Genitourinary Conditions

Urinary Tract Infections (UTI)

• Except in acute uncomplicated cystitis in women, diagnosis must be confirmed before treatment is begun and antimicrobial sensitivity should direct the therapy.
• Identify the predisposing factors and correct, if possible.
• Relief of clinical symptoms does not always include bacteriologic cure.
• Each course of treatment should be defined as failure or cure on the basis of symptoms and eradication of bacteria.
• Uncomplicated lower UTIs generally respond to short courses of therapy while upper UTI and complicated lower UTIs require longer treatment.
• Recurrences more than two weeks after cessation of therapy nearly always represent reinfection.
• Community acquired infections particularly the first infections are usually due to more antibiotic sensitive strains.
• In hospitalized patients, those requiring instrumentation and having recurrent infections, antibiotic resistant strains are the more likely cause of UTI.

Nonpharmacological

Plenty of oral fluids

Pharmacological

If symptoms are severe, antibiotics may be started empirically, after sending the urine samples. Otherwise, the antibiotics can be started as suggested by the culture and sensitivity report if symptoms are not severe.

1. The specific treatment regimen is shown in the Table 1.
2. Alkalinizing agents may be used with certain antibiotics like cotrimoxazole to prevent precipitation of crystals.
3. Tab. Pyridium up to 2 Tab. 3 times a day for the first 2-3 days as a urinary analgesic to relieve dysuria.

Prophylaxis

Antibiotics for prevention are recommended to women who have two or more episodes of infection within six months or three or more infections within one year. The recommended antimicrobials include daily or thrice weekly administration of a single dose of TMP-SMZ (80/400 mg), TMP alone (100 mg) or Nitrofurantoin (560 mg). Prophylaxis should be initiated only after bacteriuria has been eradicated with a full dose treatment regimen. Same regimen can be used as a single dose after sexual intercourse in women in whom episodes of symptomatic UTIs are related to sexual intercourse. Frequent urine cultures are essential during this period.

Suppressive antibiotics

Indicated in patients with repeated infections with an underlying cause, till the underlying cause is removed or controlled e.g. to infants and children with vesico-ureteric reflux till 3-5 years of age and to elderly requiring prolonged catheterization. The recommended drugs are same as above.
Note: See also UTIs in paediatric section.

Treatment
UTIs in pregnancy

Asymptomatic bacteriuria in pregnancy must be treated appropriately.
(CAUTION: Cotrimoxazole and furoquinolones are not recommended during pregnancy)

UTIs in elderly

Treatment is not recommended for asymptomatic infections among the elderly, particularly men.

UTIs in catheterized patients

The need for treatment and optimal type and duration of treatment for such patients with asymptomatic bacteriuria have not been established.

Removal of catheter with a short course of antibiotic may be appropriate.

If catheter cannot be removed, bacteriuria should be ignored until patient is symptomatic or at high risk of developing bacteriuria.

Follow-up

Patient should be re-evaluated within 3-5 days for relief of symptoms and urine microscopic examination and culture examination should be repeated. In upper UTIs, fever and other symptoms normally subside within 2-3 days after starting the treatment. If symptoms do not subside within 5 days, underlying abnormalities like obstruction to the urinary tract, stones or collection of pus should be looked for. If the infection relapses after an initial treatment for 14 days, a six week treatment is recommended.

Table 1: Treatment regimen for bacterial urinary tract infections

TMP – Trimethoprim, SMZ – Sulfamethoxazole

• Both the partners to clean the genitalia before and after sexual intercourse
• Avoid diaphragm with spermicide as a contraceptive
• Wipe from front to back during eblution.

Patient education

• To drink plenty of water, at least 10 glasses per day
• Not to control the urge to pass urine. To empty the bladder completely and very often.
• To empty the bladder after sexual intercourse.

References

1. Urinary Tract Infections. In : Oxford Textbook of Medicine, Weatherall DJ, Ledingham JGG. Warell DA (eds), 3rd Edition, 1996, Oxford University Press, pp-3205-3215.
2. Urinary Tract Infections and Pyelonephritis. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp-1620-1626.
3. Acute Urinary Tract Infection. Health Update. A monthly bulletin of the society for health education and learning packages 1997; 1(8): 87-93.

