Genitourinary Tract Disorders
In the wilderness, genitourinary tract disorders are common, and urinary tract infections (UTIs) constitute the majority of complaints. Also included in this chapter are pyelonephritis, urethritis, epididymitis, prostatitis, testicular torsion, urinary tract obstruction, and acute urinary retention. Gynecologic infections and emergencies are discussed in chapter 31.
Urinary Tract Infection
1. UTIs are more common in women.
2. The incidence increases in postmenopausal women and women with histories of recent frequent sexual intercourse.
3. In women the primary cause of UTI is invasion of the urinary tract by bacteria that have ascended the urethra from the introitus.
4. Most of these infections are caused by gram-negative aerobic bacteria, most often Escherichia coli.
5. UTIs are rare entities in men younger than 50 years.
6. Despite the difference in prevalence, symptoms in men and women are similar.
7. Infection of the urinary tract in a male is often associated with prostatic enlargement or infection.
Lower UTI (Uncomplicated UTI)
1. Pyelonephritis associated with chills and fever
2. Urethritis (more probable in sexually active persons with multiple or new partners)
3. Chlamydial or gonococcal cervicitis (often associated with cervical discharge)
4. Vaginal infection (associated with vaginal discharge, external irritation, or pain with intercourse)
5. Ureterolithiasis (dysuria with flank pain, restlessness, and costovertebral angle [CVA] tenderness suggests urinary tract stone[s])
Treatment
1. Perform a physical examination, including determination of temperature, abdominal examination, and assessment for CVA tenderness.
2. Perform a pelvic (bimanual) examination in a woman whose symptoms are associated with pelvic pain or vaginal bleeding. Although a formal pelvic examination using a speculum with the individual in a lithotomy position is virtually impossible in the wilderness, a simple bimanual examination might identify an adnexal or uterine process (e.g., ectopic pregnancy, pelvic inflammatory disease). Perform a pregnancy test.
3. Give oral antibiotic therapy using one of the following:
a. Trimethoprim/sulfamethoxazole one double-strength (DS, 160/800 mg) tablet bid for 3 days
b. Ciprofloxacin 500 mg bid for 3 days
c. Nitrofurantoin 100 mg bid for 5 days is a safe option for pregnant women
4. If symptoms persist after standard therapy:
5. In addition to the antibiotic therapy, provide pain relief for dysuria by administering phenazopyridine (a urinary anesthetic) 200 mg PO tid for a maximum of 2 days. Warn the patient that the urine (and possibly contact lenses) will turn orange.
Pyelonephritis
Treatment
1. Administer an oral antibiotic if the patient is nonpregnant and immunocompetent and can tolerate oral medication.
a. Reasonable antibiotic choices include ciprofloxacin 500 mg bid or levofloxacin 750 mg daily for 10 to 14 days.
2. For a severely ill, immunocompromised, or pregnant patient, initiate therapy with a parenteral antibiotic such as a third-generation cephalosporin (ceftriaxone 1 g IM or IV daily).
4. When a high fever is present:
a. Routinely administer acetaminophen 500 mg q4h or ibuprofen 600 mg q6h to make the patient more comfortable.
b. If the fever persists, consider the possibility of a resistant organism, UTI, or abscess.
5. Arrange for evacuation of immunocompromised or pregnant patients, when protracted vomiting makes oral therapy impossible, or when generalized toxicity (volume depletion, fever greater than 38.9° C [102° F] or marked CVA tenderness) is present.
6. Instruct patients to seek medical follow-up on return, even if symptoms resolve fully.
