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Patient history

First visit to hospital : 18/7/2540
 Patient profile : ผูป
้ ่ วยหญิงไทยคู่อายุ 76 ปี
 Chief complaint : ปั สสาวะแสบมา 1 เดือน PTA
ท่านจะซักประวัตอิ ะไรเพิม่ เติม?
History
Voiding disfunction
 Irritative symptom
Frequency
Nocturia
Urgency
Dysuria
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Obstructive symptom
Weak stream
Urinary Hesistancy
Straining
Prolonged micturition
Intermittency
Postvoid dribbing
Feeling of incomplete emptyness
Acute & Chronic urinary Retention
Associate symptom
- Fever, N/V, CVA tenderness, shivering
- abdominal pain and radiation
- characteristic of urine
Past history
- Previous history of urinary tract disease
- Underlying disease
:
DM
:
Neurological disease
:
Gyne - STD
:
Immunocompromised host
- SI
- Current drug : ATB
- History of radiation, chemotherapy
- History of urinary catheter or stent
Present illness

ปั สสาวะแสบตอนสุดเป็ นๆหายๆมา 1 เดือน ไม่ มี
ไข้ ไม่ เคยปั สสาวะเป็ นก้ อนกรวด รักษาที่คลินิกอาการ
ไม่ ดีขนึ ้
personal history : - Menopause เมื่ออายุ 50 ปี
- มีบุตร 5 คน
ท่านจะตรวจร่างกาย
อะไรบ้ าง
Physical Examination
• Complete Examination
• Per vagina : MIUB, Vg, Cx, Ut, Adnexa
• Suprapubic tenderness
• Costovertebral angle tenderness
Patient history
Physical examination:
PV
MIUB - Atrophy
Vagina - Atrophy
Cervix - No lesion
Uterus - Normal size
Adnexa
- No mass

ท่ านจะส่ ง Investigation อะไรบ้ าง ?
Investigation ในผ้ ูป่วยรายนี ้
UA
 Urine culture
 PAP smear
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Routine Urinalysis result
Color Yellow
Clarity Cloudy
SG
1.025
Blood
pH
6.0
Bili
Prot
3+
Uro
Glu
Negative
Nitri
Keto
Negative
Leuco
Microscopic Examination result
WBC
Numerous/HP
RBC
Many/HP
Epith Squamous cell
3-5/HP
Epith Translational cell 0-1/HP
3+
Negative
Normal
Negative
2+

Impression:
1. Vaginal atrophy
2. Cystitis
Management ของแพทย์ท่านนี ้

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Norfloxacin (200 mg) 2 tab PO bid pc #20
Follow up 1 week for urine culture results,
UA before visit doctor

Routine Urinalysis result
Color Yellow
Clarity Cloudy
SG
1.020
Blood
pH
5.5
Bili
Prot
1+
Uro
Glu
Negative
Nitri
Keto
Negative
Leuco
Microscopic Examination result
WBC
Many/HP
RBC
10-15/HP
Epith Translational cell
1-2/HP
2+
Negative
Normal
Negative
2+
Second visit (25/7/2540)
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ปั สสาวะแสบตอนสุ ด รู ้สึกเหมือนมีอะไรติดอยู่ กินยาแล้วไม่ดีข้ ึน
Urinalysis ซ้ าพบว่ายังมี WBC, RBC
ผลเพาะเชื้อ first visit เป็ นดังนี้
Urine culture : Streptococcus spp. 5000 CFU/ml
Corynebacterium spp.5000 CFU/ml
แปลผล urine culture ว่าอย่างไร
Urine Culture
Clean Voided Specimen
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Normal: <10,000 organisms per ml
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Urinary Tract Infection
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Boys
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Organisms >10,000 per ml suggests UTI likely
Girls
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Organisms >100,000 per ml suggests UTI
Organisms >10,000 per ml needs repeat urine culture
Transurethral Catheterization
 Normal: <1,000 organisms per ml
 Urinary Tract Infection
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Organisms >100,000 per ml suggests UTI (95%)
Organisms >10,000 per ml suggests UTI
Organisms >1,000 per ml needs repeat urine
culture
Second visit (25/7/2540)
แพทย์ ได้ ส่งปรึกษากับศัลยแพทย์ ศัลยแพทย์ ยัง
ยืนยันว่ าเป็ น Cystitis
 แพทย์ ไม่ ได้ นัดผู้ป่วยให้ มาพบอีก

