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Microhematuria and Urinary Tract Infections 1/30/2018 MICROHEMATURIA AND URINARY TRACT INFECTIONS ANEESA HUSAIN, PA-C USMD CANCER CENTER ARLINGTON - UROLOGY I HAVE NO FINANCIAL DISCLOSURES THAT WOULD BE A POTENTIAL CONFLICT OF INTEREST WITH THIS PRESENTATION. MICROHEMATURIA TOPICS OF DISCUSSION • DEFINITION • HISTORY • PHYSICAL EXAM • DIFFERENTIAL DIAGNOSES • WORK UP • TREATMENT • WHEN TO REFER? 1 1/30/2018 MICROHEMATURIA DEFINED AS.. • ≥3 RBCs per HPF (HIGH POWER FIELD) ON URINE MICROSCOPY • SHOULD NOT BASE SOLELY ON ONE DIPSTICK READING • CAN CORRELATE TO DIPSTICK URINE ANALYSIS • TRACE, SMALL, MODERATE, LARGE https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-and-validity-confirmed-2016) MICROHEMATURIA TOP DIFFERENTIAL DIAGNOSES • UTI/PROSTATITIS • KIDNEY STONES • URINARY TRACT OBSTRUCTION • URINARY TRACT MALIGNANCY • NEPHROLOGIC SOURCES MICROHEMATURIA HISTORY • NEW DIAGNOSIS OF MICROHEMATURIA? • PRIOR HISTORY OF GROSS OR MICROHEMATURIA? • PRIOR WORK UP • COMORBIDITIES • PELVIC RADIATION • SURGICAL HISTORY • FOR WOMEN, ASK ABOUT MENSES AND/OR MENOPAUSE • ANTICOAGULATION OR BLOOD THINNERS • SYMPTOMS 2 1/30/2018 MICROHEMATURIA HISTORY - SYMPTOMS • DYSURIA • FREQUENCY • URGENCY • DIFFICULTY VOIDING • INCONTINENCE – PAD USAGE • ABDOMINAL OR BACK PAIN • PERINEAL PAIN MICROHEMATURIA PHYSICAL EXAM • ABDOMINAL EXAM • CVA/FLANK TENDERNESS • GU EXAM • MALE – CONSIDER MEATAL STENOSIS, BALANITIS, TESTICULAR PAIN, PROSTATITIS, PROSTATE ENLARGEMENT • FEMALE – CONSIDER VAGINAL BLEEDING, YEAST INFECTION, ATROPHIC VAGINITIS MICROHEMATURIA DIFFERENTIAL DIAGNOSES • UTI/PROSTATITIS • RADIATION CYSTITIS • KIDNEY STONES • POST-OP SURGICAL CHANGES: PROSTATE REGROWTH, • URINARY TRACT OBSTRUCTION CRYOABLATION, MESH/SLING EROSION • URETERAL STONES • BALANITIS, VAGINITIS, VAGINAL BLEEDING UPJ OBSTRUCTION, HYDRONEPHROSIS • • NEPHROLOGICAL SOURCES • URETERAL STRICTURE • BPH • URETHRAL STRICTURE • URINARY TRACT MALIGNANCY • RENAL TUMORS • BLADDER TUMORS • URETERAL TUMORS 3 1/30/2018 http://humananatomylesson.com/anatomy-of-urinary-system/ MICROHEMATURIA WORK UP • URINE MICROSCOPY • URINE SPECIMEN SHOULD BE MID-STREAM VOID OR CATHETERIZED SAMPLE • URINE CULTURE • URINE CYTOLOGY • CT-IVP • CYSTOSCOPY (AUA RECOMMENDS FOR PATIENTS ≥ 35 OR WITH RISK FACTORS FOR URINARY TRACT MALIGNANCY) https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-and-validity-confirmed-2016) MICROHEMATURIA URINE SEDIMENT MICROSCOPY https://www.researchgate.net/profile/Bensson_Samuel/publication/273897399/figure/tbl4/A https://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911 S:391968115970051@1470463889150/Table-4-Urinalysis-With-Urine-CS-Reflex.png 4 1/30/2018 MICROHEMATURIA URINE CULTURE http://www.sciencephoto.com/media/855408/view http://www.lbah.com/word/bladder-stones/ MICROHEMATURIA CT-IVP KIDNEY/URETERAL STONES http://www.imagingpathways.health.wa.gov.au/index.php/imaging- pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic MICROHEMATURIA CT-IVP UPJ OBSTRUCTION AND HYDRONEPHROSIS http://radiopaedia.org/images/1228468 5 1/30/2018 MICROHEMATURIA CT-IVP RENAL MASS INVADING COLLECTING SYSTEM http://uronotes2012.blogspot.com/2012/04/neoplastic-renal- masses-benign-adenoma.html MICROHEMATURIA URINE CYTOLOGY • SCREENS URINE FOR ATYPICAL OR MALIGNANT CELLS • CANNOT