11

Urinary Tract Urinary Tract Infection/ISKInfection/ISK

22

33

Urinary Tract Urinary Tract Infection/ISKInfection/ISK

Berkembang biaknya mikro organisme di Berkembang biaknya mikro organisme di dalam saluran kencing.dalam saluran kencing.

Urin: Piuria(lekosit urin>10/LPB)pd urin Urin: Piuria(lekosit urin>10/LPB)pd urin sentrifus,lekosit urin porsi tengah 2000/ml atau sentrifus,lekosit urin porsi tengah 2000/ml atau 200.000/jam (hrs dihindari kontaminasi).200.000/jam (hrs dihindari kontaminasi).

Bila yg diperiksa aspirasi kandung Bila yg diperiksa aspirasi kandung kemih,adanya 800/ml dianggap infeksi.kemih,adanya 800/ml dianggap infeksi.

Hematuri:juga dpt terjadi pd ISK/bukan jenis Hematuri:juga dpt terjadi pd ISK/bukan jenis glomeruler(+bila >5/LPB)glomeruler(+bila >5/LPB)

Proteinuri:pd pielonefritis akut/kronik a.tetapi Proteinuri:pd pielonefritis akut/kronik a.tetapi tdk selalu bermakna infeksi. tdk selalu bermakna infeksi.

44

Urinary Tract Urinary Tract Infection/ISKInfection/ISK

Bakteriuria:Bakteriuria: Dasar diagnosis ISK,dg biakan/tanpa Dasar diagnosis ISK,dg biakan/tanpa

kontaminasi.kontaminasi. Pada penelitian adanya kuman hasil Pada penelitian adanya kuman hasil

biakan 100.000 koloni/ml berarti(+).biakan 100.000 koloni/ml berarti(+).

55

Lokasi ISKLokasi ISK

• ATAS:ginjal/pyelonefritis, dan ATAS:ginjal/pyelonefritis, dan intrarenal,abses renal,dg gejalaintrarenal,abses renal,dg gejala

• sakit pinggang,suhu sakit pinggang,suhu tinggi,mual,muntah,hematuria.tinggi,mual,muntah,hematuria.

• BAWAH: uretritis,cystitis,prostatitis.dg BAWAH: uretritis,cystitis,prostatitis.dg gejalagejala

• sering kencing,disuria,nyeri supra sering kencing,disuria,nyeri supra pubik.pubik.

66

Urinary Tract InfectionUrinary Tract Infection

LowerLower

urethritis/uretraurethritis/uretra

cystitiscystitis

prostatitisprostatitis

UpperUpper

pyelonephritispyelonephritis

intrarenal and intrarenal and perinephric abscessperinephric abscess

77

Urinary Tract InfectionUrinary Tract Infection

Urinary tract infection—most common source of Urinary tract infection—most common source of bacteremia, a dangerous systemic infection in bacteremia, a dangerous systemic infection in long-term care facilitieslong-term care facilities

Bacteremia—40 times more likely to occur in Bacteremia—40 times more likely to occur in catheterized than non-catheterized residentscatheterized than non-catheterized residents

Bacteremia leads to significant morbidity and Bacteremia leads to significant morbidity and mortality in the vulnerable elderlymortality in the vulnerable elderly

Nicolle, 2005Nicolle, 2005

Sorc smbr Vul snstf

88

History & Physical History & Physical ExaminationExaminationAge-related Risk Factors for UTIAge-related Risk Factors for UTI

Advanced AgeAdvanced Age Fecal incontinence/impactionFecal incontinence/impaction Incomplete bladder emptying or neurogenic bladderIncomplete bladder emptying or neurogenic bladder Vaginal atrophy/estrogen deficiencyVaginal atrophy/estrogen deficiency Insufficient fluid intake/dehydrationInsufficient fluid intake/dehydration Indwelling foley catheter or urinary catheterization or Indwelling foley catheter or urinary catheterization or

instrumentation proceduresinstrumentation procedures

Impckt pnguh kuwt

99

Urinary Tract InfectionUrinary Tract Infection

Pathogenic Pathogenic microorganisms in urine, microorganisms in urine, urethra, bladder, kidney, urethra, bladder, kidney, prostateprostate

Usually growth > 10Usually growth > 1055 organisms per milliliterorganisms per milliliter

From midstream “ clean From midstream “ clean catch” urine samplecatch” urine sample

If from catheter specimen If from catheter specimen can be significant with 10can be significant with 1022 or 10or 1044 organisms per mL organisms per mL