Third visit (2/2/2541)

Chief complaint: ปั สสาวะแล้ วปวดตอนสุด
ปั สสาวะบ่ อย เป็ นๆหายๆมาหลายครัง้

Routine Urinalysis result
Color Yellow
Clarity Turbid
SG
1.025
Blood
pH
5.5
Bili
Prot
2+
Uro
Glu
Negative
Nitri
Keto
Negative
Leuco
Microscopic Examination result
WBC
Many/HP
RBC
30-35/HP
Epith Squamous cell
rare/HP
Epith Translational cell rare/HP
3+
Negative
Normal
Negative
3+
Third visit (2/2/2541)
: พบ pyuria, hematuria,
proteinuria
 Impression : Cystitis
 Medications : Norfloxacin (200 mg) 2 tab PO
bid pc #28
 Follow up
: 7 days, UA before visit doctor

ผล UA
Fourth visit (9/2/2541)

Chief complaint: อาการไม่ ดีขนึ ้

Routine Urinalysis result
Color Yellow
Clarity Turbid
SG
1.025
Blood
3+
pH
5.5
Bili
Negative
Prot
3+
Uro
Normal
Glu
3+
Nitri
Negative
Keto
Negative
Leuco
3+
Microscopic Examination result
WBC
Numerous/HP
RBC
3-5/HP
Epith Translational cell
rare/HP
Bact Bacilli & Cocci
few/HP
Fourth visit (9/2/2541)
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UA
: พบ WBC numerous
,microscopic hematuria, bacteria-few
PV
: Normal
Impression : suspected for underlying
disease
Medications : Norfloxacin (200 mg) 1 tab
qid pc PO #20
ส่ ง Urine culture
Follow up
: 3 days and plan for IVP
Fifth visit (13/2/2541)
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Urine culture results
: Negative
CXR
: Normal
Medication
: norfloxacin 1x4
Made an appoint : for IVP at 23/2/2541
ท่ านคิดว่ า indication ในการทา IVP
ของผู้ป่วยรายนีค้ ืออะไร?
เรามารู้ จัก IVP กันดีกว่ า
IVP - Indication

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ดูสภาวะการทางานของไตในโรคต่างๆ
ดูความผิดปกติทางกายภาพ
- stone disease (site of obstruction & renal function)
- Preoperative or base-lined ESWL
- Acute colicky abdominal pain
- Heamaturia screening
- Suspect or unusual infection , TB
- pre and post op urosurgery (transplant kidney)
- Suspect uroepithilial tumor (TCC)
- Quesionable abnormalities on nuclear medical and
ultrasonogram
IVP - contraindication
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แพ้สารไอโอดีน ถามเรื่ องอาหารทะเล และควรระวังในผูป้ ่ วยที่มี
ประวัติ หอบหื ด หรื อภูมิแพ้อื่น
serum Cr > 4 mg %
การเตรียมผู้ป่วย

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Bowel preparation
Fluid restriction (becareful for kidney
insufficiency Ex DM , MM and emergency
case)
การทา IVP
1. ถ่ายภาพ plain KUB (scout film)
 2. ฉี ดสารทึบรังสี
 3. ถ่ายภาพเหมือน plain KUB 5, 10, 25 นาที
และเวลาอื่นตามจาเป็ น ให้เห็น pelvocaliceal
system ,ท่อไต ,bladder

Sixth visit (23/2/2541)

ผู้ป่วยมีอาการดีขนึ ้ แต่ ผลการตรวจปั สสาวะ
ยังพบ RBC, WBC, No bacteria เหมือนเดิม