DIAGNOSE CANCER SOLELY BASED ON CYTOLOGY • RELATED TESTS • NMP-22 • FISH • BLADDER CX • IF CYTOLOGY TESTS ARE POSITIVE OR ABNORMAL, CYSTOSCOPY IS RECOMMENDED http://www.urologyhealth.org/urologic-conditions/urine-cystology?article=85 http://medical.olympusamerica.com/products/flexible-cysto-nephroscope/cyf-5 6 1/30/2018 NORMAL BLADDER TUMOR CYSTITIS http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img http://www.webpathology.com/image.asp? =PMC3725437_jmedlife-06-140-g002&req=4 case=51&n=26 URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT http://stgeorgeurology.com.au/optical- http://www.virtantiq.com/Urinary+Blad http://www.canjurol.com/article.php?ID=2357 urethrotomy der+Stone+Removal CYSTOSCOPIC FINDINGS MICROHEMATURIA POST-OP SURGICAL CHANGES THAT CAN ALSO BE NOTED ON CYSTOSCOPY: • PROSTATE REGROWTH • PROSTATE CRYOABLATION • MESH/SLING EROSION MICROHEMATURIA TREATMENT SHOULD BE BASED ON TEST RESULTS 7 1/30/2018 MICROHEMATURIA Test: Positive Urine Culture Diagnosis: Urinary Tract Infection Treatment: Antibiotic based on culture sensitivities http://www.lbah.com/word/bladder-stones/ MICROHEMATURIA DIAGNOSIS: PROSTATITIS SYMPTOMS: PERINEAL PAIN, DYSURIA, URETHRAL PAIN, FREQUENCY, URGENCY, WEAK STREAM, HEMATOSPERMIA, PAINFUL EJACULATION TESTS: NO SPECIFIC ROUTINE TEST; CULTURE MAY BE POSITIVE OR NEGATIVE ; POSITIVE SEMEN CULTURE TREATMENT: ANTIBIOTICS, NSAIDS, ALPHA BLOCKERS, WARM SITZ BATHS, AVOIDANCE OF DIETARY IRRITANTS MICROHEMATURIA Test: CT scan Diagnosis: Obstructing UPJ stone Treatment: Oral medication + Hydration, Shockwave Lithotripsy (ESWL), or Ureteroscopic Laser Lithotripsy *refer to urology http://www.imagingpathways.health.wa.gov.au/index.php/imaging- pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic 8 1/30/2018 MICROHEMATURIA Test: CT scan Diagnosis: UPJ Obstruction and Hydronephrosis Treatment: possible options based on further work up include ureteral dilation or pyeloplasty *refer to urology http://radiopaedia.org/images/1228468 MICROHEMATURIA Test: CT scan Diagnosis: Renal Mass Invading collecting system Treatment: Radical Nephrectomy *refer to urology http://uronotes2012.blogspot.com/2012/04/neoplastic-renal- masses-benign-adenoma.html NORMAL BLADDER TUMOR CYSTITIS http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img http://www.webpathology.com/image.asp? =PMC3725437_jmedlife-06-140-g002&req=4 case=51&n=26 TURBT – TRANSURETHRAL MONITOR VS. TREAT RESECTION of BLADDER DEPENDING ON TUMOR OTHER TESTS CYSTOSCOPIC FINDINGS - Treatment 9 1/30/2018 URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT http://stgeorgeurology.com.au/optical- http://www.virtantiq.com/Urinary+Blad http://www.canjurol.com/article.php?ID=2357 urethrotomy der+Stone+Removal DILATION vs. VIU SURGICAL (Visual Internal TREATMENT MEDICAL vs. SURGICAL Urethrotomy) vs. (CYSTOLITHOLAPAXY) THERAPY (such as TURP) URETHROPLASTY CYSTOSCOPIC FINDINGS - Treatment MICROHEMATURIA TREATMENT CONTINUED… • BALANITIS: LOTRISONE OR SIMILAR, CONSIDER CIRCUMCISION • ATROPHIC VAGINITIS: VAGINAL ESTROGEN (IF NO RISK FACTORS) • ABNORMAL VAGINAL BLEEDING: REFER TO GYNECOLOGY MICROHEMATURIA NEPHROLOGIC SOURCES Refer to nephrology … • If urological work up is negative AND • Patient has history of medical diseases that may cause microhematuria • Casts are present in urine microscopy