1010

EtiologyEtiology

Most common is Gram neg. bacteriaMost common is Gram neg. bacteria E. coli = 80% of uncomp. acute UTIE. coli = 80% of uncomp. acute UTI Proteus – assoc. with stonesProteus – assoc. with stones Klebsiella – assoc. with stonesKlebsiella – assoc. with stones EnterobacterEnterobacter SerratiaSerratia PseudomonasPseudomonas

1111

EtiologyEtiology

Gram pos. cocciGram pos. cocci Staphylococcus saprophyticus 10-15 % Staphylococcus saprophyticus 10-15 %

acute UTI in young femalesacute UTI in young females Enterococci – occas. in acute uncomp. Enterococci – occas. in acute uncomp.

cystitiscystitis Staphylococcus aureus – assoc. with renal Staphylococcus aureus – assoc. with renal

stones, instrumentation, increased susp. of stones, instrumentation, increased susp. of bacteremic kidney infectionbacteremic kidney infection

1212

EtiologyEtiology

Urethritis from chlamydia, gonorrhea, – Urethritis from chlamydia, gonorrhea, – acute symp female with sterile pyuriaacute symp female with sterile pyuria

Candida or other fungal species – Candida or other fungal species – commonly assoc. with cath. or DMcommonly assoc. with cath. or DM

MycobacteriaMycobacteria

1313

BENTUK KHUSUS ISKBENTUK KHUSUS ISK ISK BERULANG:sumbatan saluran ISK BERULANG:sumbatan saluran

kemih:batu,tumor,prostat,kehamilankemih:batu,tumor,prostat,kehamilan

ISK BERKOMPLIKASI:kelainan struktur,dg gejala ISK BERKOMPLIKASI:kelainan struktur,dg gejala panas sp sepsis,gg panas sp sepsis,gg akut,kejang,terapi:penambahan akut,kejang,terapi:penambahan cairan,elektrolit,nutrisi.cairan,elektrolit,nutrisi.

ISK PADA DM(10-50%):neuropati /aliran air ISK PADA DM(10-50%):neuropati /aliran air kemih,angiopati /kelainan pembuluh darah.prinsip kemih,angiopati /kelainan pembuluh darah.prinsip pd DM kuman lebih mudah pd DM kuman lebih mudah berkembang.Penanganan dg anti biotik sesuai k/s berkembang.Penanganan dg anti biotik sesuai k/s selama 14 hari,kendalikanDM.selama 14 hari,kendalikanDM.

BENTUK KHUSUS ISKBENTUK KHUSUS ISK ISK PADA MANULA:ok proses ISK PADA MANULA:ok proses

fisiologis,frekuensi meningkat.ok fisiologis,frekuensi meningkat.ok perubahan degeneratif,imunologi,sekresi perubahan degeneratif,imunologi,sekresi menurun,hipertrofi prastat,prolaps menurun,hipertrofi prastat,prolaps uteri,nutrisi,hipertensi,pengobatan uteri,nutrisi,hipertensi,pengobatan sama,sesuaikan,karena fungsi ginjal sama,sesuaikan,karena fungsi ginjal berkurang.berkurang.

ISK pd KEHAMILAM:yg asimptome 40% Dpt ISK pd KEHAMILAM:yg asimptome 40% Dpt mengalami PNA/Pyelo Nefr.Akut.Perubahan mengalami PNA/Pyelo Nefr.Akut.Perubahan hormonal,fungsi ginjal.Kelahiran hormonal,fungsi ginjal.Kelahiran prematur,pengelolaan sama. prematur,pengelolaan sama.

1414

1515

PathogenesisPathogenesis

Usually ascent of bacteria from urethra to Usually ascent of bacteria from urethra to bladder to kidneybladder to kidney

Vaginal introitus, distal urethra colonized Vaginal introitus, distal urethra colonized by normal floraby normal flora

Gram negative bacilli from bowel may Gram negative bacilli from bowel may colonize at introitus, periurethracolonize at introitus, periurethra

AscendingAscending

Dari uretra,-ves.urinaria-ginjal.Dari uretra,-ves.urinaria-ginjal.

Penyebab tersering terjadinya ISK.ok Penyebab tersering terjadinya ISK.ok penyebaran bakteri melalui cara ini kurang penyebaran bakteri melalui cara ini kurang menjaga kebersihan,inkontinensia urine,Jarak menjaga kebersihan,inkontinensia urine,Jarak uretra-anal yg dekat(Hvidberg et al.2000.)uretra-anal yg dekat(Hvidberg et al.2000.)

