Elderly Urinary Tract Disorders Fix

Elderly Urinary Tract
Disorders
Sahala Panggabean
Department of Internal Medicine
Faculty of Medicine
UKI
26 October 2016
Urinary Tract Infection
Introduction and Definition
• Urinary Tract Infection (UTI): the presence and
multiplication of antimicrobial pathogens within the
urinery tract.
• Limited to the bladder (cystitis, lower UTI) and serious
consequences can occur if the infection spreads to the
kidneys (acute pyelonephritis, upper UTI).
• Women are most at risk of developing a UTI. About half
of all women will develop an UTI episode during their
lifetimes, and many will experience more than once.
• UTI is the second most common type of infection in
human, accounts for 8.3 million doctor visits per year.
Figure 23.1
Epidemiologic categories of UTI
Epidemiologically UTI’s are sub divided into:
1. Cathether-associated or nosocomial infections

2. Community-aquired infections
Acute community-aquired infections are very common and
account for more than 7 million office visits annually
3. Asymptomatic bacteriuria is more common among elderly
men and women.
.
Bacterial Etiology of UTI
Routes of spreads
 Ascending transurethral route
 From the lower UT is the
commonest
 At first there is colonization
of the distal
urethra & introitus in female
by coliform
bacteria
 Hematogenous
 Through blood stream e.g.
septicaemia
 Lymphatics
 Direct extension from vesico
colic fistula
Risk Factors for UTI
Conditions affecting Pathogenesis
• Gender and sexual activity

• Pregnancy
• Obstruction
• Neurogenic Bladder Dysfunction
• Vesicoureteral Reflux
• Bacterial Virulence Factors
• Genetic Factors
Signs and Symptoms in adults
Older children or an adult may experience the