Routine Urinalysis result
Color Yellow
Clarity Turbid
SG
1.025
Blood
pH
6
Bili
Prot
3+
Uro
Glu
Negative
Nitri
Keto
Negative
Leuco
Microscopic Examination result
Granular cast 1-2/LP
WBC
Numerous/HP
RBC
3-5/HP
Epith Squamous cell
2-3/HP
Bact Cocci
few/HP
Yeast cell
1-2/HP
3+
Negative
Normal
Negative
2+
Sixth visit (23/2/2541)
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ผล IVP:
Scout film show no opaque stone
Spondylosis with kyphoscoliosis
Post intravenous injection of the contrat
sodium,focal caliectasis of left lower pole kidney, probably
non opaque stone
Contracted bladder with thickened wall, chronic
cystitis
Impression:
- Frequent UTI &
- Abnormal lower pole of left kidney
Consult urologist
Seventh visit (27/2/2541)
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Terminal dysuria and Nocturia 4-5 ครั ง้
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Reevaluate IVP  Normal study
จากประวัติและตรวจร่ างกายที่ผ่านมา
ท่ านนึกถึงโรคอะไรบ้ าง?
Seventh visit (27/2/2541)

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Plan for cystoscopy at 7/4/2541
Medications: Flavoxate, Imipramine
ท่านคิดว่าการส่ง cystoscopy ในผูป้ ่ วย
รายนีเ้ หมาะสมหรือไม่ ?
และส่งเพื่อดูสิ่งใดและคิดถึงอะไร ?
Indication for cystoscope
1) Frequent or persistent urinary tract infections
2) Blood in the urine (hematuria)
3) Loss of bladder control (incontinence)or
overactive bladder
4) Painful urination, pelvic pain or interstital cystitis
5) Urinary blockage:prostate enlargement or stricture
of the urethra
6) Stone in the urinary tract
7) Any abnormal growth, lesion, tumor
www.thedoctorslounge.net
Eighth visit (7/4/2541)
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Cystoscopy findings:
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Extranal geniralia : normal
Urethra : normal
Generalized hyperemia of bladder mucosa
Bleeding when dilatation with water
No tumor mass
DDx : TB cystitis, I.C., CIS
Biopsy bladder was done
Plan: Urine culture 3 days, Urine AFB
Rx: Norfloxacin
Follow up 2 week
The photomicrograph
shows 2 granulomatous
foci in the lamina propria
underlying the lamina
propria.
•There is also an
accompanying lymphocytic
infiltrate.
Ninth visit (24/4/2541)
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มี Terminal dysuria, Nocturia เพิ่มขึน้ เป็ น 10 ครัง้
No CVA tenderness
Biopsy result:
 Granulomatous inflammation consistent with tuberculosis
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AFB stain: negative
Plan: Start HRZE, CXR, Sputum AFB 3 days
Rx: Imipramine
Tenth visit (19/6/2541)
Culture result: Mycobacterium
tuberculosis
 นัด 3 เดือน UA before visit

