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A 28 year old G0 calls the office with complaints of lower abdominal pressure and urinary frequency. She has been in the office four times over this past year for dysuria and has been treated for UTI. She is sexually active on Apri for contraception. She has a negative GYN history. She feels her UTI symptoms seem to be occurring within 12 hours of intercourse.
PMH – PCOS
Medications – Loestrin 1/20, Mvi, Omega 3
Allergies – Ciprofloxacin
Vitals: T=98.4, B/P=118/72, Pulse = 84
| Color, Urine | yellow |
| Clarity, Urine | Turbid |
| pH, Urine | 5.5 |
| Glucose, Urine | Negative |
| Protein, Urine | 100 mgdL |
| Ketones, Urine | Negative |
| Blood, Urine | Large |
| Nitrite | Positive |
| Leukocytes Urine | Large |
| Specific Gravity, Urine | 1.020 |
| White Blood Cells, Urine | 818 |
| Red Blood Cells, Urine | >900 |
| Bacteria, Urine | Many |
| Hyaline Casts | <=10 |
Culture results with >100,000 CFU/ML Escherichia coli
| Escherichia coli Not Specified | |
| Ampicillin | <=8 ug/ml Sensitive |
| Ampicillin + Sulbactam | <=1/.5 ug/ml Sensitive |
| Cefazolin | <=2 ug/ml Sensitive |
| Cefepime | <=2 ug/ml Sensitive |
| Ceftriaxone | <=1 ug/ml Sensitive |
| Ciprofloxacin | <=1 ug/ml Sensitive |
| Gentamicin | <=1 ug/ml Sensitive |
| Nitrofurantoin | <=32 ug/ml Sensitive |
| Tobramycin | <=1 ug/ml Sensitive |
| Trimethoprim + Sulfamethoxazole | <=2/38 ug/ml Sensitive |
- What would you include in your focused physical exam?
- What diagnostic tests would you include today?
- What is your interpretation of these results?
- Would you select to treat this patient?
- What does MIC mean? How does it influence choosing a treatment?
- Explain your reasoning for selecting the treatment you chose.
- What would your choice be if she was pregnant?
- Explain why women are at higher risk for urinary tract infections.
- As you finish your visit she asks, “What can I do to prevent this from happening?” How do you answer this question, and what can she do to prevent them from happening in conjunction with sexual relations?
References are below with hyperlinks
- Urinalysis: A Comprehensive Overview – AAFP
- ACOG practice bulletin – Treatment of Urinary Tract Infections in Non-pregnant women
- ACOG vide- Recurrent Urinary Tract Infection Prevention
- ACOG – FAQ Urinary Tract Infections
- Managing acute UTIs in postmenopausal women
- American Cancer Society – Prostate Cancer Screening Guidelines
- American Urological Association – Prostate Cancer Screening Guidelines
- American Urological Association – Evaluation and Management of Testosterone Deficiency
- American Urological Association – Kidney Stones
- United States Preventative Task Force – Prostate Cancer Screening
- American Academy of Clinical Endocrinologists – Reproductive Medicine – Male Sexual Dysfunction
- American Academy of Clinical Endocrinologists – Reproductive Medicine – Evaluation and Treatment of Hypogonadism in Male Patients
Expert Solution Preview
Introduction:
The case describes a 28-year-old woman with lower abdominal pressure and urinary frequency. She has a history of dysuria and has been treated for UTI multiple times in the past year. The patient is sexually active and on Apri for contraception. The following questions will address the focused physical exam, diagnostic tests, interpretation of the results, treatment selection, MIC, and prevention strategies for urinary tract infections.
1. What would you include in your focused physical exam?
The physical exam would include an abdominal exam to assess for tenderness or masses. A genital exam may also be performed to rule out pelvic inflammatory disease or any vaginal or cervical abnormalities. An exam of the pelvic floor muscles may also be useful to rule out any muscle spasms or pelvic floor dysfunction, which can contribute to urinary symptoms.
2. What diagnostic tests would you include today?
The diagnostic tests for a suspected UTI include a urinalysis, urine culture, and sensitivity testing.
3. What is your interpretation of these results?
The results indicate the presence of a urinary tract infection caused by Escherichia coli, with a colony count of 100,000 CFU/ML. The urinalysis also shows the presence of large amounts of leukocytes, as well as blood in the urine. The results of the sensitivity testing allow for targeted antibiotic therapy.
4. Would you select to treat this patient?
Yes, treatment is necessary for this patient, given the positive culture results, symptoms, and previous history of UTIs.
5. What does MIC mean? How does it influence choosing a treatment?
Minimum inhibitory concentration (MIC) refers to the lowest concentration of an antibiotic required to inhibit bacterial growth. It is used in sensitivity testing to determine the most effective antibiotic treatment options for bacterial infections. The MIC value influences the choice of treatment, as antibiotics with lower MIC values are more effective in inhibiting bacterial growth, and therefore, the preferred treatment option.
6. Explain your reasoning for selecting the treatment you chose.
The patient’s urine culture results show sensitivity to multiple antibiotics that include Trimethoprim + Sulfamethoxazole, Ciprofloxacin, and Nitrofurantoin. However, the patient has an allergy to ciprofloxacin, and nitrofurantoin has a limitation in treating upper UTIs. Therefore, trimethoprim/sulfamethoxazole is a reasonable first-line option for treating uncomplicated cystitis.
7. What would your choice be if she was pregnant?
If the patient were pregnant, amoxicillin, cephalexin, and nitrofurantoin would be the best options for treatment, as these are compatible with pregnancy.
8. Explain why women are at higher risk for urinary tract infections.
Women have a shorter urethra than men, which makes it easier for bacteria to travel from the outside of the urethra up into the bladder. Sexual activity can also contribute to the risk of UTIs by introducing more bacteria into the urinary tract. Hormonal changes during pregnancy, menopause, and the use of hormonal contraceptives can also increase a woman’s susceptibility to UTIs.
9. As you finish your visit, she asks, “What can I do to prevent this from happening?” How do you answer this question, and what can she do to prevent them from happening in conjunction with sexual relations?
To prevent UTIs, the patient should ensure proper hygiene, urinate before and after sexual activity, and drink plenty of fluids. The patient should also avoid irritating feminine hygiene products and make sure to wipe from front to back after using the restroom. Using a vaginal estrogen cream may also help prevent recurrent UTIs in postmenopausal women. Additionally, taking a low-dose antibiotic after intercourse may be an option for individuals who experience UTIs in association with sexual activity.
