Download - Dr. Maryam Emami. Urologist. Urinary tract infections (UTI) are a common cause of morbidity and account for more than 7 million visit to physicians, offices

Dr. Maryam Emami. Urologist Dr. Maryam Emami. Urologist

Urinary tract infectionsUrinary tract infections (UTI) are a common cause of morbidity and (UTI) are a common cause of morbidity and

account for more than 7 million visit to physicians, offices account for more than 7 million visit to physicians, offices

Careful diagnosis and treatment result in success full resolution of Careful diagnosis and treatment result in success full resolution of

infection in instance infection in instance

Urinary tract infectionUrinary tract infection is an inflammatory response of the urothelium to is an inflammatory response of the urothelium to

bacterial invasion that is usually associated with bacteriuria and pyuriabacterial invasion that is usually associated with bacteriuria and pyuria

UTI are more common in women than in men UTI are more common in women than in men

Acute bacterial cystitis involve young women and Acute bacterial cystitis involve young women and 25%-30%25%-30% of women of women

between the age of between the age of 2020 and and 4040 years. years.

A prevalence that is A prevalence that is 30 items30 items more than in men more than in men

Infection Infection

Site of origin Site of origin

Pyelonephritis Pyelonephritis Urethritis Urethritis Cystitis Cystitis

Acute Acute chronicchronic

Cystitis Cystitis

Bacterial Bacterial Non bacterial Non bacterial

Radiation Radiation Interstitial Interstitial

Route of infection Route of infection

Ascending route Ascending route Hematogenous route Hematogenous route Lymphatic route Lymphatic route

Urinary pathogens Urinary pathogens

Gram negativeGram negative

1.1. Ecoli most common cause of UTI Ecoli most common cause of UTI 85% of community-acquired and 85% of community-acquired and 50% hospital-acquired infection50% hospital-acquired infection

2.2. Proteus Proteus

3.3. Klebsiella Klebsiella

Gram positive Gram positive

1.1. E.FaecalisE.Faecalis

2.2. Staphylococcus Staphylococcus Saprophiticous Saprophiticous

Primary bladder defenses Primary bladder defenses

Immune response Immune response Low pHLow pH Osmolarity Osmolarity Ureasalt organic acidUreasalt organic acid

Vaginal defenses Vaginal defenses

Lacto bacilli Lacto bacilli

Clinical presentation Clinical presentation

Dysuria, frequency, urgency, suprapubic pain or Dysuria, frequency, urgency, suprapubic pain or

lower abdominal pain voiding of small urine lower abdominal pain voiding of small urine

volumes volumes

Men with acute cystitis may have a syndrome Men with acute cystitis may have a syndrome

resembling non STD urethritis resembling non STD urethritis

Diagnosis Diagnosis

Rapid screen methods Rapid screen methods Urine analysis Urine analysis

1.1. NitriteNitrite Bacteruria Bacteruria

2.2. Leukocyte esteraseLeukocyte esterase pyuria pyuria

1.1. 10 count/ml 10 count/ml

2.2. 10 count/ml with urinary symptom10 count/ml with urinary symptom

Urine cultureUrine culture

1.1. Pyuria Pyuria

2.2. Hematuria (40%-60)Hematuria (40%-60)

3.3. Bacteriuria Bacteriuria

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Treatment Treatment I: I: MenMen (young healthy) (young healthy)

Duration : Duration : 7 days7 days

Drug of choice : Drug of choice : TMP-SMX, TMP, fluroquinoloneTMP-SMX, TMP, fluroquinolone

II: II: WomenWomen

IIa: healthy women : IIa: healthy women :

Duration : Duration : 3 days 3 days

Drug of choice : Drug of choice : Fluroquinolone, TMP-SMX, Nitrofurantion Fluroquinolone, TMP-SMX, Nitrofurantion

IIb: symptom for > 7 day or recurrent UTI or age > 65 yr or diabete or diaphragm use IIb: symptom for > 7 day or recurrent UTI or age > 65 yr or diabete or diaphragm use

Duration : Duration : 7 day 7 day

Drug of choice : Drug of choice : TMP-SMX, Fluroquinolone TMP-SMX, Fluroquinolone

