Hey whats going on guys, and today were going to talk about cystitis pyelonephritis. The reason why I wanted to group these two together, is because they are simply a continuation of each other. So, we start off with cystitis, and if this goes untreated, it will eventually lead to pyelonephritis. We can consider these two diseases the same of differing severity. Lets go ahead, and well go over each of the disease processes together side by side, so we can see how we can differentiate between the two disease processes. Cystitis is simply an infection of the bladder. This is most common in women, and less common in men. Now, we can also differentiate cystitis, from uncomplicated cystitis and we can differentiate that from complicated cystitis. Now, complicated cystitis is simply an infection of the urinary bladder, however, the patient is also pregnant, a male, has a foley catheter, or has some kind of structural abnormality with their kidneys that makes it more difficult to get rid of the infection. The may also have diabetes or have some other type of immunosuppression that will make eradicating this disease process a little more difficult. These patients require a few extra things: a longer duration of therapy and closer monitoring because there can be more complications and are more prone to develop into pyelonephritis.
The symptoms are going to be very similar. With cystitis, you’re going to have dysuria (which simply means you have pain with urination), suprapubic pain (lower abdominal pain), urinary frequency (you have to use the bathroom very often), urgency (you have the urge to use the bathroom). Now, a lot of the times, although these patients are going very frequently or they feel like they have to go very frequently, not a lot comes out. So, its a lot of dribbling that actually occurs with these patients. Now, the main differentiating factor between cystitis and pyelonephritis is going to be fever. Your not going to see fever with pyelonephritis. So, if you see a patient with burning on urination, urinary frequency, but they have fever, we have pyelonephritis. So don’t be tricked into thinking this is cystitis. The only way to have fever is to have systemic infection. Now, by definition, cystitis is only infection of the urinary bladder so its very localized to the bladder. If it leaves the bladder, now we have systemic infection. If it leaves the bladder, now we have pyelonephritis and were going to have fever, chills, and flank pain. And the reason we have flank pain with pyelonephritis is because now its affecting the kidney right? So, if it goes to the right kidney, were going to have right flank pain. If the infection spreads to the left kidney were going to have left flank pain. So, very important, fever or chills in the vignette is going to be pyelonephritis.
Now the physical exam. The only thing your going to see on exam with cystitis is suprapubic tenderness to palpation. So, your going to push on the bladder and your going to have pain because of all that inflammation from the infection. Pyelonephritis may also have suprapubic pain, but they are also going to have CVA tenderness. So your going to pound with your fist on their flank and if you have pain, if this illicits pain, this is CVA tenderness (costovertebral angle tenderness). This is indicative of pyelonephritis. Now, this can also be present with nephrolithiasis, but your not going to have burning with urination with nephrolithiasis, your not going to have bacteria with nephrolithiasis, your not going to have painful urination with nephrolithiasis. So this is something to keep in mind as well.
Diagnosing is basically based on the dipstick and the history. Your going to do the dipstick and look for protein, your going to see white blood cells, leukocytes, and nitrites. So, you can have all different types of abnormalities on dipstick, but the most specific thing your going to look for is nitrites. Nitrites are specific for bacteria and most commonly your going to see ecoli. You can also see staph, proteus, and klebsiella. Ecoli is by far the most common pathogen isolated with cystitis. Pyelonephritis will have the exact same history apart from the fever and will have the exact same dipstick findings, however, pyelonephritis will present with white blood cell casts on urine analysis. So, the dipstick doesn’t really tell you much as far as differentiating cystitis from pyelo, because they are going to be identical. You have to actually send the urine out and do a urine analysis which will give you casts; white blood cell casts are specific to pyelonephritis.
The treatment differs a little. Cystitis is a very localized infection. We have bactrim (trimethroprim/sulfamethoxazole), fluoroquinolones (ciprofloxacin, levofloxacin, they end in oxacin) and Nitrofurantoin (macrobid). The treatment of choice for pregnancy is nitrofurantoin or macrobid because its safe. It doesn’t cause adverse effects to the fetus. Bactrim or trimethroprim/sulfamethoxazole should generally be avoided in pregnancy and is considered a category D; this is a folic acid antagonist. Women who are pregnant have an increased need for folic acid. So, if we give them a folic acid antagonist were taking away that folic acid and it is predisposing these patients to having fetal abnormalities, teratogenicity, so a lot of complications. You definitely want to avoid bactrim in the third trimester, especially over 32 weeks gestation, because its also associated with kernicterus in the newborn. So, first trimester and third trimester is bad. You can probably use in the second trimester, but we have different options available. For the most part, consider this a category D and for the most part consider this contraindicated in pregnancy. Fluroquinolones are the treatment of choice as well, however, also contraindicated in pregnancy. For complicated cystitis, fluoroquinolones are the treatment of choice. So, for example if cystitis develops in a male, diabetic, immunosuppression, your going to give ciprofloxacin. If a child develops cystitis, bactrim is your therapy of choice. In a pregnant woman, use macrobid. In complicated cystitis, your going to use fluoroquinolones. In pyelonephritis, the treatment of choice is a fluoroquinolone. Macrboid does not infiltrate the renal parenchyma sufficiently to get rid of pyelonephritis. So, you never want to use macrobid for pyelonephritis; it will not eradicate the infection. Bactrim is a good choice for pyelonephritis, but is second line. Really the first choice of treatment in pyelonephritis is a fluoroquinolone. Now, if you have pyelonephritis in pregnancy, fluoroquinolones are contraindicated, bactrim is contraindicated, and your going to have to admit these patients to the hospital for IV antibiotics. Pyelonephritis in those with pregnancy or those who other wise had complicated cystitis should probably be admitted to the hospital for IV therapy.
This was a quick presentation on cystitis and pyelonephritis. I hope you guys learned something. Before I let you guys go, i want to leave you with a quote, and this is: perception is reality. Now, what does this mean. This means that what you believe will become your reality. If you think your going to be the best PA, if you think your going to pass your exams, if you can visually see yourself being the best and passing all of your exams, this will translate into your personal reality. Perception is reality, remember that. You can find me over at physicianassistantboards.com. You can also find me on my twitter at PA_boards or at Facebook/PABoards1.