HematogenHematogenSistem imun yg rendah,mempermudah penyebaran infeksi secara hematogen,ada beberapa hal yg mempengaruhi struktur dan fungsi ginjal,mepermudah penyebaran,yi penumpukan urine ,distensi kandung kemih,bendungan intra renal.

1616

LIMFOGENLIMFOGEN

Penyebaran bakteri secara langsung dari Penyebaran bakteri secara langsung dari organ yg letakya berdekatan melalui jalur organ yg letakya berdekatan melalui jalur limfatik.Seperti infeksi usus besar yg limfatik.Seperti infeksi usus besar yg berat atau abses retro peritoneal(jarang berat atau abses retro peritoneal(jarang terjadi(Gillenwater et al.,2002).terjadi(Gillenwater et al.,2002).

1717

1818

Routes of bacterial invasion

1. Ascending• common

2. Hematogenous• staphylococcus

• mycobacterium tuberculosis

• salmonella

3. Lymphatic: rare

BJN-T3x

1919

Host defences

1. Bladder • bladder emptying• mucosal phagocytes

2. Antibacterial substances3. Anti-adherence

mechanisms• kidney, bladder &

prostatic secretions

BJN-T3x

2020

??

Predisposing conditions to Predisposing conditions to UTIUTI

FemaleFemale Short urethra, proximity to anus, termination Short urethra, proximity to anus, termination

beneath labiabeneath labia Sexual activitySexual activity

PregnancyPregnancy 2-3% have UTI in preg, 20-30% with asx bacteriuria 2-3% have UTI in preg, 20-30% with asx bacteriuria

may lead to pyelo may lead to pyelo Increased risk of pyelo = decreased ureteral tone, Increased risk of pyelo = decreased ureteral tone,

decreased ureteral peristalsis,decreased ureteral peristalsis,

2121

??

Predisposing conditionsPredisposing conditions

Neurogenic bladder dysfunction or bladder Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying)diverticulum (incomplete emptying)

Age - Postmenopausal women with uterine or Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, of estrogen, decreased normal flora, concomitant medical conditions such as DMconcomitant medical conditions such as DM

Vesicoureteral refluxVesicoureteral reflux Bacterial virulenceBacterial virulence GeneticsGenetics Change in urine nutrients, DM.Change in urine nutrients, DM.

2222

Urethritis Urethritis ??

Acute dysuria, frequencyAcute dysuria, frequency Often need to suspect sexually Often need to suspect sexually

transmitted pathogens esp. if sx more transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic than 2 days, no hematuria, no suprapubic pain,pain,

2323

Cystitis/inf.bladderCystitis/inf.bladder

Sx: frequency, dysuria, urgency, Sx: frequency, dysuria, urgency, suprapubic painsuprapubic pain

Cloudy, malodorous urine (nonspec.)Cloudy, malodorous urine (nonspec.) Leukocyte esterase positive = pyuriaLeukocyte esterase positive = pyuria Nitrite positive (but not always)Nitrite positive (but not always) WBC (2-5 with sx) and bacteria on urine WBC (2-5 with sx) and bacteria on urine

microscopymicroscopy

2424

PyelonephritisPyelonephritis

FeverFever chills, diarrhea, tachycardia, gen. muscle chills, diarrhea, tachycardia, gen. muscle

tenderness tenderness

Tenderness with deep abdominal Tenderness with deep abdominal tendernesstenderness

Possibly signs of Gram neg. sepsisPossibly signs of Gram neg. sepsis

2525

??

PyelonephritisPyelonephritis

LeukocytosisLeukocytosis Pyuria with leukocyte casts, and bacteria Pyuria with leukocyte casts, and bacteria

and hematuria on microscopyand hematuria on microscopy Complications: sepsis, papillary necrosis, Complications: sepsis, papillary necrosis,

ureteral obstruction, abscess, decreased ureteral obstruction, abscess, decreased renal function if scarring from chronic renal function if scarring from chronic infection, in pregnancy – may increase infection, in pregnancy – may increase incidence of preterm laborincidence of preterm labor

2626

Catheter-Catheter-Associated Associated ?? Urinary Tract InfectionsUrinary Tract Infections

10-15% of hosp. patients with indwelling 10-15% of hosp. patients with indwelling catheter develop bacteriuriacatheter develop bacteriuria

Risk of infection is 3-5% per day of Risk of infection is 3-5% per day of catheterizationcatheterization

