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UTI is the most common medical complication of pregnancy Why is pregnancy considered a high-risk condition with asymptomatic bacteriuria Both hormonal and mechanical changes predispose the pregnant woman with asymptomatic bacteriuria to develop acute pyelonephritis, which is associated with preterm birth and perinatal death Pyelonephritis in pregnancy will lead to septicemia in 10 20% and acute respiratory distress syndrome (ARDS) in 2% of cases It is estimated to occur in 4 7% of pregnant patients If left untreated, up to 40% of cases will progress to pyelonephritis Screening for asymptomatic bacteriuria using urine culture is recommended at the first prenatal visit Nitrofurantoin for 70 days is first line If ineffective, amoxicillin, trimethoprim-sulfamethoxazole or a cephalosporin can be used for 3 days Quinalones are generally not used during pregnancy A urine culture should be done 1-2 weeks after completion of therapy Monthly urine cultures should be done and suppressive antibiotics should be considered
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How prevalent is asymptomatic bacteriuria in pregnancy
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6: Urogynecology
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Treatment and follow up are similar to asymptomatic bacteriuria Acute pyelonephritis should be treated with intravenous (IV) antibiotics and hospitalization Suppressive antibiotics should be given following treatment to any pregnant patient treated for acute pyelonephritis
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Describe the signs and symptoms of urethritis Dysuria, but with a more gradual onset and milder symptoms than with acute cystitis Hematuria is rare and points to cystitis more than urethritis Urethritis is often associated with abnormal vaginal discharge or bleeding (because of related cervicitis) A mucopurulent discharge from the urethral os is usually found on examination History of an STD; new sexual partner in past weeks; partner with urethral symptoms Pyuria on urinalysis and mucopurulent cervicitis or herpetic lesions are usually found A positive GC, Chlamydia, or herpes test result can confirm the diagnosis Most common: Chlamydia trachomatis (5 20%) Neisseria gonorrhea (<10%) Genital herpes Others: Candida, Trichomonas What is irritant urethritis Dysuria that occurs as a reaction to an irritant such as a condom, tampon, or any other product inserted into the vagina
What are the risk factors for urethritis
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ACUTE PYELONEPHRITIS
Describe the symptoms of acute pyelonephritis Typical presentation: flank pain, fever (>38 C), CVA tenderness, nausea/vomiting, cystitis symptoms
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Section II: Topics in Gynecology
What is the differential diagnosis for acute pyelonephritis
Gastrointestinal: cholecystitis, appendicitis, pancreatitis, diverticulitis Gynecologic, pelvic inflammatory disease (PID), ectopic pregnancy Pulmonary: lower lobe pneumonia Genitourinary: urinary calculi
How is the diagnosis definitively made
Most patients can be diagnosed based on history and physical examination alone Urinalysis: pyuria is almost always found; white cell casts, if found, indicate renal origin; gram-negative bacteria on Gram stain Urine cultures and possible blood cultures should be taken at time of diagnosis for antimicrobial susceptibility
What is the most common pathogen that causes acute pyelonephritis Describe the pathophysiology of acute pyelonephritis
E coli (70 95%); S saprophyticus (5 20%) Uropathogens from the fecal flora colonize the vaginal introitus and infect the urethra They then ascend via the urethra to the bladder and then into the kidneys It is also possible that the kidneys could be seeded from bacteria in the lymphatics Increased sexual intercourse; history of UTI within past year; diabetes; stress incontinence within the past 30 days; a new sexual partner within the past year; spermicide use; family history of UTIs Outpatient treatment: trimethoprimsulfamethoxazole or a quinolone for 10 14 days; if enterococcus is suspected, add amoxicillin until cultures return Inpatient treatment: indicated if patient is noncompliant, cannot tolerate PO, is severely ill, or is pregnant; initial treatment is ceftriaxone, ampicillin and gentamycin, or aztreonam
What are the risk factors associated with developing uncomplicated acute pyelonephritis
How is acute pyelonephritis treated
What should be done if flank pain does not resolve after 2 3 days
An ultrasound or CT to rule out perinephric or intrarenal abcess or ureteral obstruction
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6: Urogynecology
When should a patient be followed up after treatment for acute pyelonephritis
Two weeks after completion of therapy or as soon as symptoms recur
Pelvic Organ Prolapse
How significant is pelvic organ prolapse (POP) in women in the United States Approximately 200,000 procedures for POP are performed annually The lifetime risk for undergoing surgery for urinary incontinence or prolapse is 11% The risk of requiring a repeat procedure may be as high as 29% Refers to the relaxation of the normal connective tissue supports of any of the pelvic organs (uterus, vaginal apex, bladder, rectum) and its associated vaginal segment from its normal anatomic location
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