following symptoms with UTI:
– Painful urination (dysuria)
– Pain in the pelvic or suprapubic area
– Flank or lower back pain (with a kidney infection)
– Frequent urination
– Inability to produce more than a small amount of
urine at a time
– Incontinensia urinae
– Cloudy urine or with unusual smell
Lower Urinary Tract Infection -
Cystitis
• Uncomplicated (Simple) cystitis
– In healthy woman, with no signs of systemic
disease
• Complicated cystitis
– In men, or woman with comorbid medical
problems.
• Recurrent cystitis
Uncomplicated (simple) Cystitis
• Definition
– Healthy adult woman (over age 12)
– Non-pregnant
– No fever, nausea, vomiting, flank pain
• Diagnosis
– Dipstick urinalysis (no culture or lab tests needed)
• Treatment
– Trimethroprim/Sulfamethoxazole for 3 days
– May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrim-
resistance
• Risk factors:
– Sexual intercourse
• May recommend post-coital voiding or prophylactic antibiotic
use.
Complicated Cystitis
• Definition
– Females with comorbid medical conditions
– All male patients
– Indwelling foley catheters
– Urosepsis/hospitalization
• Diagnosis
– Urinalysis, Urine culture
– Further labs, if appropriate.
• Treatment
– Fluoroquinolone (or other broad spectrum antibiotic)
– 7-14 days of treatment (depending on severity)
– May treat even longer (2-4 weeks) in males with UTI
Pyelonephritis
• Infection of the kidney
• Associated with constitutional symptoms – fever, nausea, vomiting,
headache
• Diagnosis:
• Urinalysis, urine culture, CBC
• Treatment:
• 2-weeks of Trimethroprim/sulfamethoxazole or
fluoroquinolone
• Hospitalization and IV antibiotics if patient unable to take po.
• Complications:
– Perinephric/Renal abscess:
• Suspect in patient who is not improving on antibiotic therapy.
• Diagnosis: CT with contrast, renal ultrasound
• May need surgical drainage.
– Nephrolithiasis with UTI
• Suspect in patient with severe flank pain
• Need urology consult for treatment of kidney stone
• Septicemia
Prostatitis
• Symptoms:
– Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
• Diagnosis:
– Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
– The finding of an edematous and tender prostate on physical
examination
– Will have an increased PSA (Prostat Specific Antigen)
– Urinalysis, urine culture
• Treatment:
– Trimethoprim/sulfamethoxazole, fluroquinolone or other broad
spectrum antibiotic
– 4-6 weeks of treatment
• Risk Factors:
– Trauma
– Sexual abstinence
– Dehydration
Urethritis
• Chlamydia trachomatis
– Frequently asymptomatic in females, but can present with dysuria,
discharge or pelvic inflammatory disease.
– Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
– Pelvic exam – send discharge from cervical or urethral os for chlamydia
PCR
– Chlamydia screening is now recommended for all females ≤ 25 years
– Treatment:
• Azithromycin – 1 g po x 1
• Doxycycline – 100 mg po BID x 7 days
• Neisseria gonorrhoeae
– May present with dysuria, discharge, PID
– Send UA, urine culture
– Pelvic exam – send discharge samples for gram stain, culture, PCR
– Treatment:
• Cipro – 500 mg po x 1
• Levofloxacin – 250 mg po x 1
• Ofloxacin – 400 mg po x 1
Diagnostic Testing
 Proteinuria, pyuria, hematuria microskopis are usually
found in urinalysis, glomerular cast is a sign for
pyelonephritis.
 The urine culture is an important diagnostic procedure
to determine the type and number of bacteria in urine.
 Microscopic bacteriuria which is best assessed with
Gram-stained urine seiment, is found in 90% of
specimens from patients whose infections are
associated with colony counts of at least 105/mL, and
this finding is very specific.
 Urine culture and antimicrobial susceptibility testing.
 Ultrasound exam to look for stones and obstruction.
 BNO – IVP to look for structural abnormality.
PREVENTIONS
 Women who experience frequent symptomatic UTIs (3
per year on average) are candidates for long-term
administration of low-dose antibiotics directed at
preventing recurrences.
 Such women should be advised to avoid spermicide use
and to void soon after intercourse. Daily or thrice-weekly
administration of a single dose of TMP-SMX (80/400 mg).
 Prophylaxis should be initiated only after bacteriuria has
been eradicated with a full-dose treatment regimen.
 All pregnant women should be screened for bacteriuria in
the first trimester and should be treated if bacteriuria is
demonstrated.
Preventions - 2
• Drink plenty of liquids, especially water.

• Wipe from front to back. Doing so after urinating and
after a bowel movement helps prevent bacteria in the
perineum from spreading to the vagina and urethra.
• Voiding as soon as possible after intercourse
• Avoid potentially irritating feminine products.
Obstructive:
1. Benign Prostate
Hyperplasia
2. Urolithiasis
What is the Prostate?
• Walnut sized gland at base

of male bladder
• Surrounds the urethra
• Produces fluid that
transports sperm during
ejaculation
• Prostate grows to its normal
adult size in a man’s early
20s; it begins to grow again
during the mid-40s
Normal vs. Enlarged Prostate
• As the prostate enlarges,

pressure can be put on the
urethra causing lower
urinary tract symptoms
(LUTS)
• Prostate size does not
correlate with degree of
obstruction or severity of Normal Prostate Enlarged Prostate
symptoms.
Symptoms of BPH (LUTS)
• Frequent urination during the day and/or night

• Sudden urge to urinate
• Burning, painful urination
• Weak urine flow
• Sensation the bladder is not empty after urination
• Inability to urinate
• Trouble stopping and starting of urine flow
BPH Can Affect Quality of Life
Many men who suffer from BPH may

experience a reduction in quality of life.
• Up to 95% of men with moderate symptoms
are unhappy and don’t want to spend the
rest of their life with these symptoms
• 51% of men say BPH interferes with one
aspect of their normal life
• Studies show 49% of men experience
sexual problems associated with LUTS
• BPH also affects men’s partners quality of
life, daily routines and relationships
How Does BPH Affect Quality of Life?
How is an Enlarged Prostate Diagnosed?
• Medical History
• Physical Exam*
‒ Prostate Exam
• Digital rectal exam (DRE)
‒ Urinary Output Testing
• Peak urinary flow (Qmax) testing
• Post-void urine volume testing
‾ Ultrasound
*Additional testing is optional and may be done at physician’s discretion and/or depending on patient symptoms
Treatment Options Overview
WATCHFUL WAITING/ MINIMALLY INVASIVE INVASIVE