IIc: pregnancy IIc: pregnancy

Duration : Duration : 7 day 7 day

Drug of choice : Drug of choice : Amoxicillin, Cephalexin, Nitrofurantoin, TMP-SMXAmoxicillin, Cephalexin, Nitrofurantoin, TMP-SMX

Urologic evaluation is unnecessary in women and is Urologic evaluation is unnecessary in women and is

usually unnecessary in young men who respond to usually unnecessary in young men who respond to

therapy therapy

Excretory urographyExcretory urography is useful in patient with risk factor such as : unexplained is useful in patient with risk factor such as : unexplained

hematuria, obstructive symptom, neurogenic bladder, renal calculi, fistula, sever hematuria, obstructive symptom, neurogenic bladder, renal calculi, fistula, sever

disease (D.M) disease (D.M)

CystoscopyCystoscopy should be perfumed in men or women who have frequent reinfections and should be perfumed in men or women who have frequent reinfections and

symptoms suggestive of obstruction, bladder dys function and fistula symptoms suggestive of obstruction, bladder dys function and fistula

Follow up Follow up

Novisit & follow up is Novisit & follow up is

recommended in young recommended in young

women after therapy women after therapy

Visit, urinalysis, urin Visit, urinalysis, urin

culture are recommended in culture are recommended in

older women, or those with older women, or those with

potential risk factor & men potential risk factor & men

Recurrent urinary tract infection Recurrent urinary tract infection

Men Men womenwomen

Uncommon Uncommon

Refer to urologist Refer to urologist

Therefore, at a minimum Therefore, at a minimum

endoscopic evaluation is endoscopic evaluation is

indicated indicated

Young women Young women

Vaginal mucosal receptivity Vaginal mucosal receptivity

diaphragm-spermicid and tampon diaphragm-spermicid and tampon

Vaginal clonization with Ecoli Vaginal clonization with Ecoli

Post menopausal Post menopausal

Lack of estrogen Lack of estrogen

Change microflora Change microflora

(lacto bacillia) (lacto bacillia)

Acute PyelonephritisAcute PyelonephritisAcute pyelonephritis is defined as inflammation of theAcute pyelonephritis is defined as inflammation of the

kidney and renal pelvis, and its diagnosis is usually madekidney and renal pelvis, and its diagnosis is usually made

clinicallyclinically..

A. PRESENTATION AND FINDINGSA. PRESENTATION AND FINDINGS

Patients with Patients with acute pyelonephritis acute pyelonephritis present with, present with,

chill ,fever, and costo vertebral angle tendernesschill ,fever, and costo vertebral angle tenderness..

lower-tract symptoms such as dysuria, frequency urgencylower-tract symptoms such as dysuria, frequency urgency

. .. . Urinalysis : Urinalysis :

commonly demonstrates the presence of WBCs and red commonly demonstrates the presence of WBCs and red

blood cells in the urine.blood cells in the urine.

blood analysis blood analysis : : Leukocytosis, increased erythrocyteLeukocytosis, increased erythrocyte

sedimentation, and elevated levels of C-reactive proteinsedimentation, and elevated levels of C-reactive protein

are commonly seen on blood analysisare commonly seen on blood analysis

E. coli is the most commonE. coli is the most common

causative organism, accounting for 80% of the causative organism, accounting for 80% of the casescases..

Klebsiella, Proteus, Enterobacter, Pseudomona SerratiaKlebsiella, Proteus, Enterobacter, Pseudomona Serratia

Citrobacter account for the remaining casesCitrobacter account for the remaining cases..

gram-positive bacteria, gram-positive bacteria, Streptococcus faecalis and SStreptococcus faecalis and S . .

Aures can be important causes of pyelonephritisAures can be important causes of pyelonephritis

MANAGEMENTMANAGEMENT

Empiric therapy with intravenous ampicillin andEmpiric therapy with intravenous ampicillin and

aminoglycosides is effective against a broad aminoglycosides is effective against a broad range of uropathogens,range of uropathogens,

including enterococci and including enterococci and Pseudomonas species.Pseudomonas species.

Alternatively, amoxicillin with clavulanic acid or Alternatively, amoxicillin with clavulanic acid or a third generationa third generation

cephalosporin can be used.cephalosporin can be used.


Fever from acute pyelonephritis may persist forFever from acute pyelonephritis may persist for

several days despite appropriate therapy.several days despite appropriate therapy.

