KULIAH BEDAH DASAR 2014

1. INTRODUCTION
2. PATHOGENESIS
3. ETIOLOGY
4. CLINICAL MANIFESTATION
5. DIAGNOSIS
6. THERAPY



Scanlon, Valerie C. Essentials of Anatomy and Physiology, 5th ed. USA. F.A. Davis Company. 2007
INTRODUCTION
Scanlon, Valerie C. Essentials of Anatomy and Physiology, 5th ed. USA. F.A. Davis Company. 2007
Scanlon, Valerie C. Essentials of Anatomy and Physiology, 5th ed. USA. F.A. Davis Company. 2007

Scanlon, Valerie C. Essentials of Anatomy and Physiology, 5th ed. USA. F.A. Davis Company. 2007
DEFINITIONS


UTI
Inflammatory response of the urothelium to
bacterial invasion that is usually associated
with bacteriuria & pyuria
BACTERIA
presence of bacteria in the urine, which is
normally free of bacteria, can be
symptomatic or asymptomatic
PYURIA
presence of WBC in the urine, is generally
indicative of infection & an inflammatory
response of the urothelium to the bacterium

EPIDEMIOLOGY
Age Female Male Risk factor
<1 0,7 2,7 Foreskin,anatomic GU abnormalities
1-5 4,5 0,5 Anatomic GU abnormalities
6-15 4,5 0,5 Functional GU abnormalities
16-35 20 0,5 Sexual intercourse,diaphragm use
36-65 35 20 Surgery, prostate obstruction,
catheterization
>65 40 35 Incontinence, catheterization,
prostate obstruction
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
INCIDENCE OF UTI
0.7
4.5 4.5
20
35
40
2.7
0.5 0.5 0.5
20
35
< 1 1 - 5 6 - 15 16 - 35 36 - 65 > 65
Chart Title
FEMALE MALE
PATHOGENESIS
GU TRACT
DIRECT
SPREAD
LYMPHO-
GEN
HEMATO-
GEN
ASCENDING
B. Host factors
UTI's present more in women than men shorter
urethra and the much closer association of the
urethra to the anus

Sexual intercourse contributes to the increased
number of UTI's seen in women

Any anatomic obstruction, or neurological disorder
leading to the failure to completely eliminate the urine
can lead to UTI

Men in their 40's have problems with the prostate
gland enlarging resulting in obstruction of the urethra.



DEFENSE MECHANISM
1. urine factor :
Urea concentration and high osmolarity
Low pH of urine kill bacteria
2. Hydrokinetic factor :
Periodic urinary flow / Wash out
Dilution of rest urine cause of urinary flow from kidney
Bladder emptying

3. Mucosal factor :

Mucosa of the bladder consist of more than one layer
cells

Mucosa of the urinary tract and bladder covered by
mucus prevent microorganism attachment

Prostatic secretion : has an antibacterial effect

Secretion of local IgA prevent attachment of
microorganism and neutralize toxin

Perioxidase on the mucosal layer has a bactericidal
effect

ALTERATIONS IN HOST DEFENSE
MECHANISM
Obstruction
Vesicoureteral Reflux
Underlying Disease : DM
Renal Papillary Necrosis
Pregnancy
Spinal Cord Injury
C. Bacterial factors
The most important virulence factor of
bacteria is the enhanced ability to adhere to
uroepithelial cells.

Adhesin play a role in determining which
bacteria invade & extend of infections, toxin
and urease

S. Aureus expresses many potential virulence
factors such as proteins, enzymes and toxins

E. coli is by far the most common cause of
UTIs, accounting for 85% of community-
acquired & 50% of hospital-acquired
infections.



Alteration in defens mechanism
-Escherichia coli, which is responsible for 80
% of infections that are acquired outside of
hospitals

-Other Gram-negative rods such as
Klebsiella, Enterobacter, and Proteus
spp. are relatively common, each
accounting for 3 to 5 % of infections

-Within the hospital environment,
Pseudomonas aeruginosa, Serratia
marscesens, and other Gram positive
bacteria such as Enterococcus faecalis,
and Staphylococcus epidermidis are
more resistant, common hospital-acquired
phatogens.
ETIOLOGY
Gram-positive organisms,
particularly coagulase-negative
staphylococci and
enterococci, cause some
infections

Staphylococcus saprophyticus
causes about 10 % of UTI in
young women

Candida albicans is also a
frequent pathogen in
hospitalized patients,
particularly if diabetes is present

Schrier, Robert W. Diseases of the Urinary Tract, 8th ed. USA. Lippincot Williams. 2007.
79
11
3
3
2
2
2
ETIOLOGI
E. Coli
Staphylococcus
Klebsiella
Mixed
Proteus
Enterococcus
Other
Symptoms & signs
Dysuria
Frequency
Urgency
Suprapubic pain
Flank pain
Hematuria
DIAGNOSIS
Urine & UT are normally free of bacteria &
inflammation

1. Urinalysis
Urinalysis provides a rapid screen for UTIs. The
urine can be immediately evaluated for
leukocyte esterase, a compound produced
by the breakdown of white blood cells
(WBCs) in the urine.
Urinary nitrite is produced by reduction of
dietary nitrates by many gram-negative
bacteria. Esterase and nitrite can be
detected by a urine dipstick.
Microscopic examination of the urine for
WBCs and bacteria is performed after
centrifugation. Piuria : > 5 leucocytes per
mm
3



2. Urine Culture
Bacteriuria : Midstream > 10
5
cfu/mL
Suprapubic > 10
3

cfu/ml

The diagnosis of UTI : based on a
quantitative urine culture : > 100,000
colony-forming units (10
5
CFU) per ml of
urine, was termed "significant bacteriuria."

