Urinary tract infections

1. Urinary Tract Infections
Mohammad Yahya Tailakh
5th year medical student
University of Jordan

2. What is UTI?
 Inflammation of the urothelium due to microorganism invasion.
 Urinary tract infection is a term that is applied to a variety of clinical conditions ranging
from the asymptomatic presence of bacteria in the urine to severe infection of the
kidney with resultant sepsis.
 Clinical presentation:
 The most frequent chief complaint related to urinary tract infection (UTI) is dysuria.
 urinary frequency, and urgency are approximately 75% predictive for UTI.
 acute onset of hesitancy, urinary dribbling, and slow stream are only approximately 33%
predictive for it.

3. anatomy

5. Epidemiology
 The incidence of true urinary tract infection (UTI) in adult males younger
than 50 years is low (approximately 5-8 per year per 10,000), with adult
women being 30 times more likely than men to develop a UTI. The incidence
of UTI in men approaches that of women only in men older than 60 years.
 in infants age group bacteriuria is more common in males while from 1-5
years its more common in females .
 The causes of UTI in peds is commonly caused by congenital anomalies
[reflux, obstruction]

6. General Definitions
 Recurrent UTI : more than 2 infections in 6 months or 3 infections in 1 year
 Isolated UTI : more than 6 months between one infection and another.
 Uncomplicated UTI : UTI in structurally and functionally (both) normal urinary
tract with normal immunity and low risk of bacterial virulence ,majority are
females
 Complicated UTI : one of these or more present; male, pt with structurally or
functionally abnormal kidney , immunocompromised , chance of increased
bacterial resistant (hx of ABx use or hospitalization) , majority are males i.e if
UTI occurred in a male its most likely to be complicated
 Bacteriuria : significant amount of bacteria in urine >10^5ml. sym or asym
[asym should be treated in :1-children 2- pregnancy 3- immunocompromised
 Pyuria : presence of WBC in urine more than 5 HPF. /sterile!
Without presence of bacteria.

7. Pyelonephritis
 • It means infection of the renal parenchyma and renal pelvis.
 Risk factors : VUR, DM, pregnancy, congenital malformation , indwelling
catheter, obstruction.

8. Types :
-Acute pyelonephritis
-Chronic pyelonephritis
-Emphysematous pyelonephritis
-Xanthogranulomatous pyelonephritis

9. Acute pyelonephritis
 Presentation ranges from mild illness to sepsis, pt may be well or ill.
 Signs and symptoms : loin pain, nausea, vomiting, fever, chills, rigor , may be
associated with lower UTI symptoms, tachycardia , costovertebral angle
tenderness
 Histology : neutrophils infiltrates
 M.c.c : ascending infection ; E.coli .
 Can be also Hematogenous ,lymphatics spread.

10. Investigation and treatment
 Investigations: UA ,culture,CBC [leukocytosis ], KFT[creatinine].
 Blood culture is preserved for immunocompromised patients
 TREATMENT :
 Out pt :oral flouroquinilone ,broad spectrum ABX .
 In pt : IV flouroquinolone s &aminoglycosides
 Urine culture should be repeated 1-2 wks after ABX.

11. Criteria for
admission to
hospital:
1- extremes of age
2- complicated
3- persistent vomiting
4- failure out pt

12. Clinical case
 65 year old male, diabetic, with IHD came to the ER with bilateral flank pain ,fever,
lower UTI symptoms , +ve renal angle and suprapubic tenderness,what to do ?
 it's a complicated UTI until proven otherwise
 Do CT scan without contrast
 If stone is found then its an obstructive pyelonephritis which is a life threatening
condition where pt may became shocked at anytime so Management will be with IV
fluids , IV antibiotics send blood culture don't remove the stone at this time but it’s
a must to relieve the obstruction by putting a uretric (double j) stent pr a
nephrostomy tube , after pt stabilization manage to remove the stone

14. Chronic pyelonephritis :
 Recurrent pyelonephritis .
 Causes : VUR ,chronic obstruction .
 Histology : fibrosis
 Signs and SX : asym to renal failure >. Fever, weight loss, nausea, vomiting,
flank pain

