week 7 project

Internal Medicine 14: 18-year-old female for pre-college physical

You are working with Dr. Sattovia today in her general medicine clinic. She asks you to evaluate Judy Pham, an 18-year-old female here for a pre-college physical.

You walk into the exam room and introduce yourself.

Ms. Pham tells you she lives at home with her parents and 15-year-old sister, although next month she will leave home for college and live in a dormitory. She gets along well with her family but is looking forward to moving away and having some independence. She has never had a serious illness and feels "fine" now. She has no allergies and takes no medications. Her parents and grandparents are healthy, and the review of systems is negative.

TEACHING POINT

HEEADSSS Approach to Adolescent Counseling

The HEEADSSS approach to adolescent counseling addresses the main categories of Home/health, Education/employment, Eating disorders, Activities, Drugs, Sexuality, Safety/violence, and Suicide/depression. View examples of   screening questions  for the HEEADSSS history.

One of the nice qualities about the HEEADSSS approach is that it starts with less threatening issues and proceeds to more personal questions, so the interviewer has a chance to establish rapport before exploring sensitive, intrusive topics. Be sure to ask questions in a nonjudgmental way, and avoid questions that can be answered with "OK" or with a "Yes/No" (i.e., "Do you get along with your mom and dad?"; "How are you doing in school?"; "Do you have any activities outside of school?"; "Do you do drugs?"; "Are you sexually active?"; "Are you careful about being safe?").

Remember to avoid making assumptions about a teen's behaviors. For example, don't assume that your patient is heterosexual, sexually active, or even dating.

By using the HEEADSSS approach, you learn that Ms. Pham likes to go to movies, baseball games, and sometimes parties with her friends. At these parties there has been beer, and sometimes marijuana, which she tried once. She drinks beer once every few months, and has gotten drunk once. She does not smoke cigarettes. She has not had problems with sadness or depression. You then decide to move on to her sexual history.

"Are you going out with anyone right now?"

"Not with any one person. Mostly I hang out with groups of friends. I've never had a steady boyfriend, but I'd like to someday. I met a really nice guy at orientation last month, and he'll be living in the same dorm as me. I'm hoping to get to know him better."

"Have any of your relationships been sexual relationships?"

"I don't think I'm ready for sex yet! I want to be close to the person and be able to trust him when it happens. I'm a little nervous about the whole thing, since I've never done it before."

You tell Ms. Pham that when she thinks about becoming sexually active, she should see a physician to discuss birth control options, and remind her that condoms are necessary to prevent sexually transmitted infections.

You think about other issues of safety that are important to address during a health maintenance visit.

Which of the following questions are appropriate for addressing the issue of safety? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Do you always wear a seat belt in the car?

· B. Do you ever drink and drive?

· C. Do you feel safe at home and school?

· D. Do you wear a helmet when you go biking, skateboarding, or ride a four-wheeler?

· E. Have you ever been physically abused in a relationship?

· F. Have you ever ridden with a driver that was drunk or on drugs?

· G. Have you ever witnessed violence?

SUBMIT

Answer Comment

> The correct answers are A, B, C, D, E, F, G

The second “S” in HEADSS is for Safety/Violence. Examples of the types of questions you would ask include: “Have you ever been in a relationship or involved with someone that made you feel unsafe or disrespected? If someone hurt you, whether a family member, friend or stranger, how do you think you’d react? Speaking of safety, do you wear a seatbelt when you drive? What about when you’re a passenger in someone else’s car?”

TEACHING POINT

Adolescent Interview - Safety

Violence

The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape, and school violence are all common. In many urban communities, up to one in four students report carrying a weapon to school. Family violence and dating violence cross all economic and social boundaries.

Injuries

For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is important to address the use of seat belts and bike helmets with every adolescent.

Even though you address the safety issues most prevalent in the patient's community first, do not skip any part of the history based on assumptions about the patient's ethnic background or economic status.

You step out of the room to present Ms. Pham's history to Dr. Sattovia.