ท่านคิดว่าเมื่อไหร่จะสงสัยว่า
ผู้ป่วย
รายนี ้เป็ น Complicated
cystitis ?
Causes
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Normal Host
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Nephrolithiasis associated infection
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Escherichia coli (80%)
Staphylococcus saprophyticus (10-15% of young women)
Proteus (urease positive)
Klebsiella
Sexually Transmitted Diseases
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Chlamydia
Neisseria gonorrhoeae
Herpes Simplex Virus II (Genital Herpes)
Associated risk factors
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Sexually active women
Men with Prostatitis or BPH
Pregnancy
Urinary Tract Obstruction
Neurogenic bladder dysfunction
Vesicoureteral reflux
Symptoms
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Dysuria
Urinary Frequency
Urinary Urgency
Suprapubic pain (especially after voiding)
Hematuria (30%)
http://www.fpnotebook.com/URO17.htm
Differential Diagnosis:
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Pain at onset of urination suggests urethritis
External Dysuria suggests Vaginitis
Long, insidious onset suggests Chlamydia
trachomatis
http://www.fpnotebook.com/URO17.htm
Labs
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Urinalysis
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Urine Leukocyte Esterase
Urine Nitrite
Urine White Blood Cells on microscopy
Urine Culture
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Positive for >100,000 organisms
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Women with Dysuria have <100,000 organisms in
30% cases
http://www.fpnotebook.com/URO17.htm
Management
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General measures in women
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Women should clean perineum wiping front to
back
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Women should empty bladder before, after
intercourse
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Avoid Contraceptive Diaphragm
http://www.fpnotebook.com/URO17.htm
Management
Antibiotics
Uncomplicated Treatment Course: 3 days (except
noted)
Antibiotic Resistance increasing
Trimethoprim Sulfamethoxazole (Septra): 9-18%
Ampicillin: 28-33%
Nitrofurantoin resistance low
Fluoroquinolone resistance low
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Avoid as first line agents if possible
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Consider in areas of high Septra resistance areas
Management
Acute Uncomplicated UTI
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Bactrim DS 1 po bid
Nitrofurantoin 100 mg PO qid for 7 days
Macrobid 100 mg PO bid for 7 days
Cephalexin (Keflex) 250-500 mg PO qid
Doxycycline 100 mg PO bid
Augmentin 875 mg PO bid
http://www.fpnotebook.com/URO17.htm
Management
Resistant UTI organisms
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Ciprofloxacin 250 mg PO bid
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In healthy older women, 3 days equivalent to 7 days
Vogel (2004) CMAJ 170:469-73
Norfloxacin 400 mg PO bid
Ofloxacin 200 mg PO bid
http://www.fpnotebook.com/URO17.htm
Complication
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Infection that ascending to kidney
 pyelonephritis, renal failure, sepsis
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Vesicoureteral reflux in children & pregnant
women
Complicated UTI
A clinical syndrome in men or women
characterized by the development of the
systemic and local signs and symptoms of
fever, chills, malaise, flank pain, back pain,
and CVA pain or tenderness, occurring in the
presence of a functional or anatomical
abnormality of the urinary tract or in the
presence of catheterization.
Complicated bladder infections
Bladder infections are classified as
complicated when they affect people with an
abnormality of the urinary system that makes
these infections more difficult to treat. All
bladder infections are considered complicated
when they affect men, because the long male
urethra should prevent bacteria from gaining
access to the bladder.
Complicated cystitis
Unresolved or persistent bladder infection,
whereas other use it to mean 3 or more bouts of
bladder infection occurring in the course of 1 year
Inclusion Criteria for Complicated UTI
1. Documentation of pyuria
2. One or more of following (defined UTI)
- dysuria
- urgency
- frequency
- suprapubic pain
- fever with chill - CVA tenderness
3. Present of one or more (defined complicated UTI)
-Instrument catheter or intermittent catheter
-Impaired bladder emptying
-Obstructive uropathy due to outlet obstruction
#Guidance for Industry
Complicated Urinary Tract Infections and Pyelonephritis - Developing Antimicrobial Drugs for Treatment
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Drug Evaluation and Research (CDER)
July 1998
Clin-Anti

Complicated cystitis
TB
DM
Immunocompromise
Radiation cystitis
Functional anomaly
Structure anomaly
Interstitial cystitis
General diagnosis/Evaluation
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Urine culture is necessary with complicated
UTIs prior to treatment
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Urologic investigation : Ultrasound, plain
KUB, IVP, CT, Cystoscopy
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Baseline renal function studies need to be
completed prior to contrast imaging
Interstitial cystitis
Definition :
clinical syndrome define by chronic
symptoms of urgency ,frequency, and /or
pain in the absence of any other resonable
causation
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Etiology: unknown
Pathogenic role of mast cells in the detrusor and/or mucosal
layers of the bladder
Deficiency in the glycosaminoglycan layer on the luminal
surface of the bladder, resulting in increased permeability of
the underlying submucosal tissues to toxic substances in the
urine
Infection with a poorly characterized agent (eg, a slowgrowing virus or extremely fastidious bacterium)
Production of a toxic substance in the urine
Neurogenic hypersensitivity or inflammation mediated locally
at the bladder or spinal cord level
Manifestation of pelvic floor muscle dysfunction or
dysfunctional voiding
Autoimmune disorder
•
Pathophysiology
A variety of etiologies have been
proposed, none of which adequately
explains the variable presentations
•
Pathology
lession on bladder wall
mucosa – บวมแดง มีแผล เลือดออก
Interstitial cystitis คืออะไร ?