Parenteral therapyParenteral therapy

should be maintained until the patient defervesces.should be maintained until the patient defervesces.

If bacteremiaIf bacteremia

is present, parenteral therapy should be continuedis present, parenteral therapy should be continued

for an additional 7–10 days and then the patient should for an additional 7–10 days and then the patient should bebe

switched to oral treatment for 10–14 daysswitched to oral treatment for 10–14 days..

Emphysematous Emphysematous pyelonephritispyelonephritis

Emphysematous Emphysematous pyelonephritis is a necrotizingpyelonephritis is a necrotizing

infectioninfection

characterized by the presence of gas within the renalcharacterized by the presence of gas within the renal

parenchyma or perinephric tissue.parenchyma or perinephric tissue.

About 80–90% of patientsAbout 80–90% of patients

with emphysematous pyelonephritis have diabeteswith emphysematous pyelonephritis have diabetes’’

Other cases are associated with urinary tract obstructionOther cases are associated with urinary tract obstruction

from calculi or papillary necrosisfrom calculi or papillary necrosis

PRESENTATION AND PRESENTATION AND FINDINGSFINDINGS

Patients with emphysematous pyelonephritis presentPatients with emphysematous pyelonephritis present

fever, flank pain, and vomiting that fever, flank pain, and vomiting that failsfails initial initial managementmanagement

with parenteral antibioticswith parenteral antibiotics

PneumaturiaPneumaturia

may be present. Bacteria most frequently culturedmay be present. Bacteria most frequently cultured

from the urine include from the urine include E. coli, Klebsiella pneumoniaeE. coli, Klebsiella pneumoniae,,

RADIOGRAPHIC IMAGINGRADIOGRAPHIC IMAGING

The diagnosis of emphysematous pyelonephritis is The diagnosis of emphysematous pyelonephritis is mademade

after radiographic examination. Gas overlying theafter radiographic examination. Gas overlying the

affected kidney may be seen on a plain abdominal affected kidney may be seen on a plain abdominal radiographradiograph

((KUBKUB.).)

CT scan is much more sensitive in detectingCT scan is much more sensitive in detecting

the presence of gas in the renal parenchyma thanthe presence of gas in the renal parenchyma than

renal ultrasonographyrenal ultrasonography..

Emphysematous PyelonephritisEmphysematous Pyelonephritis

In combinationIn combinationwith medical treatment, percutaneous drainagewith medical treatment, percutaneous drainage

appears to be helpful in accelerating resolutionappears to be helpful in accelerating resolution

infection and minimizing the morbidity and mortalityof infection and minimizing the morbidity and mortalityof the infectionthe infection

Nephrectomy mayNephrectomy may

be required if there is no function in the affected kidneybe required if there is no function in the affected kidney..

About 3–4 weeks of parenteral antibiotic About 3–4 weeks of parenteral antibiotic therapy is therapy is required.required.

Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis

Xanthogranulomatous pyelonephritis )XGP( is a form ofXanthogranulomatous pyelonephritis )XGP( is a form of

chronic bacterial infection of the kidneychronic bacterial infection of the kidney . .

The affectedThe affected

kidney is almost always hydronephrotic and obstructedkidney is almost always hydronephrotic and obstructed..

In most cases, XGP occurs unilaterallyIn most cases, XGP occurs unilaterally..

Characteristically, foamy lipid-laden histiocytes )xanthomaCharacteristically, foamy lipid-laden histiocytes )xanthoma

cells( are present and may be mistaken for renalcells( are present and may be mistaken for renal

clear cell carcinomaclear cell carcinoma


Patients with XGP commonly present with flank painPatients with XGP commonly present with flank pain,,

fever, chills, and persistent bacteriuria. On physical examination, afever, chills, and persistent bacteriuria. On physical examination, a

flank mass can often be palpatedflank mass can often be palpated..

Urinalysis commonly demonstratesWBCs and proteinUrinalysis commonly demonstratesWBCs and protein

Serum blood analysis reveals anemiaSerum blood analysis reveals anemia

and may show hepatic dysfunction in approximately 50%and may show hepatic dysfunction in approximately 50%

of the patientsof the patients

Because XGP primarilyBecause XGP primarily

occurs unilaterally, azotemia or renal failure is not seenoccurs unilaterally, azotemia or renal failure is not seen

E. coli or Proteus species E. coli or Proteus species are commonly cultured from the urineare commonly cultured from the urine


..In some cases, XGP is misdiagnosed as a renalIn some cases, XGP is misdiagnosed as a renal

tumortumor..