You and Dr. Sattovia then return to the exam room and advise Ms. Pham that she should receive the Tdap booster because it protects against whooping cough, and the influenza vaccine when it is available. Dr. Sattovia tells Ms. Pham about the HPV vaccine and gives her some information on the HPV vaccine to read.

After washing your hands, you do a general physical exam:

Physical Exam

Vital signs:

· Temperature is 36 C (96.8 F)

· Pulse is 76 beats/minute

· Respiratory rate is 16 breaths/minute

· Blood pressure is 96/50 mmHg

· Weight is 47.6 kg (105 lbs)

· Height is 160 cm (63 in)

· Body mass index is 18.6 kg/m2

Head, eyes, ears, nose and throat (HEENT):

· Head: Normocephalic, atraumatic

· Eyes: PERRLA, EOMI

· Ears: Tympanic membranes visible, good cone of light

· Nose: Septum midline, mucosa pink and moist

· Throat: Good dentition, no erythema or exudate

· Neck: Thyroid is normal size, no nodules; no lymphadenopathy

Lungs: Clear to auscultation in all lung fields.

Cardiovascular: Normal heart sounds, no murmur.

Abdominal: Normoactive bowel sounds; tympanic/resonant to percussion; no hepatosplenomegaly; no tenderness to palpation.

Extremities: No cyanosis, clubbing, or edema; 2+ peripheral pulses.

Neurologic: Alert and oriented to person, place, and time; cranial nerves intact; strength 5/5 in all extremities; deep tendon reflexes 2+ in all extremities; no gross sensory abnormalities.

Skin: No lesions.

Ms. Pham asks if she needs a pelvic exam because many of her friends have had one when they went to the doctor.

You review your history and physical with Dr. Sattovia, ask Ms. Pham if she has any questions (she does not), and wish her well. She says she will return for the HPV vaccine after she speaks with her mother. You remind her that it is a series of three injections and let her know that she can receive the vaccine here or at her university's health service.

Three months later, Ms. Pham is home for Thanksgiving break and has returned to the clinic. You look at the chart:

Chief concern: "trouble urinating"

Dr. Sattovia asks you to talk to Ms. Pham about her symptoms first, then you will both examine her.

You enter the room, introduce yourself again, and proceed. You ask:

"How are things going?"

"This urine problem has been bothering me for a couple of days. I've never had anything like it."

"Tell me about your symptoms."

"Well, for the past two days I feel like I have to go to the bathroom constantly, and the urge to go is bad, like I might not make it. But, when I do go, there is only a little bit of urine, and it burns. This morning there was blood, and I have this pain down by my bladder. My roommate says this is how she felt when she had a bladder infection."

After these open ended questions you begin to drill down into the problem with more specific questions and find that Ms. Pham has not experienced:

· fever

· vomiting

· back pain

· vaginal discharge

The major risk factor for a UTI in this age female is sexual intercourse so you ask some open-ended questions around that.

"Are you seeing anyone now?"

"Actually, yeah. We've been dating for two months. I like him a lot. I probably should have mentioned this up front, but we've started having sex, and I'd like to do something about birth control."

"Do you have pain with vaginal intercourse?"

"No, not really."

"What have you used for birth control so far?"

"Condoms mostly, but not every single time."

"When was your last menstrual period?"

"A week ago, and it was just like it usually is."

Based on the key findings of the case so far, select the top three diagnoses on your differential at this time.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Bacterial vaginosis

· B. Candidiasis

· C. Cervicitis with urethritis

· D. Cystitis

· E. Interstitial cystitis

· F. Nephrolithiasis

· G. Pelvic inflammatory disease

· H. Pyelonephritis

SUBMIT

Answer Comment

> The correct answers are C, D, G

See the Teaching Point below regarding the best answers.

