Urinary Tract Infection

Dr.Abdulmalik Tayib
Consultant & Assistant Professor.
Department of Urology

Non specific Urinary Tract Infection

Common Organisms:
-Aerobic gram negative rods :
E.Coli(most common),
klebsiella sp,Proteus sp(mirabilis),Pseudomonas
aerugenosa.
-Gram-positive cocci:enterococci,Staphylococcus
aureus.
-Other pathogens:
Clamydiae(chlamydia trachomatis).
Myocoplasmas(Ureaplasma urealyticum).

Diagnosis
Urine collection:
In men:
voided urine is generally adequate for
diagnostic purposes,no cleaning required in
circumcised men:
1st 10 mls represent urethral specimen.
Midstream represents bladder specimen.
In female:
Contamination is more common.
Careful spread of labia, wash the introitus and
periurethral area before collecting a mid stream
urine.
Some time may require mid catheterized specimen.

DIAGNOSIS
In infants or patients with spinal cord injury catheter
specimen is advisable.
Urinalysis:
Cloudy urine commonly used to represent pyuria or
large amount of amorphous phosphate.
The odor rarely clinically significant.
Bacteria and leukocyte:
Nitrite: when +ve it suggests the presence of more
than 100,000 organisms/ml,40-60% accurate.
False +ve test may occur in patients taking vit C.
Leukocyte estrase:It is good indicator of pyuria.

Diagnosis
Urinalysis
Microscopic examination:
WBC >5-8/hpf.
RBCs.
Urine culture:
70% of patients with UTI will have 100 000 CFU
(colony forming unit) /ml.
30% 100 - 10 000 CFU/ml.

Classification
Natural History:
1st Infection.
Recurrent Infection.
-Unresolved bacteruria.
-Bacterial persistance.
-Reinfection(most common cause).
Clinical and pathological presentation:
Specific: caused by specific organisms,each of
which causes a clinically unique disease
that lead to specific pathological tissue
reaction.

Classification
Non Specific:
Organisms causing common clinical and tissue
reactions.

Modes of Bacterial Entry

4 modes of bacterial entry:
1-Ascending infection from the urethra:
more in women: short urethra.
Rectal bacterial colonization in the
perineum and vaginal vestibule.
2-Hematogenous spread: T.B.
staphylococci causing pri renal, renal abscesses.
Less common in adult.
3-Lymphatogenous:
Little evidence lymphatic route play role in UTI.
4-Direct extension from neighboring organs: V.V.F
Vesico-intestinal fistula, inflammatory bowel
or pelvic diseases.

Acute pyelonephritis
Definition: bacterial infection causing inflammation of the
parenchyma and pelvis of the kidney.
E.coli (80%),Klebsiella,Proteus,Pseudomonas,Serratia
Mode of infection:
Ascending from lower urinary tract as in VUR,urinary
obstruction.
Hematogenous:staphylococi.
Clinical features:
Fever(high),chills.
Flank pain.
Lower urinary tract symptoms.
Nausea, vomiting.
Physical Exam; Tachycardia, tender flank, paralytic ilius.

Diagnosis
CBC:Leucocytosis.
Urinalysis: numerous
WBCs,RBCs,Leucocyte
casts, bacteria.
Urine culture: always
positive.
Blood culture:
Imaging Techniques:
IVP.
U.S:rule out obstruction.
C.T : to diagnose intrarenal ,
perirenal abscess formation.
U.Cyst.

Management
In toxic patient:
Hospitalization.
Bed rest.
I.V fluids.
Parentral antibiotics(Ampicillin,Aminoglycosides),
to cover both enterococci and pseudomonas spp.
In resistant cases Trimethoprim-Sulfamethoxazole
combined with aminoglycoside or fluoroquinolones
or parentral third generation cephalosporins,for 1015days.
As out patient flouroquinolone or TMP-SMX.

Management
Renal abscess requiring
drainage.
Complications: Septicemia.
Schock.

Emphysematous Pyelonephritis
Definition:
-Necrotizing renal infection characterized by gas within
the renal parenchyma or perinephric tissue.
-80-90% D.M.
-Urinary tract infection from stone or papillary necrosis in
all cases.
-Mortality 43%
- E.coli most common.
-Klebsiella and proteus less common.

Emphysematous Pyelonephritis
Symptoms:
Flank pain.
Fever.
Vomiting.
Failed initial management.
Pneumaturia.
Signs:
Tender flank .
Sick patient.
Septic.
Laboratory:
Urine and blood culture almost +ve.
Radiological:
Plain X-ray: gas shadow over the affected area.

Emphysematous Pyelonephritis
-U.S: Obstruction.
-IVP of limited value.
-C.T: presence of air inside the collecting system.
Management:
Fluids
IV Antibiotics.
Relieve obstruction.
Percutaneous drainage.
Nephrectomy.

Chronic Pyelonephritis
Definition:
Process of renal scarification and atrophy resulting in
renal insufficiency.
Cause:
Repeated infections in presence of urinary tract
abnormalities either structural or functional:
D.M
Calculi
Analgesic nephropathy.
Obstructive nephropathy.
In children VUR.