https://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911 10 1/30/2018 URINARY TRACT INFECTIONS • SOURCES/CAUSES • CONSTIPATION (WOMEN MORE SUSCEPTIBLE) • INTERCOURSE • EXPOSURE TO BACTERIA FROM POOLS, BATHTUB, LAKE, ETC. • KIDNEY STONES • ANATOMICAL ABNORMALITY • URINARY TRACT OBSTRUCTION • VESICOURETERAL REFLUX • INCONTINENCE • URINARY RETENTION • RECENT INSTRUMENTATION • CYSTOSCOPY, CATHETER, SURGERY • ATROPHIC VAGINITIS URINARY TRACT INFECTIONS • SYMPTOMS • DYSURIA • HEMATURIA OR DISCOLORED URINE • PELVIC PAIN • LOW BACK PAIN • SENSATION OF INCOMPLETE BLADDER EMPTYING • FREQUENCY/URGENCY • WORSENING INCONTINENCE URINARY TRACT INFECTIONS http://zeroinfections.blogspot.com/2012/08/urinary-tract-infections.html 11 1/30/2018 URINARY TRACT INFECTIONS • PYELONEPHRITIS • FEVER, UNILATERAL FLANK PAIN (CAN BE IN ADDITION TO ABOVE UTI SYMPTOMS) • SHOULD BE TREATED URGENTLY http://www.medicinenet.com/kidney_infection/article.htm http://www.pafmj.org/editor_images/PATTERN%20OF%20URINARY%20FIGURE1.jpg URINARY TRACT INFECTIONS • TREAT BASED ON CULTURE & SENSITIVITIES • URINE CULTURES NOT ALWAYS (+) FOR PROSTATITIS AND URETHRITIS • PRE-EMPTIVE TREATMENT • CAN USE PRIOR C&S IF AVAILABLE TO DETERMINE ANTIBIOTIC SELECTION • SYMPTOMATIC RELIEF • URINARY ANALGESICS (URIBEL, PYRIDIUM, AZO) • ALPHA BLOCKERS FOR PROSTATITIS URINARY TRACT INFECTIONS • COMMON BACTERIA • E.COLI (MOST COMMON) • KLEBSIELLA • ENTEROCOCCUS • PROTEUS • PSEUDOMONAS • STAPHYLOCOCCUS • COMMON ANTIBIOTICS USED • FLUOROQUINOLONES (LEVAQUIN, CIPRO) • BACTRIM • NITROFURANTOIN • CEPHALOSPORINS (CEFTIN, KEFLEX) • PENICILLINS 12 1/30/2018 URINARY TRACT INFECTIONS • UTI PREVENTION • HYGIENE (REGARDING GARMENTS, SEXUAL ACTIVITY) • BOWEL MANAGEMENT • HYDRATION • CRANBERRY SUPPLEMENTS • PROPHYLACTIC ANTIBIOTICS/ANTISEPTICS • KEFLEX • BACTRIM (OR TRIMETHOPRIM IF SULFA ALLERGY) • NITROFURANTOIN (RISK OF PULMONARY FIBROSIS WITH CHRONIC USE) • ADDRESSING STONES, INCONTINENCE, BLADDER EMPTYING, ANATOMICAL ABNORMALITY • VAGINAL ESTROGEN FOR ATROPHIC VAGINITIS IN POST-MENOPAUSAL WOMEN MICROHEMATURIA & URINARY TRACT INFECTIONS • URINARY TRACT INFECTION (UTI) IS A POSSIBLE SOURCE OF MICROHEMATURIA • UTI SHOULD BE SUSPECTED BASED ON SYMPTOMS AND PRIOR HISTORY • SYMPTOMS CAN INCLUDE DYSURIA, FREQUENCY, URGENCY, PELVIC PAIN, BACK PAIN • CONSIDER PRIOR HISTORY OF RECURRENT OR CHRONIC UTI MICROHEMATURIA & URINARY TRACT INFECTIONS • IF UTI IS SUSPECTED, A URINE CULTURE SHOULD BE SENT • ANTIBIOTICS MAY BE STARTED EMPIRICALLY IF UTI IS SUSPECTED AND PATIENT IS SYMPTOMATIC OR AT HIGH RISK FOR DEVELOPING A MORE SERIOUS INFECTION (PYELONEPHRITIS/SEPSIS) • IF AVAILABLE, REVIEW PRIOR ANTIBIOTIC SENSITIVITIES 13 1/30/2018 MICROHEMATURIA & URINARY TRACT INFECTIONS IN LIGHT OF GROWING ANTIBIOTIC RESISTANCE, MICROHEMATURIA SHOULD NOT BE TREATED WITH ANTIBIOTICS UNLESS A URINARY TRACT INFECTION IS STRONGLY SUSPECTED WHEN TO REFER TO UROLOGY? MICROHEMATURIA URINARY TRACT INFECTIONS • URINE MICROSCOPY >3 RBCS • RECURRENT INFECTIONS • IN-OFFICE DIPSTICK UA + ON 2 TESTS • PERSISTENT SYMPTOMS • SUSPICIOUS IMAGING FINDINGS • SUSPECTED PYELONEPHRITIS • UTI WITH KIDNEY STONES • RISK FACTORS • SUSPCIOUS IMAGING FINDINGS • SMOKING HISTORY • INCONTINENCE • URINARY RETENTION • AGE Aneesa Husain, PA-C USMD Cancer Center Arlington Arlington, TX 76017 817-417-1100 [email protected] 14.
