Introduction
Urinary tract infection (UTI) is among the most prevalent infections in senior citizens. The condition is common in long-term care facilities, and it has been noted that UTI is only second to respiratory infections in inpatients and community-dwelling seniors aged above 65 years old (Rowe & Juthani-Mehta, 2013). As many Americans age, the burden associated with the UTI in senior citizens is most likely to escalate, resulting in the need for enhanced diagnostic, management, and prevention practices important to advance the health of older persons. The purpose of this term is to discuss Lower Urinary Tract Infection, which is the infection that occurs at or below the area of the bladder.
Clinical Scenario
A 65-year-old community-dwelling man presents with inflammatory symptoms in the lower urinary tract, such as fever, urinary frequency, urinary agency, dysuria, variable suprapubic discomfort, nocturia ((nighttime frequency), and notably gross hematuria. He complains of low back pain for the last five days while fever has been noted for the last two days.
Over the past two days, the patient has worsened with the symptoms of pain noted as 9/10 and nausea. A culture test has shown the presence of extended-spectrum beta-lactamase Escherichia coli, and the patient had a similar condition more than six months ago noted with a similar organism separated. The patient also responded to nitrofurantoin treatment.
Subjective
Chief Complaint
The patient chief complaints were dysuria. He also complained of urinary frequency, urgency, discomfort, and fever.
History of Present Illness
The patient had complained of a five-month urinary urgency. The condition was characterized by frequent waking per night to void, weak stream and straining. The patient appeared otherwise ill and uncomfortable. While back pain and fever were not specific, they suggested the presence of pyelonephritis. Notably, atypical symptoms were observed in the patient.
The initial assessment of the patient revealed dysuria, at least three nighttime frequencies, urinary urgency, and urinary inconsistence. The further assessment also indicated suprapubic discomfort, mild dehydration, febrile, bladder spasm, incomplete bladder emptying post void, a trace of blood in the urine (hematuria), and foul-smelling urine.
Review of Systems
HEENT
The patient lacked any deformity or swelling in the skull, and the neck was without any deformity. The patient had normal eye dilation and the ear and nose were normal. He, however, presented dry oral mucosa.
Pulmonary
The patient’s lungs were clear to auscultation.
Heart
The patient had a fast resting heart rate of more than 100 per minute, which was noted as abnormal.
Gastrointestinal
The gastrointestinal system was normal in the patient.
Genitourinary
Possible structural and functional abnormalities of the GU system, including obstruction, flank pain, suprapubic pain, genital irritation, low back pain, and tenderness were observed in the patient.
Neurologic
The patient reported confusion and drowsiness.
Past medical history
The patient was previously treated for UTI and hypertension. Recurrent UTI was suspected for the patient.
Immunizations
The patient underwent the required immunizations.
Past Surgical History
There was no case of past surgical history observed or stated.
Allergies
The patient reported no known drug allergies (NKDA).
Medications
The patient is currently on lisinopril 10 mg daily.
Family Medical History
The family has a history of hypertension and diabetes.
Social History
The patient is sexually active and reported having more than one partner in the last six months.
Objective
Lab data
The laboratory workups, including dipstick test and urinalysis, revealed white blood cell count of 10,000, 90% neutrophils while hematocrit, platelets, and electrolytes were within the normal range. The patient had a bun of 24 and a creatinine of 1.0. Further, urinalysis revealed ++LE (leukocyte esterase), TNTC WBCs with clumps and multiple bacteria confirmed as E. coli.
Physical Examination
Vital signs were reported as T 38.9, BP 95/55, HR 115: RR27: and sat 93%RA.
Head
The patient generally had no asymmetrical or deformities in the head.
Eyes
The dilation of the eyes was generally normal.
Ear, Nose, Mouth, and Throat
The examination revealed dry oral mucosa.
Neck
A normal neck was observed in the patient.
Lungs
The lung examination revealed that the patient had normal lungs, which was reported as clear to auscultation and the breath sounds were equal bilaterally (Lungs CTA, BS = B).
Heart
Cases of tachycardic, RR, no m/r/g were reported following cardiovascular examination.
Abdomen
Abdominal pain was noted as burning, constant, localized, and severe. Flank, suprapubic, genital, low back pain was noted. Moderate suprapubic tenderness was also observed in the patient. Additionally, CVA tenderness was also noted.