TEACHING POINT

Differential of Dysuria, Urinary Frequency, and Hematuria

Most Likely Diagnoses

Cervicitis with urethritis	· Several sexually transmitted infections, such as chlamydia, gonorrhea, and trichomoniasis can cause cervicitis with concomitant urethritis and dysuria similar to that seen here. · Symptoms that occur gradually over several weeks are more likely with a sexually transmitted urethritis.
Cystitis	· Cystitis is an inflammation of the bladder caused most commonly by bacterial infection. · A non-specific term often used interchangeably with cystitis is "urinary tract infection." Urinary tract infection can denote infection of any portion of the urinary tract, including the kidneys (pyelonephritis) or urethra (urethritis). · Hematuria, urinary frequency, and dysuria are all common features of cystitis. · Urinary frequency and dysuria can also be seen with urethritis, but hematuria is rarely seen with that condition. The presence of hematuria points to cystitis rather than urethritis in this patient. · Note that fever is not seen with cystitis. When fever is present in the setting of urinary symptoms, pyelonephritis should be considered.
Pelvic inflammatory disease	· Pelvic inflammatory disease, often called PID, is the name for a spectrum of disorders of the upper female genital tract, including endometritis, tubo-ovarian abscess, and salpingitis.  · Often sexually transmitted infections are the source of PID, which can lead to infertility if not treated.  · Females with PID may have subtle symptoms, and physical exam findings of cervical motion tenderness and uterine or adnexal tenderness are important diagnostic features of PID.  · In addition to vaginal discharge, abdominal and pelvic pain are common in PID—more so than with the other diagnoses. · Fever is variably present in PID, and is more likely in severe cases.

Less Likely Diagnoses

Bacterial vaginosis	· Bacterial vaginosis is a condition marked by increased malodorous vaginal discharge. · It is caused by an imbalance of naturally occurring vaginal flora. · It is not an inflammatory condition, therefore pain and burning are rarely seen. · Sexual activity is a risk factor for bacterial vaginosis, but there is no clear evidence that it is transmitted sexually.
Candidiasis	· Candidiasis is an often-neglected cause of dysuria and is perceived as pain or burning when urine comes in contact with an inflamed perineum or labia.  · A vaginal yeast infection may cause inflammation of the perineum and the urethral orifice, called "vaginitis," that leads to dysuria. This so-called "external dysuria" is most common with candida and trichomonas vaginitis, but it is also present in patients with genital ulcers from herpes simplex and in irritant vaginitis from soaps, hygiene products, condoms, and spermicides. · Urinary frequency, urgency, or hematuria are symptoms related to the bladder and urethra. When present, they speak against the diagnosis of vaginitis.
Interstitial cystitis	· Interstitial cystitis, also known as painful bladder syndrome, is a chronic pain syndrome characterized by frequency, urgency, and dysuria. · However, it is less likely to present with hematuria and is less likely to have such an acute onset.
Nephrolithiasis	· Although nephrolithiasis can cause hematuria, it usually does not present with dysuria or urinary frequency.
Pyelonephritis	· Pyelonephritis is an infection of the kidney or upper urinary tract.  · Dysuria may be present, but is rarely the only symptom. · Symptoms that suggest the diagnosis of pyelonephritis are flank pain, fever, chills, nausea, vomiting, and prostration, none of which is present here.  · Fever is usually present with pyelonephritis, but not always, so a lack of fever argues against this diagnosis.

You present the history to Dr. Sattovia and tell her that you have concluded the most likely explanation for her symptoms is cystitis. Because Ms. Pham has a new sexual partner, you also think a sexually transmitted infection such as gonorrhea is possible, and you want to rule out pelvic inflammatory disease. You would like to perform a pelvic exam to establish the diagnosis.

Dr. Sattovia agrees with your assessment and will accompany you to perform the pelvic exam. She also asks you if you think a Papanicolaou (Pap) test for cervical cancer screening should be performed at this time.

Question

Which of the following are current recommendations for cervical cancer screening? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Females who have received the HPV vaccine do not need to be screened.

· B. Females with no prior abnormal Pap tests should have a yearly Pap test performed with the liquid-based cytology technique until age 65.

· C. Females without a cervix who have had a hysterectomy for benign conditions do not need to have Pap tests.

· D. Pap tests can be discontinued at age 65 if a female has had three or more documented consecutive negative Pap tests, and no abnormal Pap tests in twenty years.

· E. Screening Pap tests should begin within three years of onset of sexual activity even if age is less than 21.

