

Referensi

ASYMTOMATIC BACTERIURIA
Essentials of diagnosis Asymtomatic patient Urine culture with > 10 5 organism,or bacteria in spun urine, or dipstick positive for leukocytes and/or nitrites

General Considerations

Diagnosis criteria are not well defined Should be routinely screened and treated : pregnant women Hospitalized patients with indwelling catheters are out side the scope

Treatment

Should be guided by local rates of resistance First-line treatment: 7 days of Amoxicillin Penicillin-allergic : nitrofurantoin/ cephalosporin

ACUTE URETHRAL SYNDROME

Essential of diagnosis Dysuria Frequency and urgency No vaginal discharge Dipstick may be negative or positive Negative culture

General considerations

Is a term used by some to describe a young, healthy, sexually active woman who complains of recent-onset of cystitis but does not meet older, strict guidelines for diagnosis.

Clinical Findings
Patient at low risk of STD: - no testing might be appropriate - testing only after failure of empirical treatment for cystitis Patient at higher risk of STD: - Chlamydia testing by cervical swab or urin PCR, might be appropriate

Differential Diagnosis

This syndrome is clearly not well defined It is usually taken to represent an early cystitis It can be a sexually transmitted disease (STD)

Treatment

Usual cystitis agents or STD agents, depending assesment Chlamydia trachomatis was found to be high in at lest one study routine Chlamydia testing for patients who do not respond completely to a course of antibiotics would be highly recommended.

URETHRITIS
Essentials of diagnosis Pain or irritation on urination No frequency or urgency Discharge from the urethra (predominantly males) Vaginal discharge possible

General Considerations

Isolated urethritis in men or women is almost always a sexually transmitted disease, most often caused by C trachomatis. Symptoms that have gradual onset and/or persist without evolution into classic cystitis symptoms.

Clinical Findings

It can very difficult to separate a symptomatic Chlamydia infection from a bacterial cystitis with coliform organisms Testing for both may be required

ACUTE BACTERIAL PROSTATITIS

Essentials of diagnosis Dysuria, frequency, urgency Tender prostate Systemic symptoms such as fever, nausea, vomiting Leukocyte esterase or nitrite on dipstick Positive urine culture

General Considerations

Categorization of prostatitis: - I : Acute bacterial prostatitis - II : Chronic bacterial prostatitis - IIIA: inflammatory chronic pelvic pain syndrome - IIIB: noninflammatory chronic pelvic pain syndrome - IV :asymptomatic inflammatory prostatitis

Clinical Findings
A.

Symptoms and signs - dysuria, frequency, and urgency - low back, perineal, penile, and/or rectal pain - tense or boggy tender prostate - fever and chills

B. Laboratory findings - a urine dipstick is positive for leukocyte esterase and/or nitrites - urine culture is positive for a single uropathogen C. Imaging studies : D. Special test: prostatic massage is generally not done for acute bacterial prostatitis it may lead to acute bacteremia

Diferential diagnosis

Abnormal anatomy: urethral strictures, polyps, diverticulae, rdudancies, or valves anywhere in the system from the penis to the kidneys

Complications

Ascending infection Infection-related stones Abscess Fistula Cyst Acute urinary retension

Treatment

Quinolone antibiotics for 28 days Kotrimoxazole

Prognosis

Very good for acute uncomplicated bacterial prostatitis

CHRONIC BACTERIAL PROSTATITIS

Essentials of diagnosis Dysuria, frequency, urgency Symptoms for more than 3 months Urine dipstick positive forleukocyte esterase and/or nitrites Pyuria on microscopy Positive four-glass or two-glass test for prostatic origin

General considerations

Chronic bacterial prostatitis is quite rare

Prevention

Early and sufficient treatment of acute bacterial prostatitis may prevent chronic prostatitis

Clinical findings
Symtoms and signs - dysuria, frequency, and urgency - prostatic tenderness on examination - low back, perineal, penile, and/or rectal pain - present for more than 3 months B. Laboratory findings - urine dipstick is positive and/or a four-glass or two-glass test for prostatic origin is positive
A.

C. Imaging studies - A transrectal prostatic ultrasound should be done if abscess or stones are suspected D. Special test 1. Four-glass test 2. Two-glass test

Complications

Ascending infection Infection-relatd stones Abscess Fistula Cyst Acute urinary retention

Treatment

Trimethoprim Trimethoprim/sulfamethoxazole Quinolones For up to 12 weeks

Prognosis

Not known

UNCOMPLICATED BACTERIAL CYSTITIS

Essentials of diagnosis Dysuria Frequency and/or urgency Dipstick positive Positive urin culture > 10 4 organisms No vaginal discharge, fever, or flank pain

General Considerations

Acute, uncomplicated cystitis is most common in women Approximately 33% of all women will have experienced at least one episode of cystitis by the age of 24 years 40-50% will experience at least one during their lifetime. Young womens risk factors include sexual activity, use of spermicidal condoms or diaphragm, and genetic factors such as blood type or maternal history of reccurent cystitis It is rare in men with normal urinary anatomy under the age of 35 years.

Prevention

Sexual activity (four or more episode/month) Use of spermicidal condoms Use of unlubricated condoms Use od diaphragms and/or cervical caps Recommending change in contraception Prophylactic antibiotics either low-dose daily or postcoital antibiotics

Clinical findings
A.

Symptoms and signs - dysuria, sudden onset - suprapubic pain - cloudy - Smelly urine - Frequency - urgency

B. Laboratory findings - dipstick positive

Treatment
Acute cystitis - 3 day antibiotic therapy as superior to 1 day treatment - first line tx: kotrimoxazole B. Acute cystitis in the pregnant woman - Amoxicillin for 7 days C. Prophylaxis for recurrent cystitis - low dose prophylactic antibiotics: decrease recurrency by up to 95 %
A.

COMPLICATED CYSTITIS AND SPECIAL POPULATIONS

Essensials of diagnosis Any cystitis not resolved after 3 days of appropriate antibiotic treatment Any cystitis in a special population, such as: - a diabetics - a man - a patient with an abnormal urinary tract - a patient with stones - a pregnant woman

General considerations

Referral to a urologist Cultured appropriate antibiotic

Clinical findings

X-ray CT IVP cystoscopy

Treatment

Long-course, appropriate antibiotics

PYELONEPHRITIS
Essentals of diagnosis Fever Chills Flank pain >100.000 colony-forming (CFU) on urine culture

General considerations

Infection of the kidney parenchyma Upward spread of cystitis/ hematogenous Bacterial involved are the same as uncomplicated cystitis

Clinical findings
Symptoms and signs - fever, chills, and malaise - dysuria - flank pain - nausea and vomiting B. Laboratory findings - dipstick positive - urine culture positive
A.

Imaging studies

Not required unless the patient is diabetic or stones CT scan

DD

Bactericidal Broad spectrum Concentrate well in urine and renal tissues Aminoglycosides Amoxicillin Cephalosporin Fluoroquinolon (first line tx, outpatient) Imipenem 10 day to 2 week of antibiotics Nausea, vomiting, severe illness be admitted to the hospital for parenteral tx

Treatment