Genitalia
External genital examination showed meatal stenosis in the patient. Further, the rectal analysis revealed tenderness to show possible acute prostatitis. The penile discharge was not observed during the assessment. Given the sexual history and activity of the patient, further STI screening was recommended. Testicles appeared enlarged.
Extremities
No cyanosis/clubbing/or edema (no c/c/e) was observed in the patient.
Neuromuscular
There was no case of neuromuscular dysfunction observed in the patient.
Assessment / Diagnosis
The patient was diagnosed with lower urinary tract infection based on the presenting features, including urinary urgency, frequency, dysuria, flank, and suprapubic pain, and foul-smelling urine. Additionally, fever, nausea, low back pain, and rigors were also observed and used to confirm the presence of lower urinary tract infection in the patient.
Differential diagnostic
The differential diagnosis for prostatitis, epididymitis, and chlamydial infection was conducted, as well as urothelial carcinoma, pelvic inflammatory disease, STIs, and bladder calculi.
Plan
Acute lower UTI in the male patient was considered as complicated. Antimicrobial treatment for the patient was chosen based on the clinical presentation, known as infecting organisms and susceptibilities. The side effect profile of the antibiotic and renal function influences was also considered.
The patient education focused on the disease, treatment processes, and expected course of the disease. The patient was also advised to visit the clinic if fever increases or symptoms did not improve within two to three days. It was noted that adherence to the use of medication in terms of dose, frequency, side effects and successful completion of the treatment course was extremely important. Enhanced fluid intake to about ten glasses each day was necessary. The patient was also advised to practice voiding after intercourse.
A monitoring and follow-up plan was based on the failure of symptoms to resolve within two to three days irrespective of the treatment. Also, the advanced age of the patient was used to classify him for further consultation with a physician or nurse practitioner.
Order new labs
While the laboratory workups conducted revealed that the disease was positively identified, the notable complicating factors, including fever, flank pain, nausea, and CVA tenderness required further consultation. Hence, further laboratory analysis was necessary to evaluate upper urinary tract infection because of high fever beyond 380C.
Treatment
As previously noted, lower urinary tract infection in men is considered complicated and, thus, goals of treatment included the relief of current symptoms, eradication of infection, and prevention of recurrence and complications.
The medication preferred included cefixime 400 mg po daily 7 – 14 days; Amoxicillin-clavulanate 875 mg po BID for 7-14 days; or trimethoprim 160 mg/sulphamethoxazole 800 mg, 1 tab po bid for 7-14 days.
Non-pharmacological interventions for the patient included rest because of febrile and enhanced intake of fluids.
SOAP Analysis
Subjective Analysis
The lower urinary tract infection is now common in the community and hospitals (Jarvis, Chan, & Gottlieb, 2014), and it is observed that the condition affects about 50% to 90% of men aged 50 years or older (Hale, Choi, & Lohri, 2014). The condition has also been attributed to several cases of bacterial infection in older men (Schaeffer & Nicolle, 2016). Notably, older men who present to the emergency departments or their primary care physicians often complain of urinary urgency, urinary frequency, slowed stream, and nocturia, which are symptoms generally related to benign prostatic hyperplasia (BPH) (Elterman & Kaplan, 2014).
Objective Analysis
An objective analysis of the lower urinary tract infection starts with a physical examination that focuses on vital signs. Also, the suprapubic area of the patient was examined to eliminate possible bladder distention while the neuromuscular examination was conducted to identify possible neuromuscular dysfunction. A digital rectal examination was done to evaluate “anal sphincter tone in addition to prostate gland size, shape, and consistency” (Hale et al., 2014, p. 566). Urinalysis was done for hematuria, proteinuria, pyuria, or other potential abnormalities in the patient. Further, urinary sediment assessment and culture and sensitivity analysis were conducted to identify lower urinary tract infections.
The physician used all abnormalities observed in the patient’s past medical history, physical examination, and laboratory workups to make a treatment decision based on the diagnosis. The referral was vital because of past infection and other complicating conditions, such as fever, nausea, tenderness, and meatal stenosis.
Once all these objective examinations were conducted, it was apparent that the patient had an acute case of lower urinary tract infection from the E. coli – (80-90% of cases) (Elterman & Kaplan, 2014).