Chronic Renal Failure (CRF)

1. Identification and management of associated factors precipitating acute or chronic renal failure e.g., drugs, hypovolemia, infections, obstructive uropathy, hypertension, CHF, pregnancy or presence of any lifethreatening emergency, requiring urgent treatment e.g. hyperkalemia, pulmonary oedema, metabolic acidosis, uraemic encephalopathy or accelerated hypertension (Treat as mentioned under respective conditions).
2. Identification of specific cause of CRF and their treatment so as to delay the progress of CRF.
3. Modify loading and maintenance doses of drugs that are excreted through renal route.

Nonpharmacological

• Decrease protein intake to 0.6 g/kg/day of high quality protein.
• Phosphate restriction to 1000 g/day to reduce soft tissue calcification (avoid milk, egg etc.).
• Moderate sodium restriction to 60 mmol/day (low salt during cooking and avoiding foods rich in sodium) to control BP and oedema.
• Potassium restriction if CRF is moderate to severe (foods rich in K+ include banana, citrus fruits, coconut water, papaya etc.)
• Fluid restriction is not generally necessary until late in renal failure.
• Sodium bicarbonate (baking powder) 600 mg QID if plasma HCO3 is less than 20 mmol/liter.

Pharmacological

Control of hypertension, cardiovascular and pulmonary abnormalities

Target BP is 130/80-85 mmHg and in-patients with proteinuria >1 g/day, it is 125/75 mmHg (for details see section on hypertension).

The preferred drugs are:
Tab. Frusemide 40-160 mg per day.
Or
Tab. Amlodipine 5-20 mg per day.
And/Or
Tab. Atenolol 50-100 mg per day (contraindicated if concomitant cardiomyopathy with failure).
In diabetic nephropathy or CRF with proteinuria – ACE inhibitor/angiotensin receptor blocker with or without diuretic are preferred.

Treatment of pericarditis

Uraemic pericarditis is an absolute indication for initiation or intensification of dialysis. Heparin free dialysate should be used.

Treatment of anaemia

1. Look for common aggravating causes of anaemia e.g. (GI blood loss, iron deficiency and chronic infections) and treat. Assess iron status of patient before Erythropoietin (EPO) therapy.
2. Iron supplementation to ensure adequate response to EPO.
3. Inj. EPO subcutaneous 80-120 units/kg/week (divided into 2-3 times a week)

The target Hb should be 10-12 g/dl and optimal rate of correction should be to increase haematocrit by 4-6% over 4 week period.

Treatment of bleeding diathesis

Usually a problem arises when a patient of CRF needs to undergo some surgery.
Inj. Vasopressin (DDAVP) 0.3 mcg/kg in 100 ml of saline in 30 min, to be administered before surgery.

Treatment of bone, phosphate and calcium abnormalities and acidbase disturbances

1. Phosphate restricted diet.
2. Phosphate binding agents (aluminium based antacids)
3. Calcium carbonate- minimum of 1 g/day
4. Vit D3/Calcitriol – 0.25- 2 mcg day

Maintain serum calcium at about 10 mg% and phosphate at about 4.5 mg%

Treatment of hyperuricemia (gout) if it is symptomatic

Tab. Allopurinol 100-200 mg/day preferably after food, then adjusted according to plasma or urinary uric acid concentration. Management of metabolic acidosis should aim to maintain a near normal value of bicarbonate Calcium carbonate is usually adequate. If needed sodium bicarbonate can also be added. For monitoring the progression of renal failure measure serum creatinine and creatinine clearance. ECG may show evidence of Left ventricular hypertrophy (LVH), pericarditis or hyperkalemia.

Absolute indications for dialysis

Development of complications that cannot be controlled by conservative and pharmacological means e.g., fluid overload, severe hypertension, pericarditis, refractory hyperkalemia, severe metabolic acidosis, encephalopathy and progressive neuropathy attributable to uraemia. Renal replacement therapy (RRT) therapy should not be initiated when the patient is totally asymptomatic.