Chronic Pyelonephritis
Symptoms:
Acute infection.
Asymptomatic.
Hypertension.
Renal failure.
Diagnosis:
Urinalysis:Pyuria,Bacteriuria,Proteinuria.
Positive urine culture in acute attack.
IVU:

VCUG:

Chronic Pyelonephritis
Management:
Identifying the abnormality and correcting it.
Preventing recurrence of UTIs.
Nephrectomy in unilateral atrophy causing hypertension.

Renal Abscess
Collection of purulent material confined to the renal
parenchyma.
Due to hematogenous seeding by Staphylococci or
Gram-Negative organisms.
Symptoms: Fever. Chills. Abdominal pain. Vague
symptoms.
Laboratory:Leukocytosis,positive blood culture.
Radiological:U.S , CT.
Management:
Drainage.
Antimicrobial.

Perinephric Abscess
Collections of purulent material within the perinephric space
(between the kidney and Gerota's fascia).
Paranephric if extend beyond Gerotas fascia.
Organism:
E.Coli by ascending infection.
Predisposing Factors:
Urinary stasis.
Obstruction,calculi,
Neurogenic bladders.
DM.
Diagnosis:
same as Renal abscess.
Management: same as Renal abscess.

Cystitis
Cystitis:Bladder infection.
Acute cystitis:
Common in females(20-40yrs old).
Uncomplicated occur with any anatomical or functional
abnormalities.
Mode of infection:
Ascending fecal-perineal urethral route.
Causative organism:
E.coli
Staphylococcus.

Cystitis
Symptoms:
Frequency, urgency, dysuria, occasionally hematuria.
Diagnosis:
Urinalysis:bacteruria,hematuria,pyuria.
Urine culture:
Management:
TMP-SMX.
Amoxacillin.
Cephalosporins.
Fluroquinolones.

Cystitis
Reccurent infection:
Bacterial persistence: surgical removal of the infectious
source(stones).
Bacterial re infection: Fistulae between bladder and
bowel or vagina,pelvic surgey or irradiation.
Diagnosis:
U.S
IVU.
Cystoscopy.
Management:
ESWL.
Correction of other abnormalities.
Antibiotics.

Prostatitis
Acute Prostatitis:
Ascending infection.
Symptoms:Fever, chills, rectal, low back pain, Dysuria,
urgency,arthralgia,Malaise.
Diagnosis:
DRE extremely tender.
Urinalysis:pyuria,microscopic hematuria.
Urine culture.
Management:
Hydration,bed rest, analgesic,antipyretics.
Fluouroquinolone,TMP-SMX(4-6 weeks).

Chronic Prostatitis
Bacterial:
Same organisms as acute.
Non bacterial:
Chlamydial.

Epidydmitis
Inflamation of the epidydmis.
Ascending infection.
C.Trachomatis in men less than 40yrs.
E.coli in older men.
in severe epidydmitis may lead to epididymo-orchitis.
Symptoms:
Severe scrotal pain radiate to inguinal area and may be
to the flank.
O/E tender swallowed epidydmis.

Epidydmitis
Diagnosis:
CBC: Leukocytosis.
Urine analysis & C.S.
Management:
Antibiotics.
Epididymectomy.

Specific Infections
Caused by specific organisms,each of which causes
clinically unique disease that lead to specific
pathological tissue reaction such as:
-Tuberculosis.
-Shistosomiasis.
-Filariasis.
-Echinococcosis.

Tuberculosis
Caused by Mycobacterium tuberculosis.
Hematogenous from the lung.
The kidney and the prostate are the 1ry site in G.U.tract.
Kidney infection decent to the ureter and bladder,
Prostate to epidydmis and epidydmis to testis.
Age: 20-40.
Sex: little common in male than females.
Tuberculosis of the kidney may progress slowly(1520yrs).

Tuberculosis
Symptoms:
Asymptomatic.
Flank pain.
Vague generalized malaise,fatigability.
Low grade persistent fever.night sweets.
Symptoms of cystitis not responding to therapy.
Chronic draining scrotal sinus.
Gross or microscopic hematuria.
Active T.B else were in the body in less than 50%.

Tuberculosis
-

Signs:
Evidence of Extragenital T.B(Lung,LNs,Tonsils,Intestine)
Usually there is no enlarged or tenderness of the kidney.
Thickened non tender or slightly tender epidydmis.
Vas deferns is beaded and thickened.
Chronic draining sinus through the scrotal skin.
Hydrocele.
Nodular indurated prostate.

Diagnosis
Laboratory Findings:
Persistent Pyuria without organisms on culture.
Acid fast stains positive in 60% of the patients.
1st morning urine culture.
Anemia.
High sedimentation rate.
X-Ray findings:
Chest X-ray.
Abdominal X-R-ray:punctate calcification in the area of
the kidney,may be calcification of ureter.

IVP
- Moth-eaten appearance of the involved ulcerated
calyces.
- Obliteration of one or more calyces.
- Dilatation of the calyces.
- Abscess cavity connect to the calyces.
- Single or multiple ureteral stricture.
-Nonfunctioning kidney.

Tuberculosis
Urethrocystoscopy:
Ulcers, severe contracted bladder.
Cystogram:VUR.
Medical treatment:
Isoniazid 200-300mg daily.
Rifampin 600 mg daily.
Ethambutol 25mg/Kg daily for 2month then 15mg/kg.
Streptomycin 1Gm IM daily.
Pyrazinamide 1.5-2 Gm daily.
Treatment of the complications.