· F. Testing for human papillomavirus (HPV) as a primary screening for cervical cancer is an acceptable alternative to Pap testing for females over 30 years of age.

SUBMIT

Answer Comment

> The correct answers are C, D, F

See the Teaching Point below regarding the best answers.

TEACHING POINT

Cervical Cancer Screening Guidelines

Age	Recommendation
Under 21	Females under the age of 21 should not be tested, regardless of sexual activity.
21-29	Females between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique. HPV testing should not be used in this age range unless it is prompted by an abnormal Pap result.
30-65	There are three options for screening females between the ages of 30 to 65: 1. "Co-testing" with the Pap test and a high-risk HPV test every five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years.
Over 65	Females older than 65 who have had negative Pap tests are unlikely to have abnormal Pap tests with repeat testing so should no longer be screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing continues after the age of 65.

These guidelines apply to females without medical conditions or exposure that place them at a higher risk of cervical cancer. Females in the following groups should be screened more frequently (e.g. annually):

· those with HIV infection

· those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids)

· those with diethylstilbestrol (DES) exposure before birth

HPV vaccines target only certain genotypes of HPV. The 9-valent Gardasil-9 includes seven genotypes that cause cervical cancer (types 16, 18, 31, 33, 45, 52 and 58) and two genotypes that most commonly cause genital warts (types 6 and 11). The quadrivalent Gardasil includes the most common genotypes to cause cervical cancer (types 16 and 18) and the two genotypes that most commonly cause genital warts (types 6 and 11). But recipients of either vaccine are still at risk of developing cervical cancer. Therefore, they should receive age-appropriate screening as discussed above. However, they are at a decreased risk because types 16 and 18 are the cause of cervical cancer in a majority of cases.

Liquid-based cytology is a method where cervical cells are suspended in a vial of liquid preservative instead of spread from a brush and spatula onto a glass slide. There are fewer unsatisfactory specimens with liquid Paps, and testing for HPV can be done on fluid from the vial, if warranted. However, there are more false-positive results with liquid Pap, which can result in needless referrals for colposcopy.

You explain the steps of the exam to Ms. Pham, tell her about the tests you will obtain, and review the guidelines for doing a Pap test with her. You also tell her about HIV testing and subsequent counseling.

She replies, "Thanks for going over all of this. If it's OK, I'll pass on the HIV test. I really don't think I need it."

You explain, "If the tests for some sexually transmitted infections such as gonorrhea come back positive, we report them to the public health department. In those situations, the health department will follow up with patients by telephone to make sure everyone gets treated appropriately."

Vital signs:

· Temperature is 36.2 C (97.2 F)

· Pulse is 88 beats/minute

· Respiratory rate is 16 breaths/minute

· Blood pressure is 92/55 mmHg

· Weight is 47.6 kg (105 lbs)

· Height is 160 cm (63 in)

· Body mass index is 18.6 kg/m2

Physical Exam

General: Ms. Pham appears well.

Cardiovascular: Normal. No murmurs appreciated.

Pulmonary: Clear to auscultation.

Skin: No visible lesions.

Back: No costovertebral angle tenderness.

Abdomen: Soft with active bowel sounds and mild midline suprapubic tenderness. Percussion of the suprapubic region reveals no distention of the bladder.

Pelvic: Examination of external genitalia reveals no ulcerations, redness, or other abnormalities of the skin, labia, introitus, or Bartholin glands. There is a small to moderate amount of white mucus in the vaginal vault. The cervix appears normal.

TEACHING POINT

STI Screening Recommendations

Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.

Test results for most STIs, such as gonorrhea, chlamydia, HIV etc. must be reported to the public health department.

