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CASE STUDY 9 Urinary Tract Infection

Dated: 20 September 2007 (edited 4 December 2007)
Patient’s Name: Ong C.B. NIRC: S05*****C

TABLE OF CONTENTS
Page
1. Patient Profile 2
2. Health Assessment 2
3. Physical Examination 3
4. Diagnosis 4
5. Management 4
6. Evaluation 6
7. Learning Points 6

Mr Owen Ong, an 80 year old man, with a background history of detrusor instability and benign
prostrate hypertrophy came to the polyclinic on 7 June 2007 with chief complaint of dysuria and
urine hesistancy for 3 weeks. This case study will focus on the approach to an elderly man with
dysuria.

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PATIENT PROFILE
Mr Owen Ong (S05*****C) is an 80 year old man who had been following up in Hougang
polylcinic for diabetes mellitus, hypertension, hyperlipidemia and proteinuria since year 2002.
He was diagnosed recently in March by TTSH having benign prostatic hypertrophy and detrusor
instability. Tablet Oxybutynin 5mg twice a day was prescribed to him and he was discharged
back to the polyclinic with an open date back to TTSH Urology department. He came to the
polyclinic on 7 June 2007 with chief complaint of dysuria and urine hesistancy for 3 weeks.
This case study will focus on the approach of dysuria in elderly man and discuss the management
of suspected urinary tract infection

DRUG ALLERGY: Not known.

HEALTH HISTORY
Chief Complains: Mr Ong complained of pain at start of micturation and urine hesitancy for 3
weeks. This is associated with penile “peeling” (excoriation). Patient was started on Oxybutynin
5mg twice a day by TTSH in March 2007. He stopped taking the medications 2 weeks after SOC
discharge as his urinary symptoms were better. When the micturation pain and hesitancy
occurred 3 weeks ago, he restarted back on Oxybutynin 5mg. The dysuria worsened on
consumption. There are no urethral discharges. He did not experience any back pain, suprapubic
pain, scrotal pain nor perineal pain. The colour of the urine is normal

There was no fever, chills, nausea or vomiting. Systemic review showed no significant findings.
Mr Ong has a history of detrusor instability and benign prostatic hyperplasia.

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PHYSICAL EXAMINATION
General appearance – Looks comfortable. Temperature: 36.8 degree Celsius.
Nail beds – No pallor nor clubbing seen. Implying no peripheral cyanosis.
Tongue – Moist and pink. Implying not dehydrated and no central cyanosis.

a) CVS examination
Pulse – 72 beats per minute. Regular in rhythm.
Blood Pressure – 140/ 80mmHg.
Heart – Apex beat palpable between 4th and 5th ribs space. No thrills and heave felt. S1 and S2
sounds heard. No murmurs detected. Jugular venous pressure not raised. No pedal edema.
b) Lungs examination
Lungs – Chest expansion bilaterally equal. Vesicular breath sounds heard. There are no wheezes
or rhonchi.
c) Abdomen examination
Abdomen – Abdomen soft and non-tender. There is no organomegaly. Kidneys are non-
ballotable. Renal punch is negative and there is no costovertebral tenderness, which implies low
likelihood of pyelonephritis. His bladder is non-palpable, indicating no obvious or gross urinary
retention. Digital rectal examination reveals a prostrate of 2 and half finger width, which is
smooth and non-boggy in nature. This finding suggests of an enlarged prostrate which is not
grossly malignant nor inflammed.
d) Others
Examination of the penis is normal. There are no discharges or lesions. Thus allowing me having
a low index of suspicion for the presence of Sexually Transmitted Diseases (STD) and urethritis.
Testicular swelling and tenderness are absent.

Laboratory Tests
Urinalysis reveals: Protein negative; Glucose negative; White Blood Cells (WBC) 297; Red
Blood Cells (RBC) 25; Epithelial Cells (EC) 5; Crystals and casts not seen and few micro
organism.
Urine aerobic culture sent off, results pending.

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DIAGNOSES
Probable diagnosis: Urinary tract infection secondary to Benign Prostatic Hyperplasia causing
urinary obstruction and retention worsened by antispasmodic agent.
Differential diagnoses include: Prostatitis

MANAGEMENT
Prevalence. Disturbances of micturition is a common problem in general practice. Dysuria counts
for 5 to 15 percent of visits to family physicians (Bremnor and Sadovsky, 2002). These
symptoms are three times more common in women then in men. The combination of dysuria and
frequency is the most common of the symptoms with a female to male ratio of 5 to 1 (Murtuagh,
2006). Thus, when a male complained of dysuria with urinary hesitancy, it has to be taken much
more into serious consideration. Especially in men over 40 years old, due to the increasing
incidence of enlarged prostrate (abnormalities in urinary anatomy) which will complicate urinary
tract infection as in Mr Ong’s case.

Approach to dysuria. In the primary care setting, any complaint of dysuria should follow by a
detail history on the timing, frequency, severity and location of dysuria (Bremnor and Sadovsky,
2002 and Roberts and Hartlaub, 1999). Differentiating the dysuria be it on initial urination or
after voiding is important as urethral inflammation usual presents as pain on onset of urination
while bladder inflammation or infection will present as the latter. It is important to inquire about
obstructive symptoms such as weak stream, hesitancy, intermittency and dribbling which had
been left out during this case. Noting the degree of obstruction is important as it might indicate
the severity of the problem. In the history, other symptoms might give indication to different
diagnosis: rectal pain or perineal aching might indicate prostatitis; urethral discharge may
indicate sexually transmitted disease. Presence of urethral discharge requires determining the
color, type and amount of discharges. Sexual history, will also be needed in the approach in such
instances. A brief questionnaire of the various systemic symptoms on the side of caution to
exclude dysuria due to systemic causes such as autoimmune conditions like spondyloarthropathy
is helpful (Roberts and Hartlaub, 1999).