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  • Let's Talk About What's Hard
    Let’s Talk About What’s Hard “Bobby” Duc Tran, MD, MSc Assistant Professor, Emory University 2017 HoG State Meeting Case Presentation March 3, 2017 WARNING The following presentation contains some foul language, nudity, and images that some viewers may find upsetting Case Presentation • 32yo white male • Past medical history: • severe hemophilia B • hemophilic arthropathy of bilateral knees and elbows • Marfan’s syndrome • atrial fibrillation • blind in one eye • hepatitis C • Current hemophilia treatment: Aprolix • Previous issues with mixing the factor. Case Presentation • Past surgeries: • Aortic root repair • Full dentition extraction • Bilateral knee arthroscopic synevectomies at 5 and 7 yo • Left orchiectomy for testicular torsion • Last seen in clinic for his annual comprehensive visit in 9/2016 Case Presentation • Called to the HTC clinic nurse on 12/5/2016 • Embarrassingly he reported: • This morning “my penis and testicles are blackish purple and feels like a bleed” • I had sex with my wife last night • Last infused 3 days ago and is not due for next infusion until tomorrow • “This has never happened before” How to talk about this? • Approach from a professional standpoint • Discuss these topics when discussing safe sexual practices • Gauge the patient’s comfort with using medical terms • Nicknames used: • Dick, dong, schlong, wiener, peen, so many more • Not wenis What to do first? • When was the bleeding recognized? • Did you hear/feel a “pop”? • Recognize associated injuries • Urethra, bladder, vascular • Consider GU referral
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  • Gonorrhoea, Chlamydia and Non-Gonococcal Urethritis (Ngu)
    MAKING IT COUNT BRIEFING SHEET 4 GONORRHOEA, CHLAMYDIA AND NON-GONOCOCCAL URETHRITIS (NGU) This Making it Count briefing sheet provides an overview on gonorrhoea, chlamydia and non-gonococcal urethritis (NGU) for sexual health promoters working with gay men, bisexual men and other men that have sex with men (MSM). These sexually transmitted infections (STIs) are three of the most common affecting MSM in the UK. They are often grouped together because they have similar modes of transmission, symptoms and treatment. What ARE THEY? • 4,488 gay and bisexual men were diagnosed with In men, gonorrhoea and chlamydia can affect the urethra chlamydia. (the tube in the penis which urine comes out of), the 5,485 gay and bisexual men were diagnosed with NGU. rectum and the throat. NGU only affects the urethra. • Among MSM, chlamydia diagnoses have been rising rapidly Gonorrhoea is caused by infection with the bacteria • over the past decade and the numbers reported as having Neisseria gonorrhoeae. NGU have also increased. There has been a reduction in • Chlamydia is caused by infection with the bacteria gonorrhoea cases in recent years. However, nearly a third of Chlamydia trachomatis. all gonorrhoea diagnoses in men occur in MSM, while approximately one in twelve men infected with chlamydia Non-gonococcal urethritis (NGU) describes • or NGU are MSM. inflammation of the urethra, for which the cause is unknown. How ARE THEY pASSED ON? NGU is usually caused by an unidentified bacteria. In many Gonorrhoea and chlamydia are caused by bacteria which cases if the necessary tests were done, this would turn out may be found in semen, in the urethra and in the rectum of to be Chlamydia trachomatis or Mycoplasma genitalium.
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