16. Emphysematous pyelonephritis :
 DM
 High mortality rate
 Gas forming bacteria m.c.c : E.coli ,klabsella , proteus.

17. Xanthogranulomatus pyelonephritis :
 rare, serious, chronic inflammatory disorder of the kidney characterized by a
destructive mass that invades the renal parenchyma.
 XGP is most commonly associated with Proteus or Escherichia coli infection
or Pseudomonas species.
 XGP is characterized by lipid-laden foamy macrophages.
 XGP shares many characteristics with true renal neoplasms in terms of its
radiographic appearance and its ability to involve adjacent structures or
organs
 Risk factors : urinary tract obstruction, infection, nephrolithiasis, diabetes,
and/or immunocompromise

18.  The overall prognosis for XGP is good
 CT scan shows renal calcification difficult to differentiate from CA
 Treatment :is a surgically managed disease that is treated with either
nephrectomy or, in rare circumstances, partial nephrectomy. Antibiotics are
used in all cases, but medical care rarely suffices for treatment.

20. Cystitis
 Inflammation of the urinary bladder .
 Most common organism : E.coli others : staph.saprophytics klebsiella,
 honeymoon cystitis .
 Types:
 -acute infectious
 -cystitis cystica and glandular cystitis
Brunn’s nests that grow into lamina propria and are transformed into urothelium lining slitlike or cystic spaces with pink fluid
 -follicular cystitis
 - hemorrhagic
 -interstitial

21.  Signs and SX: suprapubic pain ,dysuria ,frequency ,urgency , offensive smelled
urine, hematuria ,fever .
 invX : UA,culture
 TX : sulfamethoxazole

22. Urethritis
 Most common causative organism is neisseria gonorrhoea ,chlamydia .
 Signs and SX : dysuria ,discharge , meatal and penile shaft pain
 How ever ,no frequency or urgency .
 => if Dysuria without frequency then its urethritis
 gonococcal : present with sudden onset of large amount of yellow discharge
and mild dysuria
 non gonococcal : caused by clamydia trachomatis , present with gradual onset
of clear discharge
 Dx : urethral swab +culture .
 TX : sefoloxime ,azithromycin

24. Prostatitis
 is swelling and inflammation of the prostate gland, Due to reflux of infected
urine into prostatic duct.
 5% prevalence
 Risk factors : UTI, urethral catheter
 M.c organism : Ecoli, proteus, klebsiella

25. Classification
:
Acute bacterial prostatitis
Chronic bacterial
Chronic pelvic pain syndrome
Asymptomatic inflammatory
prostatitis (histologic)

26. Acute prostatitis :
 presentation is with lower urinary tract symptoms in the absence of loin pain
and presence of fever (most imp distinguishing factor),
 ttt is with broad spectrum ABx, it requires hospitalization, avoidance of
urethral catheter, if needed use suprapubic catheter

27. o Chronic prostatitis
 Causes :Recurrent infection , trauma .
 Sx : Painful bowel movement ,hematuria, painful voiding ,painful ejaculation
 treatment is with NSAID, steroids, alpha blockers, alpha reductase inhibitors,
if refractory to medical ttt microwave heat therapy

28. chronic pelvic pain syndrome
 is a pelvic pain condition in men, and should be distinguished from other
forms of prostatitis ,also known as Chronic nonbacterial prostatitis
 Signs and symptoms
 lasting longer than 3 months. Symptoms may wax and wane. Pain can range
from mild to debilitating. Pain may radiate to the back and rectum, making
sitting uncomfortable. Pain can be present in the perineum, testicles, tip of
penis, pubic or bladder area.[5] Dysuria, arthralgia, myalgia,
unexplained fatigue, abdominal pain, constant burning pain in the penis, and
frequency may all be present. Post-ejaculatory pain, mediated by nerves and
muscles, is a hallmark of the condition.

29. Causes
 Nerves, stress and hormones
 Food allergies
 Climate