Renal Replacement Therapy (RRT):

The choice of modality include – haemodialysis, continuous ambulatory peritoneal dialysis or renal transplantation, the choice depends on many factors – their availability, patient’s preference and availability of potential donors. Only kidney transplantation offers the potential for nearly complete rehabilitation .

Patient education

• Counselling as most of these patients have varying reactions to illness from anger to depression. Prepare the patient physically and psychologically for renal replacement therapy, when ESRD is inevitable.

References

1. Chronic Renal Failure. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., pp 1551-62.
2. Chronic Renal Failure. In; Oxford Textbook of Medicine, Weatherall DJ, Ledingham JGG, Warrell DA (eds), 1996, Oxford University Press, pp 3294-3306.

Acute Renal Failure (ARF)

Treatment

Identify the causative factors and triggering event and treat accordingly for disease-specific therapy and prevention and management of uraemic complications.
Nutrition: Restrict dietary protein to 0.6 g/kg/day and carbohydrate to 100 g/day.

Treatment
Pre-renal ARF

1. Replacement fluids – Tailored according to the composition of lost fluids e.g. Blood transfusion/packed RBCs (if oliguria despite fluid correction) – in haemorrhage.
   Normal Saline (0.9%) in case of burns, pancreatitis, diabetic ketoacidosis.
   Hypotonic saline (0.45%) if increased urinary or GI losses.
   (Fluid intake = 500 ml + urine output + fluid loss from other sources)
2. Management of pulmonary edema, if present.
3. In patients with cirrhosis complicated by ARF, fluids should be administered slowly and titrated against JVP. Large volume paracentesis should be accompanied by IV albumin.

Intrinsic renal ARF (should be managed by a specialist) Approach for treatment depends upon the likely cause.

1. Acute glomerulonephritis, vasculitis – glucocorticosteroids, cyclophosphamide, and/or Plasmapheresis.
2. Allergic interstitial nephritis – glucocorticoids.
3. Malignant hypertension, toxemia of pregnancy – aggressive control of blood pressures.

Post-renal ARF

1. Suprapubic catheterization.
2. Referral to a urologist for removal of obstructing lesion.

Other essential measures

1. Strict intake/output recording.
2. Monitor serum K+ and acid-base status.
3. Reverse causative renal insult e.g. restore haemodynamics, eliminate nephrotoxins.
4. Prevention and treatment of complications.
5. Volume overload

• Restrict salt (1-2 g/day- avoid all table/cooking salt and avoid food rich in sodium like milk) and water.
• Inj. Fresemide IV dose depending upon extent of overload, usual dose is 40-120 mg/day.
• Dialysis.

Hyponatremia

1. Restrict free water intake (<1 litre/day).
2. Avoid hypotonic IV solutions.

Hyperkalemia

1. Restrict dietary Potassium ( K+) 40 mmol/d (no food containing K+).
2. Inj. Glucose insulin drip- 50 ml of 50% of dextrose with 10 units of plain insulin over 10 min.
   And/Or
   Inj. Sodium bicarbonate 50-100 ml of 4.2% IV 10 min.
   And/Or
   Inj. Calcium gluconate 10 ml of 10% solution over 5 min.
   (More than one steps taken if levels of serum K+ > 6.5)
3. Cation exchange resins e.g. Sodium or Calcium polystyrene sulphonate 15 g orally 6 hourly.

Metabolic acidosis

1. Restrict dietary protein (0.6 g/kg/day).
2. Inj. Sodium bicarbonate IV to maintain an arterial pH of >7.2.

Hypocalcaemia

1. Tab. Calcium carbonate 1 g/day or
2. IV Calcium gluconate 10% 10-20 ml given over 20 minutes (if tetany).

Hyperphosphataemia

1. Restrict dietary phosphate intake (<800 mg/day).
2. Calcium carbonate as above.

Hyperuricaemia

1. Treatment necessary only if uric acid is >15 mg %.

Dialysis is indicated for any of the following:

1. Overt uremia manifesting as encephalopathy, pericarditis, uremic bleeding.
2. Intractable fluid overload.
3. Refractory hyperkalemia.
4. Rise in urea >20 mg% or creatinine >1 mg% in 24 hours.
5. Severe acidosis producing circulatory compromise.