UTI after one-time bladder cath approx. 2%UTI after one-time bladder cath approx. 2% Gram neg. bacteremia most significant Gram neg. bacteremia most significant

complication of cath-induced UTIcomplication of cath-induced UTI Greater antimicrobial resistanceGreater antimicrobial resistance

2727

Diagnosis of UTIDiagnosis of UTI

HistoryHistory Physical examPhysical exam LabLab

Urinalysis with micro = WBC, bacteriaUrinalysis with micro = WBC, bacteria Urine culture Urine culture Sensitivities of culture for tailored antibiotic therapySensitivities of culture for tailored antibiotic therapy May dx acute uncomp. cystitis based on hx, PxExm, May dx acute uncomp. cystitis based on hx, PxExm,

no need for culture to treatno need for culture to treat

2828

DiagnosisDiagnosis

UrinalysisUrinalysis Leuk. pos. = pyuriaLeuk. pos. = pyuria Nitrite pos. from urea prod. bact. (but not Nitrite pos. from urea prod. bact. (but not

always)always) Micro – WBC (even 2-5 in patient with sx)Micro – WBC (even 2-5 in patient with sx) Micro – BacteriaMicro – Bacteria

2929

DiagnosisDiagnosis

Urine cultureUrine culture Once 10Once 1055 colonies per mL considered colonies per mL considered

standard for dx but misses up to 50%standard for dx but misses up to 50% Now, 10Now, 1022 to 10 to 1044 accepted as significant if accepted as significant if

patient symptomaticpatient symptomatic Needed in upper UTI, comp. UTI, and in Needed in upper UTI, comp. UTI, and in

failed treatment or reinfectionfailed treatment or reinfection Sensitivities for better tailoring of txSensitivities for better tailoring of tx

3030

Treatment Treatment ??

Uncomp. cystitis with less than 48 hours Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx of sx, non-pregnant, usu. 3 days tx sufficientsufficient Bactrim Bactrim Cipro or other FQ (avoid in preg.)Cipro or other FQ (avoid in preg.) Nitrofurantoin (7 days)Nitrofurantoin (7 days) AugmentinAugmentin Bladder analgesis, PyridiumBladder analgesis, Pyridium

3131

TreatmentTreatment

Uncomp. cystitis in pregnant patientUncomp. cystitis in pregnant patient Requires longer tx of 7-14 daysRequires longer tx of 7-14 days Cephalosporin, nitrofurantoin, augmentin, Cephalosporin, nitrofurantoin, augmentin,

sulfonamides.sulfonamides.

3232

AsymptomaticAsymptomatic ?? BacteriuriaBacteriuria

101055 org/mL growth org/mL growth Empiric treatment of all asymptomatic Empiric treatment of all asymptomatic

bacteriuria in pregnancy. bacteriuria in pregnancy.

3333

Asymptomatic Asymptomatic BacteriuriaBacteriuria

Treatment failures: repeat tx based on Treatment failures: repeat tx based on sensitivities for 1 week, then prophylactic sensitivities for 1 week, then prophylactic therapy for remainder of pregnancytherapy for remainder of pregnancy

Prophylaxis: Nitrofurantoin, Ampicillin, Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMXTMP/SMX

3434

TreatmentTreatmentRecurrent uncomp. UTIRecurrent uncomp. UTI

3 or more episodes in one year, 2 in 6 3 or more episodes in one year, 2 in 6 monthsmonths

Bactrim QD for 3-6 months. Single dose Bactrim QD for 3-6 months. Single dose at symptom onset or one tab post-coitusat symptom onset or one tab post-coitus

Measures for prevention: voiding after Measures for prevention: voiding after intercourse, good hydration, frequent and intercourse, good hydration, frequent and complete voidingcomplete voiding

3535

Management RUTIManagement RUTI (Conceptual Model)(Conceptual Model)

RUTIRecurent

VUR(VU Reflux)

RENALSCARRING

End Stage Renal Disease

Pre-eclampsia

Hypertension

Prophylactic antibiotics prevent recurrent UTI

Surgery corrects VUR

3636

Reinfection Vs RelapsReinfection Vs Relapsee

• ReinfectionReinfection : : RRUTI caused by different pathogen UTI caused by different pathogen any time or original infecting strain >13 days any time or original infecting strain >13 days after of original UTIafter of original UTI

• RelapsRelapsee : recurrent UTI caused by same species : recurrent UTI caused by same species causing original UTI w/in 2 wks after therapy causing original UTI w/in 2 wks after therapy

• UncomplicatedUncomplicated : UTI in host w : UTI in host withithout underlying out underlying renal or neurologic diseaserenal or neurologic disease

• ComplicatedComplicated : UTI in setting of underlying : UTI in setting of underlying structural, medical or neurologic diseasestructural, medical or neurologic disease

3737

PathogenesisPathogenesis

• The pathogenesis of recurrent UTI is The pathogenesis of recurrent UTI is assumed to be the same as with assumed to be the same as with sporadic infection.sporadic infection.