Which tests would be the most appropriate to perform during the pelvic exam for this patient? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Gram stain and culture of the endocervix for Neisseria gonorrhea and Chlamydia trachomatis

· B. Microscopic examination of a slide with a drop of vaginal discharge and normal saline

· C. Microscopic examination of a slide with a drop of vaginal discharge and potassium hydroxide

· D. Nucleic acid amplification testing for Neisseria gonorrhea and Chlamydia trachomatis

· E. Smelling a slide with a drop of vaginal discharge and normal saline

· F. Smelling a slide with a drop of vaginal discharge and potassium hydroxide

SUBMIT

Answer Comment

> The correct answers are B, C, D, F

TEACHING POINT

Recommended Pelvic Exam Tests in the Setting of Suspected STIs

Microscopic examination of slide with drop of vaginal discharge and normal saline	The saline-prepped or "wet mount" slide allows for diagnosis of Trichomonas and bacterial vaginosis.
Microscopic examination of slide with drop of vaginal discharge and potassium hydroxide	The potassium hydroxide slide is used to visualize  budding yeast  and  hyphae  that are seen with candida vaginal infections.
Nucleic acid amplification testing (NAAT) for  N. gonorrhea and  C. trachomatis	The best way to test for chlamydia and gonorrhea during a pelvic exam is nucleic acid amplification testing (NAAT) for N. gonorrheaand C. trachomatis. NAAT is a sensitive and specific assay and has replaced culture methods. It can be used on urine specimens as well.
Smelling a slide with a drop of vaginal discharge and potassium hydroxide	Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test. The production of a fishy odor indicates a positive test. A positive whiff-amine test is seen in bacterial vaginosis.

Tests not indicated:

Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of Neisseria gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid testing.

Smelling a slide with normal saline is not useful.

You place a drop of vaginal discharge from the fornix on two slides. Dr. Sattovia puts potassium hydroxide on one slide, and saline on the other. You place the probe for gonococcal and chlamydia testing in the cervical os for 30 seconds, and then put it in transport medium.

Ms. Pham's bimanual examination is normal. The uterus is normal-sized and not tender. There are no adnexal masses or tenderness, and there is no tenderness with cervical motion.

You remove your gloves, wash your hands, and help Ms. Pham up to the sitting position. "It's OK to get dressed now. I'll be back to talk with you after I look at the slides."

TEACHING POINT

What to Look for on Wet Mount Slides

· In the case of trichomoniasis, wet mount slides reveal  trichomonads , which are flagellated protozoans. The treatment is a single dose of 2 grams of metronidazole.

· Clue cells  can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of abnormal vaginal discharge in females of childbearing age, is a condition characterized by reduced numbers of normal vaginal lactobacilli and overgrowth of other vaginal bacteria. Clue cells are epithelial cells entirely covered with these bacteria, giving the perimeter a "furlike" appearance. The treatment of BV is a course of metronidazole 500 mg twice daily for seven days.

· It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis, and atrophic vaginitis.

· Ms. Pham's wet mount slides reveal no yeast, trichomonads or clue cells.

· There are two to five white cells per high-power field.

· The pH of the vaginal discharge is 4.0.

· The whiff-amine test is negative.

· After an unrevealing microscope examination of the cervical specimen, you think that Mrs. Pham most likely has cystitis.

·

TEACHING POINT

Diagnostic Tests for Cystitis

Microscopic urinalysis

Pyuria, defined as at least two to five leukocytes per high-powered field in a  spun urine specimen , is present in almost all females with cystitis, and evaluation of midstream urine for white blood cells is the most valuable lab test for urinary tract infection. If white cells are not present in the urine, an alternative diagnosis should be considered.

Urine dip stick

In ambulatory settings, urine dipstick testing has largely replaced microscopy to confirm the diagnosis of urinary tract infection (UTI), because it is cheaper, faster, and more convenient. Dipsticks detect the presence of leukocyte esterase and nitrite and have comparable accuracy to microscopic urinalysis in the diagnosis of cystitis. However, they may be negative in low-colony count infections (less than 104 colonies/mL). Therefore, patients should also have a microscopic urinalysis performed.

Tests not indicated for diagnosis of cystitis

· Microscopic evaluation of the urine for  bacteriuria  is generally not recommended for acute cystitis because bacteria in low quantities (less than 104 colonies/mL) are difficult to find, even with Gram stain.