Physical examination of the abdomen can provide information of possible kidney or bladder
pathology. Renal punch will be positive, with tenderness over costovertebral angle in instances

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of pyelonephritis. Examination of the penis and testicles are necessary in a male complaining of
dysuria. A digital rectal examination should also be performed for signs of prostatitis, BPH or
prostrate cancer.

What happened to cause Mr Ong’s dysuria? Mr Ong was diagnosed with having Detrusor
Instability in TTSH and he was prescribed antispasmodic agent Oxybutynin to relieve his urinary
urgency. He stopped the medications for a period of time after some improvement in urgency.
Mr Ong also has BPH, which made him prone to UTI. In late May, Mr Ong experienced dysuria
and resumed oxybutynin, causing urinary retention when bladder tone decreased and reduced
effective voiding. All these in addition to the already enlarged prostrate causing obstruction. The
second phase resulted in more severe urinary stasis and caused worsening dysuria.

Laboratory Tests. Although urine dipstick test is useful in the detection of UTI, a positive nitrate
suggests a probable UTI; however, a negative test does not rule out the diagnosis. This is because
certain bacteria (e.g. Enterococcus species) may be nitrate negative (Roberts and Hartlaub,
1999). Urine Fine Microscopy (UFEME) remains the gold standard for evaluating dysuria
(Bremnor and Sadovsy, 2002). Urine culture should be done when colony counts greater than
102 per ml in uncomplicated UTI. The purpose of culture besides detecting the causative agent is
also to guide the antibiotic treatment. An appropriate antibiotic treatment will reduce the risk of
developing antibiotic resistant organisms. According to the MOH Clinical Practice Guidelines in
use of antibiotics in adults (2006), urine cultures are essential, before and after treatment of all
men with UTI. Other groups of patients requiring before and after treatment urine culture are
shown in Table 1. Antibiotic therapy should be changed if isolated organism is resistant. In Mr
Ong’s case, it is fortunate that the causative organism in his urine infection is susceptible to
ampicillin/ amoxicillin.

· Pregnant women
· Those with recurrent UTI
· Pyelonephritis
· All men with UTI
· All patients with complicated UTI
Table 1: Groups of patients requiring Urine Culture before and after treatment

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Treatment and Plans. Mr Ong was asked to stop Oxybutynin for the time being. He was also
given Amoxicillin 500mg and Clavulanate acid 125mg twice a day till the next appointment.
Although for complicated urinary tract infections of mild to moderate severity, when symptoms
warrant initiation of empirical therapy, oral fluroquinolones or trimethoprimsulphamethoxazole
is recommended, the choice of choosing Amoxicillin-clavulanic acid is that the patient has taken
that medication before without any allergies and its broad spectrum nature of this beta-lactam-
beta-lactamase-inhibitor combination. Besides, 86.6% Escherichia coli infections are susceptible
to Amocivillin-clavulanic acid, assuming the causative agent is a Gram-negative bacilli, and
E.Coli is the commonest pathogen in Singapore community according to MOH (2006).
Antibiotic treatment of complicated urinary tract infections should be based on cultures and
sensitivity. The next appointment is 2-week later with a re-evaluation of the UFEME and a
repeat urine culture. The plan is to monitor Mr Ong for the resolution of the infection and to refer
back to the Tan Tock Seng hospital if need be.

EVALUATION
Urine culture shows Streptococcous algalactiae (Group B) susceptible to ampicillin and
nitrofurantoin 2 weeks later. Streptococcous algalactiae is an uncommon pathogen in urinary
tract infection. Mr Ong was well with no more dysuria symptoms. There is also an improvement
in the UFEME results: WBC 15; RBC 15. A referral letter was written back to TTSH to review
his detrusor instability condition.

APN RFLECTION AND LEARNING POINTS
Dysuria is a common complaint in the polyclinic setting. An APN has to be aware that gender is
an important factor to consider when approaching a patient with dysuria. Also with an
increasing aging population, it is worthwhile to watch out for urinary problems related to aging
like detrusor instability and the medications used in the management. In Mr Ong’s case, the
medication might be the cause for further urinary retention resulting in UTI.

Interpretation of dipstick and UFEME results is an essential skill of an APN managing chronic
diseases. This is because both hypertension and diabetes panel have urine dipstick test in the
laboratory workup. Thus knowing the difference between haemature, pyuria and infection; their
probable and differential diagnoses; and co-management with the physicians can be a great help

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as team member in the chronic disease management. The usage of antibiotics in a UTI should
also be very cautious especially in complicated UTI groups and is best discussed with physician
in charge.

REFERENCES
Bremnor, J.D. and Sadovsky, R. (2002). Evaluation of dysuria in adults. American Academy of
Family Physicians, 65(8), p. 1589-1596.

Ministry of Health, Singapore (2006). Clinical practice guidelines: use of antibiotics in adults.
Retrieved on 18 September 2007 from http://www.moh.gov.
sg/mohcorp/uploadedFiles/Publications/Guidelines/Clinical_Practice_Guidelines/UseofAntibioti
csinAdults.pdf

Murtuagh, J. (2006). General Practice. 2nd edition. Australia: McGraw-Hill Professional
Publishing.

Roberts, R.G. and Hartlaub, P.P. (1999). Evaluation of dysuria in men. American Academy of
Family Physicians, 60, p.865-872.

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