• Most uropathogens originate in the Most uropathogens originate in the rectal flora, colonize the periurethral rectal flora, colonize the periurethral area and urethra, and ascend to the area and urethra, and ascend to the bladder.bladder.

• Hematogenous spread to kidney is Hematogenous spread to kidney is rare.rare.

3838

• Changes in behavior Changes in behavior

• Contraception Contraception

• Postcoital voiding and liberal fluid intake  Postcoital voiding and liberal fluid intake 

• Cranberry/strawberries juiceCranberry/strawberries juice

Management of RUTIManagement of RUTI

1.1. One effective approach: prevention of infection One effective approach: prevention of infection through the use of long-term, prophylactic through the use of long-term, prophylactic antimicrobials (at least 6 monthsantimicrobials (at least 6 months ) )

2. Initial prevention of UTI as a way of minimizing antibiotic exposure

3939

Antimicrobial prophylaxisAntimicrobial prophylaxis

• It has been demonstrated to be highly effective in reducing the risk of recurrent UTI in women

• Advocated for women who experience two or more symptomatic UTIs within six months or more over 12 months :- Continuous prophylaxis

- Postcoital prophylaxis

- Self-treatment   

4040

Frequent UTI

Patient education

Failed prior antibiotic prophylaxis OrRelapse?

(Same organism w/in 2 weeks of previous UTI)

Episodes related to intercourse

Initiated 3 day antibiotic regimen

3 or more episodes/year

Daily / thrice weekly prophylaksis:

•TMP 100 mgor TMP/Sx 40/200 mg

•Cephalexin 250 mg

•Nitrofurantoin 50-100mg

Post coital single-dose prophylaxis:

•TMP/Sx 40/200 mg

•Cephalexin 250 mg

•Nitrofurantoin 50-100mg

Seek occult source (IVP or renal ultrasoundonsider Urology referral

Treat longer (2-6 weeks)

Guidelines for Uncomplicated and Recurrent Urinary Tract Infection

Sentara Healthcare (SHC), Optima Health. 2007

yes

No

yes

yes

No

No

4141

Treatment of Pyelonephritis Treatment of Pyelonephritis -- Outpatient-- Outpatient

Uncomp. Nonpreg pyeloUncomp. Nonpreg pyelo Primary – any FQ x 7 days, ciproPrimary – any FQ x 7 days, cipro Alt. -- Augmentin, TMP/SMX, for 14 daysAlt. -- Augmentin, TMP/SMX, for 14 days

4242

Treatment ofTreatment ofPyelonephritis – Inpatient Pyelonephritis – Inpatient ??

Treat IV until patient is afebrile 24-48 hours. Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO medsThen, complete 2 week course with PO meds

Use FQ or amp/gent or ceftriaxone or Use FQ or amp/gent or ceftriaxone or piperacillinpiperacillin

If no improvement on IV, consider imaging If no improvement on IV, consider imaging studies to look for abscess or obstructionstudies to look for abscess or obstruction

All pregnant patients with pyelo get inpatient tx, All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediatelyappropriate IV antibiotics immediately

4343

Treatment of Treatment of Complicated UTIComplicated UTI

Catheter relatedCatheter related Amp/gent or Zosyn or ticaricillin/clav or Amp/gent or Zosyn or ticaricillin/clav or

imipenem or meropenem x 2-3 weeksimipenem or meropenem x 2-3 weeks Switch to PO FQ or TMP/SMX when Switch to PO FQ or TMP/SMX when

possiblepossible Rule out obstructionRule out obstruction Watch out for enterococci and Watch out for enterococci and

pseudomonaspseudomonas

4444

Nephrolithiasis Nephrolithiasis ??