This value was chosen because of its high
specificity for the diagnosis of true
infection, even in asymptomatic persons.

Criteria of UTI
1. Bacteriuria with quantitative >100.000
cfu/ml
2. Bacteriuria with quantitative <100.000
cfu/ml and lekocyturia
3. Bacteriuria with quantitative <100.000
cfu/ml in repeated culture, and same
kind of bacteria was found
4. Bacteriuria with quantitative <100.000
cfu/ml, only one species of bacteria, with
definite clinical symptoms
5. If the result of culture is > 1000 cfu of
fungus/ ml indicate fungal infection

Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
3. Imaging Techniques
Not required in most women w/ UTIs
Men & compromised patients or those
who dont respond to therapy require
imaging to identify abnormalities
CT & MRI provide the best anatomic data
on the site, cause, & extend of infection
PRINCIPAL OF ANTIMICROBIAL
THERAPY
Effective antimicrobial therapy must
eliminate bacterial growth in the UT
Antimicrobial resistance is increasing
because of excessive utilization
Antimicrobial selection should be
influenced by efficacy, safety, cost, &
compliance
Durations of therapy
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
KIDNEY INFECTIONS
Acute pyelonephritis classically presents as the
abrupt onset of chills, fever, & flank or costovertebral
angle tenderness but can present as symptoms as
mild as cystitis or as severe as sepsis
Emphysematous pyelonephritis is a life-threatening
infection diagnosed radiographically by the
presence of gas in the parenchyma or collecting
system & managed surgically
Renal abscesses are well delineated by CT & are
classically managed w/ intravenous antimicrobial
agents & drainage
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
KIDNEY INFECTIONS......
Pyonephrosis is a bacterial infection in a
hydronephrotic kidney. Prompt Dx is critical;
treatment entails IV antimicrobial agents &
drainage of the obstructed renal unit
Xantogranulomatous pyelonephritis is a
chronic renal infection that is often found in
poorly functioning renal units obstructed
secondary to nephrolithiasis.
Malacoplakia is anusual inflammatory disease
thought to result from abnormal macrophage
function. Michaelis-Gutmann bodies are
lysosomal inclusion bodies that characterize
this disease microscopically
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
BLADDER INFECTIONS
Bladder Infections ;
Uncomplicated Cystitis
Complicated Cystitis
Unresolved UTIs
Recurrent UTIs

Uncomplicated Cystitis should be treated
for 3 days
Asymptomatic bacteriuria should be
treated only in pregnant woman & prior to
urologic intervention
Recurrent UTIs due to bacterial persistence
require urologic management; re-infections
can be managed medically

Prostatitis
Sign and symptoms : fever, chills, dysuria,
pain in perineal region.
RT : enlarge prostate, warm and painful
4 categories :
1. Acute Bacterial Prostatitis
2. Chronic Bacterial Prostatitis
3. Non Bacterial Prostatitis
4. Aysmptomatic inflamation prostatitis
Tanagho, A. Emil, et al. Smiths General Urology 16th ed. USA. Lange. 2003.
BACTERIURIA IN PREGNANCY
Screening for bacteriuria w/ a culture should be
performed in all pregnant women during the 1st
trimester
Unlike in non-pregnant women, spontaneous
resolution of bacteriuria in pregnant women is
unlikely
All pregnant women w/ Bacteriuria should be
treated
Bacteriuria more commonly progresses to acute
pyelonephritis during pregnancy


BACTERIURIA IN ELDERLY
Bacteriuria is very common in both elderly
women & men
Infections of the UT may present as subtle
signs, & a high index of suspicion is often
required for diagnosis
Treatment of symptomatic UTI requires
modifications for physiologic &
pathophysiologic conditions of the elderly

OTHER INFECTIONS
1. Fourniers gangrene
is necrotizing fasciitis arising from the
perineal skin, scrotum, urethra, or rectum
Emergent surgical debridement & broad-
spectrum antimicrobial agents are the
essential of treatment of Fourniers
gangrene
Periurethral abscess can occur
secondarily to urethral stricture or
catheterization; treatment entails surgical
debridement, suprapubic urinary
drainage, & antimicrobial agents.
2. Funguria
Funguria is commonly associated w/
predisposing factors including indwelling
catheters, antimicrobial therapy, DM,
hospitalization, & immunosuppressed states

Symptomatic funguria may be treated w/
topical, oral, or parenteral antifungal therapy
3. Epididimitis
Ascending from vesica urinaria, prostate and
urethra
Clamidia trachomatis and N. Gonnorhea most
common in adults
E. Coli and Ureoplasma ureolyticum common in
children