ISK 2

(SISTEM GU)
Aditiawarman
SMF/Bag Penyakit Dalam
FK Unsoed/RS Margono Soekarjo
Purwokerto
Referensi
 ASYMTOMATIC
BACTERIURIA
Essentials of diagnosis
 Asymtomatic patient

 Urine culture with > 10 5 organism,or bacteria

in spun urine, or dipstick positive for
leukocytes and/or nitrites
 General Considerations
 Diagnosis criteria are not well defined
 Should be routinely screened and treated :
pregnant women
 Hospitalized patients with indwelling catheters
are out side the scope
 Treatment
 Should be guided by local rates of resistance
 First-line treatment: 7 days of Amoxicillin
 Penicillin-allergic : nitrofurantoin/
cephalosporin
ACUTE URETHRAL SYNDROME
Essential of diagnosis
 Dysuria

 Frequency and urgency

 No vaginal discharge

 Dipstick may be negative or positive

 Negative culture
 General considerations
 Is a term used by some to describe a young,
healthy, sexually active woman who
complains of recent-onset of cystitis but does
not meet older, strict guidelines for diagnosis.
 Clinical Findings
 Patient at low risk of STD:
- no testing might be appropriate
- testing only after failure of empirical
treatment for cystitis
 Patient at higher risk of STD:

- Chlamydia testing by cervical swab or

urin PCR, might be appropriate
 Differential Diagnosis
 This syndrome is clearly not well defined
 It is usually taken to represent an early cystitis
 It can be a sexually transmitted disease (STD)
 Treatment
 Usual cystitis agents or
 STD agents, depending assesment
 Chlamydia trachomatis was found to be high
in at lest one study  routine Chlamydia
testing for patients who do not respond
completely to a course of antibiotics would be
highly recommended.
 URETHRITIS
Essentials of diagnosis
 Pain or irritation on urination

 No frequency or urgency

 Discharge from the urethra (predominantly

males)
 Vaginal discharge possible
 General Considerations
 Isolated urethritis in men or women is almost
always a sexually transmitted disease, most
often caused by C trachomatis.
 Symptoms that have gradual onset and/or
persist without evolution into classic cystitis
symptoms.
 Clinical Findings
 It can very difficult to separate a symptomatic
Chlamydia infection from a bacterial cystitis
with coliform organisms
 Testing for both may be required
ACUTE BACTERIAL PROSTATITIS
Essentials of diagnosis
 Dysuria, frequency, urgency

 Tender prostate

 Systemic symptoms such as fever, nausea,

vomiting
 Leukocyte esterase or nitrite on dipstick

 Positive urine culture

 General Considerations
 Categorization of prostatitis:
- I : Acute bacterial prostatitis
- II : Chronic bacterial prostatitis
- IIIA: inflammatory chronic pelvic pain
syndrome
- IIIB: noninflammatory chronic pelvic pain
syndrome
- IV :asymptomatic inflammatory prostatitis
 Clinical Findings
A. Symptoms and signs
- dysuria, frequency, and urgency
- low back, perineal, penile, and/or rectal
pain
- tense or “boggy” tender prostate
- fever and chills
B. Laboratory findings
- a urine dipstick is positive for leukocyte
esterase and/or nitrites
- urine culture is positive for a single
uropathogen
C. Imaging studies : -
D. Special test: prostatic massage is generally
not done for acute bacterial prostatitis it may
lead to acute bacteremia
 Diferential diagnosis
 Abnormal anatomy: urethral strictures, polyps,
diverticulae, rdudancies, or valves anywhere in
the system from the penis to the kidneys
 Complications
 Ascending infection
 Infection-related stones
 Abscess
 Fistula
 Cyst
 Acute urinary retension
 Treatment
 Quinolone antibiotics for 28 days
 Kotrimoxazole

Prognosis
 Very good for acute uncomplicated bacterial
prostatitis
 CHRONIC BACTERIAL
PROSTATITIS
Essentials of diagnosis
 Dysuria, frequency, urgency