Assessment Analysis
The assessment for older men with lower urinary tract infections usually starts with a thorough medical history and physical examinations concentrated on the genitourinary system (Hale et al., 2014), and the findings are later supported with objective assessments.
It was observed that cystitis (bladder infection) is generally common in community-dwelling men. It is presented with irritative symptoms in the lower urinary tract (Schaeffer & Nicolle, 2016). Physicians or nurse practitioners usually focus on dysuria, urinary urgency, urinary frequency, nocturia, gross hematuria, and suprapubic discomfort (Schaeffer & Nicolle, 2016).
Acute bacterial prostatitis is known to reveal itself in the form of fever alongside other signs of lower urinary tract infection. Hence, culture and sensitivity analysis of a urine specimen was necessary for the identification and subsequent management of the lower urinary tract infection. The presence of a large number of bacteria indicated lower urinary tract infection. It also observed that pyuria is not specific to any infection, and it is common among older patients (Schaeffer & Nicolle, 2016). Hence, further analyses of urine specimens were necessary.
It was also noted that the patient was a suitable candidate for upper urinary tract assessment because of his high fever (Schaeffer & Nicolle, 2016). Immediate assessment using computed tomography (CT) or renal ultrasonography was vital to ensure that possible obstruction or some abnormalities were not present.
Given the past treatment of the condition and advanced age of the patient, it was observed that possible bacterial persistence could occur thin the urinary tract and, thus, different medication for complicated lower urinary tract infection was preferred.
Plan Analysis
The antimicrobial treatment for the patient was chosen based on the clinical presentation, identified infecting bacteria and susceptibilities, possible side effects of the medication, and renal activities (Schaeffer & Nicolle, 2016). Treatment agents with relatively high rates of urinary excretion were preferred (Wang, Liao, & Kuo, 2015).
For lower urinary tract infection, the first-line pharmacology intervention involves nitrofurantoin, but cefixime, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, ciprofloxacin or levofloxacin was preferred to be administered between 7-14 days. Nitrofurantoin was not selected because of its restricted tissue penetration and possible diminished impacts on bacterial prostatitis (Schaeffer & Nicolle, 2016).
The presence of complicating conditions, such as meatal fever, nausea, tenderness, and meatal stenosis, necessitated referral and further consultation.
Patient education included strict adherence to medication, voiding after intercourse, and seeking further medical attention if no improvement was observed within two to three days during medication. Additionally, non-pharmacological interventions for the patient included adequate rest and increased fluid consumption.
Conclusion
Lower urinary tract infection is now common in older people. The patient in the case study was diagnosed with the condition from E. coli that presented itself as an acute case of the lower urinary tract infection. While multiple cases of lower urinary tract infections could be easy to detect and manage, the increasing cases among senior people and resistant bacteria present considerable challenges to physicians and nurse practitioners. Hence, careful assessment with specialists is vital to ensure that effective antimicrobial agents are administered.
References
Elterman, D. S., & Kaplan, S. A. (2014). Lower Urinary Tract Symptoms in a 66-Year-Old Man. Canadian Medical Association Journal, 186(7), 525–527. DOI: 10.1503/cmaj.130449.
Hale, N., Choi, K., & Lohri, J. (2014). Primary Care Evaluation and Treatment of Men With Lower Urinary Tract Symptoms. Journal of the American Osteopathic Association, 114(7), 566-571. DOI: 10.7556/jaoa.2014.110.
Jarvis, T. R., Chan, L., & Gottlieb, T. (2014). Assessment and Management of Lower Urinary Tract Infection in Adults. Australian Prescriber, 37(1), 7-9. DOI: 10.18773/austprescr.2014.002.
Rowe, T. A., & Juthani-Mehta, M. (2013). Urinary Tract Infection in Older Adults. Aging Health, 9(5), 519-528. DOI: 10.2217/ahe.13.38.
Schaeffer, A. J., & Nicolle, L. E. (2016). Urinary Tract Infections in Older Men. New England Journal of Medicine, 374(6), 562-571. DOI: 10.1056/NEJMcp1503950.
Wang, C.-C., Liao, C.-H., & Kuo, H.-C. (2015). Clinical Guidelines for Male Lower Urinary Tract Symptoms Associated with Non-neurogenic Overactive Bladder. Urological Science, 26(1), 7–16.