A nephrectomyA nephrectomy is performed and a diagnosis is is performed and a diagnosis is

made pathologicallymade pathologically

kidney-sparing surgery kidney-sparing surgery such as a partialsuch as a partial

nephrectomy is indicatednephrectomy is indicated..

when the infection iswhen the infection is

extensive, a nephrectomy with excision of all involved tissueextensive, a nephrectomy with excision of all involved tissue

is warrantedis warranted . .

Chronic pyelonephritisChronic pyelonephritis

Chronic pyelonephritis results from repeated Chronic pyelonephritis results from repeated renal infectionrenal infection,,

which leads to scarring, atrophy of the which leads to scarring, atrophy of the kidney, andkidney, and

subsequent renal insufficiency. The subsequent renal insufficiency. The diagnosis is made bydiagnosis is made by

radiologic or pathologic examination rather radiologic or pathologic examination rather than fromthan from

clinical presentationclinical presentation..

Chronic pyelonephritis

Renal AbscessesRenal AbscessesRenal abscesses result from a severe infection that leads toRenal abscesses result from a severe infection that leads to

liquefaction of renal tissue; this area is subsequently liquefaction of renal tissue; this area is subsequently sequesteredsequestered,,

forming an abscess. They can rupture out into theforming an abscess. They can rupture out into the

perinephric space, forming perinephric space, forming perinephric abscessesperinephric abscesses..

WhenWhen

the abscesses extend beyond the Gerota’s fascia, the abscesses extend beyond the Gerota’s fascia, paranephricparanephric

abscesses developabscesses develop . .

Historically, most renal/perinephricHistorically, most renal/perinephric

abscesses result from hematogenous spread of staphylococciabscesses result from hematogenous spread of staphylococci,,

in particular from infected skin lesionsin particular from infected skin lesions..

Patients with diabetes, those undergoing hemodialysis, orPatients with diabetes, those undergoing hemodialysis, or

intravenous drug abusers were at high risk for developingintravenous drug abusers were at high risk for developing

renal abscessrenal abscesseses

PyonephrosisPyonephrosis

Pyonephrosis refers to bacterial infection of a Pyonephrosis refers to bacterial infection of a hydronephrotichydronephrotic,,

obstructed kidney, which leads to suppurativeobstructed kidney, which leads to suppurative

destruction of the renal parenchyma and potential loss ofdestruction of the renal parenchyma and potential loss of

renal functionrenal function..

Because of the extent of the infection andBecause of the extent of the infection and

the presence of urinary obstruction, sepsis may rapidlythe presence of urinary obstruction, sepsis may rapidly

ensue, requiring rapid diagnosis and managementensue, requiring rapid diagnosis and management


Patients with pyonephrosis are usually very ill, Patients with pyonephrosis are usually very ill, with highwith high

fever, chills, and flank pain. Lower-tract fever, chills, and flank pain. Lower-tract symptoms are notsymptoms are not

usually present. Bacteriuria and pyuria may not usually present. Bacteriuria and pyuria may not be presentbe present

when there is complete obstruction of the affected when there is complete obstruction of the affected kidneykidney..


Management of pyonephrosis includes Management of pyonephrosis includes iimmediatemmediate

institution of institution of antibiotic therapy and drainage antibiotic therapy and drainage of theof the

infected collecting systeminfected collecting system

PROSTATE INFECTIONPROSTATE INFECTIONAcute Bacterial ProstatitisAcute Bacterial ProstatitisAcute bacterial prostatitis refers to Acute bacterial prostatitis refers to

inflammation of theinflammation of the

prostate associated with a UTI. It is thought prostate associated with a UTI. It is thought that infectionthat infection

results from ascending urethral infection or results from ascending urethral infection or reflux ofreflux of

infected urine from the bladder into the infected urine from the bladder into the prostatic ductsprostatic ducts


Acute bacterial prostatitis is uncommon in prepubertalAcute bacterial prostatitis is uncommon in prepubertal

boys but frequent affects adult menboys but frequent affects adult men..