· Urine culture is not cost-effective and not necessary in females with cystitis, because the causative organisms and antibiotic sensitivities are predictable, and the results of the culture are not immediately available. There are certain situations when obtaining a urine culture is useful, such as in patients with refractory symptoms or those with history of urinary tract infections with antibiotic-resistant organisms.

· Urine dipstick: positive for leukocyte esterase, nitrites, and hemoglobin

· Pregnancy test: negative

· These findings strongly support your diagnosis of acute cystitis.

Most Common Causes of Cystitis

E. coli causes a majority of all cases of uncomplicated urinary tract infections.

Other common organisms include Klebsiella pneumonia, Proteus mirabilis and Staphylococcus saprophyticus.

Differentiating Cystitis from Pyelonephritis

It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

	Cystitis	Pyelonephritis
Clinical manifestations	dysuria, frequency, urgency, suprapubic pain, and/or hematuria	may or may not have symptoms of cystitis together with fever (> 38 C) and other systemic symptoms, such as chills, flank pain, costovertebral angle tenderness, and nausea/vomiting
Urinalysis	pyuria	pyuria, white blood cell casts (pathognomonic)
Treatment	short-course antibiotic therapy (three days); hospitalization usually not required	at least seven days of treatment; hospitalization may be required

Dr. Sattovia wants to make sure you can care for males with dysuria as well as females, so she takes a few minutes to review this with you.

TEACHING POINT

Dysuria in Males

Disease	Presentation	Diagnosis
UTI and cystitis	· Isolated acute cystitis is rare in males because their longer urethra hinders bacteria from reaching the bladder, and prostatic fluid has antibacterial properties. · Most males with acute cystitis have functional or anatomic abnormalities, and need further evaluation. · Symptoms of lower and upper tract infections are the same in males and females.	Midstream culture and sensitivity of the urine
Urethritis	· Usually sexually transmitted gonococcal and/or chlamydia infection. · Gonococcal urethritis is more likely in males with acute symptoms and purulent urethral discharge. · Chlamydia is likely when dysuria is present alone or with minimal discharge. Males with chlamydia infection may be asymptomatic. · Recommended that patients be treated presumptively for both gonorrhea and chlamydia, pending results. · Herpes simplex virus is a rare cause of urethritis, but may be suggested by the history of penile lesions.	· Diagnosis can be made on a Gram stain of a urethral swab. · Leukocytes and Gram-negative intracellular diplococci confirm the diagnosis of gonorrhea. · White cells without organisms suggest non-gonococcal urethritis (NGU) which is usually chlamydia but can also be Trichomonas vaginalis. · Because many outpatient offices are not equipped to do Gram stains, NAAT testing of the urethra or urine is becoming the preferred diagnostic test for gonorrhea and chlamydia.
Prostatitis	Acute prostatitis · Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy, and is caused by Gram-negative rods (Enterobacteriaceae, Pseudomonas, Proteus), Gram-positive organisms (Enterococcus, S. aureus), and sexually transmitted agents such as Neisseria gonorrhoeae and Chlamydia trachomatis. · Prostate is edematous and very tender on digital rectal examination. Chronic prostatitis · Characterized by lower urinary tract symptoms, perineal discomfort, pain with ejaculation, and occasionally deep pelvic pain that radiates to the back. The symptoms are often subtle and sometimes may be absent, and the physical exam may be normal. · This diagnosis should be considered in males with recurrent UTIs without risk factors.	Diagnosis can be difficult to make and may require submitting urine specimens gathered following prostatic massage for microscopic urinalysis and culture.
Epididymitis	· Patients with epididymitis present with dysuria, frequency, urgency, and unilateral testicular pain. · Fever and rigors may be present and there may be redness and tenderness of the entire affected testicle. · Testicular torsion should be considered in all cases, especially when the patient is an adolescent and the onset is sudden. · Epididymitis in males < 35 years is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae; in those > 35, enteric Gram-negative rods (Escherichia coli) are the most common causes.	If the diagnosis is questionable, color duplex doppler scanning should be obtained immediately.