MEDICAL THERAPIES SURGERY SURGERY
Alpha Blockers: Transurethral
Doxazosin Microwave Therapy Open Prostatectomy
Silodosin (TUMT)
Prazosin Involves the use of a
Tamsulosin (Harnal) microwave antennae
Terazosin mounted on a urethral
Relaxed prostate catheter to heat the
muscle prostate
5 Alpha-Reductase Transurethral
Inhibitors: Resection of the
Finastride Prostate (TURP)
Dutasteride (Avodart) Uses electricity to
Inhibits testosteron superheat a thin metal
conversion to band that cuts the
dihydrotestosteron prostate tissue into small
(DHT) chunks
Urolithiasis
Urolithiasis is the condition where urinary stones are formed or

located anywhere in the urinary system.
 The lower the economic status, the lower the likelihood of
renal stones
 Most at 20-49 years
 Peak incidence at 35-45 years
 Male-to-female ratio of 3:1
•cause abrupt, severe, colicky pain in the flank and
ipsilateral lower abdomen
• With radiation to the testicles or the vulvar area
• Intense nausea, with or without vomiting, usually is
present
Physical exam
 Dramatic costovertebral angle tenderness
 unremarkable abdominal evaluation
 painful testicles but normal-appearing
 constant body positional movements (eg,
writhing, pacing)
 Tachycardia
 Hypertension
 Microscopic or gross hematuria
Imaging studies
 Renal ultrasonography:
 Renal stone
 Hydronephrosis or ureteral dilation
 Misses 30 % of stones
 Plain abdominal radiograph (flat plate or KUB) misses 40 % of
stones
Management
 IV access to allow :
 Fluid
 Analgesics:
 Paracetamol
 NSAID
 Opiod
 Antiemetic
 Analgesic suppositoria
 In case of infection:
 Urine culture
 Blood culture accordingly e.g. febrile
 Antibiotics
Complication
 The most morbid and potentially dangerous aspect of
stone disease is the combination of urinary tract
obstruction and upper urinary tract infection.
 Pyelonephritis
 Pyonephrosis
 Urosepsis
 Early recognition and immediate surgical drainage are
necessary in these situations
 Obstruction relief:
 Ureteral stent insertion
 Percutaneous nephrostomy
 Definitive surgical treatment:
 Extracorporeal Shockwave Lithotripsy
(ESWL)
 Ureteroscopic Lithotripsy
 Percutaneous Nephrolithotomy
(PCNL)
 Open, laparoscopic and robotic pyelo-
lithotomy, ureterolithotomy,
cystolithotomy
 Open anatrophic nephrolithotomy
References
Comprehensive Clinical Nephrology, 5e, by Richard J. Johnson MD and Feehally DM FRCP.
Buku Ilmu Penyakit Dalam, FKUI
Roehrborn, C. Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and

Natural History. Campbell-Walsh Urology Tenth Edition. Philadelphia, PA: Saunders, an
Imprint of Elsevier, Inc.; 2012;91:2579
BPH-00977(2)b/March 2014

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Elderly Urinary Tract

Epidemiologically UTI’s are sub divided into:

1. Cathether-associated or nosocomial infections

• Gender and sexual activity

Older children or an adult may experience the

• Drink plenty of liquids, especially water.

• Walnut sized gland at base

• As the prostate enlarges,

• Frequent urination during the day and/or night

Many men who suffer from BPH may

WATCHFUL WAITING/ MINIMALLY INVASIVE INVASIVE

Urolithiasis is the condition where urinary stones are formed or

Buku Ilmu Penyakit Dalam, FKUI

Roehrborn, C. Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and

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