It is the most commonIt is the most common

urologic diagnosis in men younger than 50 yearsurologic diagnosis in men younger than 50 years

. .Patients with acute bacterial prostatitisPatients with acute bacterial prostatitis

usually present with an abrupt onset of constitutionalusually present with an abrupt onset of constitutional

((fever, chills, malaise, arthralgia, myalgia, lower back/rectalfever, chills, malaise, arthralgia, myalgia, lower back/rectal//

perineal pain( and urinary symptoms )frequency,urgency,dysuria(perineal pain( and urinary symptoms )frequency,urgency,dysuria( . .

they may also present with urinarythey may also present with urinary

retention due to swelling of the prostatretention due to swelling of the prostatee


TrimethoprimTrimethoprim

and fluoroquinolones have high drug and fluoroquinolones have high drug penetrationpenetration

into prostatic tissue and are recommended into prostatic tissue and are recommended for 4–6 weeksfor 4–6 weeks

URETHRITISURETHRITISTypes of UrethritisTypes of Urethritis

Infection/inflammation of the urethra can Infection/inflammation of the urethra can be categorizedbe categorized

into those types caused by into those types caused by Neisseria Neisseria gonorrhoeae and bygonorrhoeae and by

other organisms )other organisms )Chlamydia trachomatis, Chlamydia trachomatis, Ureaplasma urealyticumUreaplasma urealyticum,,

Trichomonas vaginalis, and herpes Trichomonas vaginalis, and herpes simplex virussimplex virus))


Patients with urethritis may present with urethral dischargePatients with urethritis may present with urethral discharge

and dysuria. The amount of discharge may vary and dysuria. The amount of discharge may vary significantlysignificantly,,

from profuse to scant amounts. Obstructivefrom profuse to scant amounts. Obstructive

voiding symptoms are primarily present in patients withvoiding symptoms are primarily present in patients with

recurrent infection, in whom urethral strictures subsequentlyrecurrent infection, in whom urethral strictures subsequently

develop. It is important to note that approximatelydevelop. It is important to note that approximately

40%40% of patients with gonococcal urethritis are asymptomaticof patients with gonococcal urethritis are asymptomatic


Pathogen-directed antibiotic therapy is requiredPathogen-directed antibiotic therapy is required . .

In patientsIn patients

with with gonococcal urethritisgonococcal urethritis, ceftriaxone )250 mg intramuscularly(, ceftriaxone )250 mg intramuscularly(

or fluoroquinolones ciprofloxacin 250 mgor fluoroquinolones ciprofloxacin 250 mg

For patients For patients with nongonococcal urethritiswith nongonococcal urethritis,,

treatment is with tetracycline or erythromycin )500 mgtreatment is with tetracycline or erythromycin )500 mg

44 times daily( or doxycycline )100 mg twice daily( for 7–14times daily( or doxycycline )100 mg twice daily( for 7–14

daysdays

EPIDIDYMITISEPIDIDYMITISCauses of EpididymitisCauses of Epididymitis

Most cases of epididymitis in men younger than 35Most cases of epididymitis in men younger than 35

years are due to sexually transmitted organisms)years are due to sexually transmitted organisms)N.gonorrhoeaeN.gonorrhoeae

and and C. trachomatisC. trachomatis;);)

those in children and olderthose in children and older

men are due to urinary pathogens such as men are due to urinary pathogens such as E. coli, In E. coli, In homosexual homosexual men who practice anal intercoursemen who practice anal intercourse,,

E. coliE. coli

and other coliform bacteria are common causative organismsand other coliform bacteria are common causative organisms..


Oral antibiotic treatment is directed against Oral antibiotic treatment is directed against specific causativespecific causative

organisms, as mentioned in the previous organisms, as mentioned in the previous sections onsections on

urethritis and UTI. In addition, bed rest, scrotal urethritis and UTI. In addition, bed rest, scrotal elevationelevation,,

and the use of nonsteroidal anti-inflammatory and the use of nonsteroidal anti-inflammatory agents areagents are

helpful in reducing the duration of the symptomshelpful in reducing the duration of the symptoms..

Download - Dr. Maryam Emami. Urologist. Urinary tract infections (UTI) are a common cause of morbidity and account for more than 7 million visit to physicians, offices

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