Factors that Contribute to Complicated Urinary Tract Infections

Anatomic or functional abnormalities of the urinary tract	Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial growth and causing complicated infections.
Hospital-acquired	Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing infections with antibiotic-resistant organisms that are found in the hospital environment.
Immunosuppressed or recently treated with antibiotics	Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated infections.
Male	Urinary tract infections in males are complicated because they are commonly associated with bladder outlet obstruction, instrumentation, or other urologic abnormalities. However, a small number of adult males can develop uncomplicated UTIs. Risk factors associated with these infections are homosexuality, intercourse with a urinary tract-infected female partner, and lack of circumcision.
Pregnant	Urinary tract infections in pregnant females are considered complicated because they can progress to and can induce preterm labor.
Urinary catheter or recent instrumentation	Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial growth.

First-Line Empiric Therapy for Cystitis

In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.

· In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a poor choice for empiric therapy.

· In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%. Therefore, these have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these antibiotics vary by geographic region and can exceed 20% in some areas.

Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas resistance rates exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant organisms (sometimes referred to as "collateral damage") and there are several “black box” warnings on fluoroquinolones due to some serious side effects. Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are not eligible to receive recommended first-line agents.

Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there are less data with these agents. The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate, second-generation cephalosporins (cefaclor), third-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances first-generation cephalosporins (cephalexin and cefadroxil).

In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug-drug interactions, recent antibiotic use, and renal function, among others.

Recommended Dosing and Duration for Cystitis Therapy

Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has similar efficacy to that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other recommended first-line agents have different recommended durations. See the table below for recommended durations of first-line agents.

First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.

Drug	Dose and interval	Duration
Trimethoprim-sulfamethoxazole	160/800 mg q 12 hours	3 days
Nitrofurantoin monohydrate macrocrystals	100 mg q 12 hours	5 days
Fosfomycin trometamol	3 gm in a single dose	1 dose

Recommended Therapy for Pyelonephritis

In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic urinalysis. Definitive antibiotic choice should be based on the results of the urine culture.

For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the local resistance rates are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be given for pyelonephritis.

Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism is known to be susceptible. Two-week regimens are generally advised when using trimethoprim-sulfamethoxazole. If trimethoprim-sulfamethoxazole is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be given before starting the course of trimethoprim-sulfamethoxazole.

Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained.

You and Dr. Sattovia give Ms. Pham the prescription for nitrofurantoin, and she says, "Thanks! But, does this mean that there is something wrong with my bladder and I'm going to get this again? Is there any way I can prevent this from coming back?"

Dr. Sattovia explains that she could get a bladder infection again, but recurrent bladder infections are common in young, healthy females even though most have normal urinary tract anatomy, and they generally do not lead to serious long-term health problems.

Indications for Imaging or Urologic Evaluation in a Patient with a UTI

Imaging studies and urologic referral are not indicated in the routine evaluation of young females with cystitis or pyelonephritis because they rarely uncover abnormalities that require treatment. However, in certain groups, further evaluation is recommended to exclude anatomic abnormalities and complications of pyelonephritis.

· Isolation of Proteus can be associated with urologic (struvite) stones so may require imaging, especially in patients with recurrent or refractory infections despite adequate antibiotic treatment.

· Recurrent pyelonephritis should prompt imaging to rule out nephrolithiasis or other urologic anomalies.

· Patients with pyelonephritis who remain febrile and show no clinical improvement within 72 hours on appropriate antibiotic therapy should have imaging to rule out obstruction or renal or perinephric abscesses. The presence of these complications often requires drainage and longer courses of antibiotics.

· Patients with suspected abnormality of the urinary tract.

CT scan or renal ultrasound is recommended as a first step to rule out nephrolithiasis or obstruction prior to urologic evaluation in these circumstances.

Urologic evaluation, including cystoscopy, should also be performed in those with persistent hematuria after infection has been eradicated.

Preventing Recurrent UTIs

1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis and urine culture. Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical irritation, or urethritis.

2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating infections. These predisposing factors should be treated if present.