Doses of all essential drugs for the underlying disease should be adjusted according to the degree of renal impairment

Prevention

Since there are no specific therapy for ischaemic or nephrotoxic ARF, prevention is very important and includes:

1. Aggressive restoration of intravascular volume in case of losses e.g. during surgery, trauma, burns, gastroenteritis etc.
2. Avoid/reduce the dose of nephrotoxic drugs appropriately.
3. Hypovolemia should be avoided in patients receiving nephrotoxic drugs.

References

1. Acute Renal Failure. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, Mc-Graw Hill Companies Inc., 2001, pp 1541-51.
2. Acute Renal Failure. In: Oxford Textbook of Medicine. Weatherall DJ, Ledingham JGG, Warrell DA (eds), 1996, Oxford University Press, pp 3279-94.

Nephrotic Syndrome

• Moderate salt restriction, usually 1-2 g/day (no cooking salt) and low cholesterol diet.
• There is no consensus regarding the optimal protein in diet for these patients. High protein diet is not recommended, as it may hasten the progression of renal disease by increasing proteinuria. A protein intake of 0.8-1 g/kg/24 h of mainly first-class proteins is recommended.

Pharmacological
Nonspecific measures

1. To reduce proteinuria in patients with diabetic nephropathy
   Tab. Captopril 6.25 – 25 mg/day in 4 divided doses.
   Or
   Tab. Enalapril 1.25 – 5 mg/day as a single dose.
   NSAIDs reduce proteinuria in some patients by altering glomerular haemodynamics but benefit must be weighed against risks.
2. Tab. Frusemide 80-250 mg/day in two divided doses (8 AM, 2 PM), depending
   upon the severity of oedema. The aim is to remove upto 1.0 kg/day of oedematous fluid.
3. Only in-patients with symptomatic thrombosis
   Tab. Warfarin 2-4 mg/day (to titrate the dose to INR of 1.5-2.0).
   Patients may be relatively resistant to heparin.

Specific – Immunosuppression

Minimal change disease
Tab. Prednisolone 1-1.5 mg/kg/day for 4 weeks; followed by 1 mg/kg/day on alternate day for upto 16-24 weeks, depending upon the time to go into remission. Upto 90% of adults go into remission when Tab. Prednisolone is continued for up to 24 weeks. 50% relapse on withdrawal of steroids. Monitor for presence of symptoms and proteinuria. Treatment of relapse is same unless the patients are resistant to steroids or relapse shortly after withdrawal of steroids (steroid dependent) or relapse occurs more than three times in a year, introduce the following:
Tab. Cyclophosphamide 2-3 mg/kg/day or chlorambucil 0.1-0.2 mg/kg/day for 8-12 weeks.
(CAUTION: Adequate hydration must be maintained and monitor for side effects e.g. cystitis, alopecia, infection, infertility, secondary malignancies)
If patients are resistant to the above following may induce remission in 60-80% of patients:
Tab./Cap Cyclosporin A 5 mg/kg daily in 2 divided doses as maintenance treatment reduced to lowest effective dose according to proteinuria and serum creatinine measurements; discontinue after 3 months if no response. Monitor these patients for renal functions.

Focal and segmental glomerulosclerosis
Specific treatment – Same as above.

Membranous glomerulopathy
Treatment of underlying disease. If idiopathic steroids and immunosuppressive treatment has no role. About 40% respond spontaneously; 30-40% remit and relapse spontaneously; 10-20% show progressive decline in GFR over 10-15 years to end stage renal disease (ESRD).

Membrano-proliferative glomerulonephritis
No effective therapy; usually progress to ESRD over 5-10 years.
(CAUTION: Patient who do not respond to steroids are excellent candidate for renal transplant)

References

1. Common Clinical Presentations and Symptoms in Renal Disorders. In: Oxford Textbook of Medicine. Weatherall DJ, Ledingham JGG, Warrell DA (eds), 1996, Oxford University Press, pp 3136-49.
2. The Major Glomerulopathies. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 1580-90.
3. Idiopathic Glomerulonephritis. In: Oxford Textbook of Medicine. Weatherall DJ, Ledingham JGG, Warrell DA (eds), 1996, Oxford University Press, pp 3153-61.