Supersat. of urine by stone forming Supersat. of urine by stone forming constituentsconstituents

Crystals of foreign bodiesCrystals of foreign bodies Freq. stone types: Calcium (most Freq. stone types: Calcium (most

common), struvite, oxalate, uric acid, common), struvite, oxalate, uric acid, staghornstaghorn

Risk factors: metabolic disturbances, Risk factors: metabolic disturbances, previous UTI, gout, geneticprevious UTI, gout, genetic

4545

NephrolithiasisNephrolithiasis

Incidence = 2-3%Incidence = 2-3% MorbidityMorbidity

Obstruction Obstruction pain pain Chronic obstruction, may be asx Chronic obstruction, may be asx loss of loss of

renal functionrenal function Hematuria (rarely dangerous by itself)Hematuria (rarely dangerous by itself) Dangerous combo = obstruction + infectionDangerous combo = obstruction + infection

4646

Nephrolithiasis Nephrolithiasis ??

More prev. in Asians and whitesMore prev. in Asians and whites Males > females, 3:1Males > females, 3:1 Struvite stones – from infection, Struvite stones – from infection,

increased in femalesincreased in females Ages 20-49Ages 20-49 RecurrentRecurrent Uncommon after 50 y.o.Uncommon after 50 y.o.

4747

NephrolithiasisNephrolithiasisPatient History Patient History

??

Often dramatic pain, poss. infection, Often dramatic pain, poss. infection, hematuriahematuria

Even nonobst. May cause sxEven nonobst. May cause sx Bladder irritating sxBladder irritating sx Renal colic because of stone in ureterRenal colic because of stone in ureter

Severe, undulating cramps because of Severe, undulating cramps because of ureter peristalsis, sever pain,ureter peristalsis, sever pain,

Pain may migratePain may migrate

4848

NephrolithiasisNephrolithiasisPatient HistoryPatient History

Duration, char, location of painDuration, char, location of pain Hx of stones?Hx of stones? UTI?UTI? Loss of renal function?Loss of renal function?

4949

NephrolithiasisNephrolithiasisPhysical ExamPhysical Exam

Dramatic, may migrate as stone movesDramatic, may migrate as stone moves Usu. Lacking peritoneal signsUsu. Lacking peritoneal signs Calculus often in area of maximum Calculus often in area of maximum

discomfortdiscomfort

5050

NephrolithiasisNephrolithiasisWorkupWorkup

UrinalysisUrinalysis Evid. Of hematuria and infectionEvid. Of hematuria and infection 24-hour urinalysis helpful in identifying 24-hour urinalysis helpful in identifying

causecause

Uric acid.Uric acid. Calcium, oxalate, uric acid in the 24 hour Calcium, oxalate, uric acid in the 24 hour

urineurine

5151

NephrolithiasisNephrolithiasisWorkupWorkup

Plain abd filmPlain abd film Renal USGRenal USG IVPIVP Helical CT without contrast (stone Helical CT without contrast (stone

protocol)protocol)

5252

NephrolithiasisNephrolithiasisTreatmentTreatment

If no obstruction or infection, stones < 5-If no obstruction or infection, stones < 5-6mm may likely pass6mm may likely pass

Restore fluid volume if dehyd.Restore fluid volume if dehyd. Analgesics – narcotics, nsaidsAnalgesics – narcotics, nsaids AntiemeticsAntiemetics Occasionally nifedipine to relax ureteral Occasionally nifedipine to relax ureteral

smooth muscle and prednisone usedsmooth muscle and prednisone used Urology consultUrology consult

5353

NephrolithiasisNephrolithiasis

Treatment Treatment ??

Surgical intervention (call urology)Surgical intervention (call urology) Extracorporeal shock-wave lithotrypsy (not in Extracorporeal shock-wave lithotrypsy (not in

pregnancy)pregnancy) Ureteral stentUreteral stent Percutaneous nephrostomyPercutaneous nephrostomy UreteroscopyUreteroscopy Indications = pain, infection, obstructionIndications = pain, infection, obstruction Contraindications = active untx infection, Contraindications = active untx infection,

uncorrected bleeding diathesis, uncorrected bleeding diathesis, pregnancy (relative)pregnancy (relative)

5454

NephrolithiasisNephrolithiasisProphylaxis Prophylaxis

Increase fluid intake (2 liters per day)Increase fluid intake (2 liters per day) 24 hour urine, eval calcium, oxalate, uric 24 hour urine, eval calcium, oxalate, uric

acid to determine dietary preventionacid to determine dietary prevention metabolic tests to determine cause (Ex: metabolic tests to determine cause (Ex:

hyperparathyroidism)hyperparathyroidism) Decrease salt intakeDecrease salt intake

THE END

5555

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