3. In patients without predisposing factors, some clinicians attempt behavioral and lifestyle modification. Because sexual activity is associated with recurrent infections, doctors often recommend that females void before and after sexual intercourse. This, and advice to wipe "front to back," increase fluid intake (including cranberry juice), and avoid full bladders, have not been proven to reduce the recurrence of infection, but they are benign maneuvers, and still make sense to many clinicians.

4. For post-menopausal females, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection.

5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at least two in six months, antibiotic prophylaxis may be considered.

Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do not differ significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than continuous prophylaxis with similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise, patient-initiated treatment upon developing symptoms can represent a cost-effective management strategy if infections are not severe and not frequent.

The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns of the patient's prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by observation for reinfection.

Dr. Sattovia also goes over some birth control options with Ms. Pham. Ms. Pham is pretty sure she wants to start the combination pill but wants to read more before she makes a final decision. You give her this  pamphlet published by the American College of Obstetricians and Gynecologists.

She takes the antibiotic prescription, and Dr. Sattovia and you wish her luck at college and tell her that you will call her when all the results of her tests are back.

TEACHING POINT

Birth Control Options

Percentage of females experiencing an unintended pregnancy within the first year of use: United States

Method	Typical use	Perfect use
No method	85	85
Spermicides	29	18
Withdrawal	27	4
Fertility awareness-based methods	25
· Standard days method		5
· Two day method		4
· Ovulation method		3
Sponge
· Parous females	32	20
· Nulliparous females	16	9
Diaphragm	16	6
Condom
· Female (Reality)	21	5
· Male	15	2
Combined pill and progestogen-only pill	8	0.3
Evra patch	8	0.3
NuvaRing	8	0.3
Depo-Provera	3	0.3
Combined injectable (Lunelle)	3	0.05
IUD
· ParaGard (copper T)	0.8	0.6
· Mirena (LNG-IUS)	0.2	0.2
Implanon	0.05	0.05
Female sterilization	0.5	0.5
Male sterilization	0.15	0.10

Adapted from WHO Medical eligibility criteria for contraceptive use (2009)

· Male latex condoms: when correctly used with each episode of intercourse are the best protection against sexually transmitted infections.

· IUDs: can be considered for females at low risk of acquiring sexually transmitted infections, since sexually transmitted infections may require removal of the IUD. Females with a history of PID can safely use the IUD with appropriate counseling. IUDs can be used as long as the female is not planning a pregnancy for at least one year, since attempting a pregnancy would require IUD removal. Females who have never been pregnant can safely use the IUD.

· Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the risk of pregnancy by at least 75%.

You drop by the office to review lab results from yesterday.

You see that Ms. Pham's chlamydia test is positive. You discuss with Dr. Sattovia what you will say to Ms. Pham and then give her a telephone call.

After introducing yourself, you ask,

"How are you doing?"

"I feel so much better! My urine symptoms are almost all gone."

"Well I'm sure glad to hear you are improving. I'm calling to tell you though, that the chlamydia test we did during the pelvic exam was positive."

"Oh, no. You get chlamydia from sex, right?"

"That's right. Chlamydia is transmitted by unprotected sexual intercourse, and often men and women don't have symptoms with it. Because you are feeling better, I suspect your urinary symptoms were caused by a bladder infection, and that the chlamydia infection so far hasn't caused you to feel bad. Nevertheless, we should treat you, because if we don't, it could lead to a serious infection of your uterus and ovaries called pelvic inflammatory disease."

Recommended Chlamydia Therapy

First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline 100 mg twice daily. The one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin are considered alternative treatment agents and require seven days of therapy.

You tell her you will call in a prescription for azithromycin and explain that she should take both pills all at once. You advise her to have blood tests to check for HIV and syphilis, and encourage her to talk with her boyfriend. You explain that he should be treated for chlamydia. He should also be tested for gonorrhea because it is common for gonorrhea and chlamydia to cause coinfection. He should be tested for HIV as well.

"Oh, and this is important: you should not have sex for a week after you and your boyfriend take the medication."

You write the prescription and fax it to the pharmacy, and fax an order to the lab for an HIV test. Ms. Pham thanks you for all of your help.