 Symptoms for more than 3 months

 Urine dipstick positive forleukocyte esterase

and/or nitrites
 Pyuria on microscopy

 Positive four-glass or two-glass test for

prostatic origin
 General considerations
 Chronic bacterial prostatitis is quite rare

Prevention
 Early and sufficient treatment of acute
bacterial prostatitis may prevent chronic
prostatitis
 Clinical findings
A. Symtoms and signs
- dysuria, frequency, and urgency
- prostatic tenderness on examination
- low back, perineal, penile, and/or rectal
pain
- present for more than 3 months
B. Laboratory findings
- urine dipstick is positive and/or a four-glass
or
two-glass test for prostatic origin is positive
C. Imaging studies
- A transrectal prostatic ultrasound should
be done if abscess or stones are
suspected
D. Special test
1. Four-glass test
2. Two-glass test
 Complications
 Ascending infection
 Infection-relatd stones
 Abscess
 Fistula
 Cyst
 Acute urinary retention
 Treatment
 Trimethoprim
 Trimethoprim/sulfamethoxazole
 Quinolones
 For up to 12 weeks

Prognosis
 Not known
UNCOMPLICATED BACTERIAL
CYSTITIS
Essentials of diagnosis
 Dysuria

 Frequency and/or urgency

 Dipstick positive

 Positive urin culture > 10 4 organisms

 No vaginal discharge, fever, or flank pain

 General Considerations
 Acute, uncomplicated cystitis is most common in
women
 Approximately 33% of all women will have
experienced at least one episode of cystitis by the age
of 24 years
 40-50% will experience at least one during their
lifetime.
 Young women’s risk factors include sexual activity,
use of spermicidal condoms or diaphragm, and
genetic factors such as blood type or maternal history
of reccurent cystitis
 It is rare in men with normal urinary anatomy under
the age of 35 years.
 Prevention
 Sexual activity (four or more episode/month)
 Use of spermicidal condoms
 Use of unlubricated condoms
 Use od diaphragms and/or cervical caps
 Recommending change in contraception
 Prophylactic antibiotics either low-dose daily or
postcoital antibiotics
 Clinical findings
A. Symptoms and signs
- dysuria, sudden onset
- suprapubic pain
- cloudy
- Smelly urine
- Frequency
- urgency
B. Laboratory findings
- dipstick positive
 Treatment
A. Acute cystitis
- 3 day antibiotic therapy as superior to 1
day treatment
- first line tx: kotrimoxazole
B. Acute cystitis in the pregnant woman
- Amoxicillin for 7 days
C. Prophylaxis for recurrent cystitis
- low dose prophylactic antibiotics: decrease
recurrency by up to 95 %
 COMPLICATED CYSTITIS AND
SPECIAL POPULATIONS
Essensials of diagnosis
 Any cystitis not resolved after 3 days of appropriate
antibiotic treatment
 Any cystitis in a special population, such as:

- a diabetics
- a man
- a patient with an abnormal urinary tract
- a patient with stones
- a pregnant woman
 General considerations
 Referral to a urologist
 Cultured  appropriate antibiotic

Clinical findings
 X-ray
 CT
 IVP
 cystoscopy
 Treatment
 Long-course, appropriate antibiotics
 PYELONEPHRITIS
Essentals of diagnosis
 Fever

 Chills

 Flank pain

 >100.000 colony-forming (CFU) on urine

culture
 General considerations
 Infection of the kidney parenchyma
 Upward spread of cystitis/ hematogenous
 Bacterial involved are the same as
uncomplicated cystitis
 Clinical findings
A. Symptoms and signs
- fever, chills, and malaise
- dysuria
- flank pain
- nausea and vomiting
B. Laboratory findings
- dipstick positive
- urine culture positive
 Imaging studies
 Not required unless the patient is diabetic or
stones  CT scan
DD
 Treatment
 Bactericidal
 Broad spectrum
 Concentrate well in urine and renal tissues
 Aminoglycosides
 Amoxicillin
 Cephalosporin
 Fluoroquinolon (first line tx, outpatient)
 Imipenem
 10 day to 2 week of antibiotics
 Nausea, vomiting, severe illness  be admitted to the
hospital for parenteral tx