UTI and Vesiculouretral Reflux

8/9/2019 UTI and Vesiculouretral Reflux

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Urinary tract infecti

Vesiculoureteral refl


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Urinary tract infection Bacteria infection – most common Viral infection Fungal infections -- rare and occur most

commonly in immunocompromised individuals (HIV/AIDS c"emot"erapy recipients#


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Prevalence $-% & in female $& in male 'sually occurs Female ) yr *ale $ yr During $st year Female + *ale , $ + .-).0 During $- year Female + *ale , $1 + $


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2redisposing 3is4 Factors 5ender

as or more common in 6oys as neonates after neonatal period incidence "ig"er in females

'rinary o6struction 2osterior uret"ral valve and uret"ral stricture *eatal stenosis Bladder nec4 o6struction

2revious '7Is 'rinary instrumentation (e.g. cat"eteri8ation# Immunocompromise Dia6etes mellitus

Bladder calculi


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Urinary tract infection 'ncomplicated '7I

Healt"y 9ormal anatomic and p"ysiologic status

:omplicated '7I A6normal anatomic and p"ysiologic status 2regnancy Dia6etes mellitus Immunocompromised Ind;elling cat"eter 2resence of symptoms ≥ 7 days


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Urinary Tract Infection 'pper urinary tract infection

2yelonep"ritis (acute c"ronic# Intrarenal a6scess 2erinep"ric a6scess


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LOWER URINARY TRACTINECTION•

Cystitis• Uret!ritis


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Cystitis An inflammation of t"e 6ladder :ommon etiologic agent

=. coli -- most common

>le6siella spp. 5roup B Streptococcus 2roteus Stap"ylococcus epidermis

2seudomonas H. influen8a =nterococcus Stap"ylococcus saprop"yticus


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Clinical feature Dysuria 'rgency Fre?uency


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Uret!ritis An inflammation of t"e uret"ra 5onococcal uret"ritis

9eisseria gonorr"eae S/S +

*ale – purulent disc"argedysuria Female -- often asymptomatic

9ongonococcal uret"ritis Variety of 6acteria + :"lamydia trac"omatis *ycoplasma

'reaplasma Adenovirus 7ric"omonas vaginalis Herpes simple virus

S/S + *ale – cloudy or ;atery disc"arge dysuria s;ollen or tender testicles Female – often asymptomatic


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UPPER URINARY TRACTINECTION• Pyelone"!ritis #acute $c!ronic%• Intrarenal a&scess• Perine"!ric a&scess


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Acute Pyelone"!ritis CEGJKLMNOPQ RTUMWXYZUM [\W] [̂GGTU_ `EGYKJ E WXCYOLNYbY

TL]Y[JLG[\L\\ZhECJKKGYXCE`ETGY[GGOJTW]GY_GTM_E XCE`M^jWL]TP\ RKkG`JLGMNOPQ RTL\\ZOZ \ZLWJET UM


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C!ronic "yelone"!ritis YZUMJKLLLQ RJT L] TLTG`OMJYTEQ RZQ UM WXNOJTjQOTUM

TKG[GYNEN JZUO_GGZYNG GGTJTK\YNZG `Q

`WJGET`E_G\ TUM\ NO RE`WJTGMNOPQ R CJKKGYXU`WZ_EWJLGXGXCJKKGYXWX`WO UM(vesico-ureteral reflu+ V'3 # NO]Y[JEENOCJKKGYXZ_EUC\ UM

q3eflu 9ep"ropat"y NOZQ JTjQO M] U[]YhP_ hEGMNOPQ RTYZUMZ]GTO\ZY


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Ty"e 'ncomplicated pyelonep"ritis+ 'pper urinary tract

infection t"at presents ;it" fever (%:# (t"oug" may6e a6sent early on# c"ills flan4 pain costoverte6ralangle tenderness and nausea/vomiting/- signs or symptoms of acute cystitis. 2at"ogens are often more resistant to typical anti6iotics t"an t"ose leading to cystitis.

:omplicated pyelonep"ritis+ 2rogression of upperurinary tract infection to emp"ysematous pyelonep"ritisrenal corticomedullary a6scess perinep"ric a6scess orpapillary necrosis.


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Renal and Perirenal A&scesses renal a&scess

'()( * +,-.(/01(0234 *567 *1871 car&uncle 9:;.F=6(G3; .H1/:; J K15H MG/'()( *

+,0 Q Aureus 9:; tre"tococci 4 *5,>5=G235 9:;?3H MG/)( *+BH.0>.(B/>-KH>)>52:1B-:71BB>B/-X>;H MG/)( *,=B/>-SX,=B


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Renal and Perirenal A&scesses '(.1+, # "erine"!ric a&scess%

\LUM[JXNOGGMT\hEUM[GhELNYbP]TY]GTLUMWXGCEjWGGMNOPQ R

LwUMP]EhEWkGUK_ [_ G[ WXCO MWOEGNOGL\\ZXGZ[GGTXKWQO CĴ LJEGMYGLJEGO_YZWQ EK\ZTYG[\

KxT WXG]GZGJTK\K]YEMJOGJZ[NYMz

QY]GCEYN{\\ `[GXK[\ K^OhEGYNEN JZWXLMkG`E]T\LUM


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Etioloy

"ttp+//emedicine.medscape.com/article/|}1-overvie;~a;aa6}66aa

'7Is are generally ascending in origin and

caused &y"erineal containants$ usually &oZel floraQ

In neonates infection is assumed to6e !eatoenous in oriin rat"er t"anascending. 7"is feature may eplaint"e nonspecific symptoms associated;it" '7I in t"ese patients.


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Etioloy [acterial "at!oens are t!e ost coon cause of "yelone"!ritis.

Bacterial sources of pyelonep"ritis include t"e follo;ing+ Esc!eric!ia coli - 7"is is 6y far t!e ost coon oranis

causing more t"an |1& of all cases of acute pyelonep"ritis

=tended-spectrum 6eta-lactamase–producing = coli is 6ecomingmore fre?uent•0€ >le6siella oAytoca and species 2roteus species =nterococcus faecalis and species 5ram-positive organisms including stap"ylococcal species andgroup B Streptococcus- 7"ese are rare causes of acute

pyelonep"ritis

-


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Pat!o"!ysioloy 7"e ost i"ortant virulence factors in patients ;"ose

urinary tracts are normal govern ad"erence or attac"ment to "ost mucosal cells.

Ad"esins molecules mediating attac"ment are ont"e surfaces of 6acteria or 6acterial appendages. 7"ree maor ad"esins associated ;it" strains of = coli

causing '7I are 2A2 AFA and SFA.

Host defenses against t"e development of '7I relateprimarily to anatomic and p"ysiologic considerations. 7"e a6ility to empty t"e 6ladder of urine regularly and

completely is t"e most important "ost defense

mec"anism against infection.


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Pat!o"!ysioloy

tp+//;"at-;"en-"o;.com/acp-medicine/urinary-tract-infections-part-$/


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Presentin sy"tos and sinsin infants and c!ildren Zit! UTI

Age group Symptoms and signs*ost common ------------------


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Presentin sy"tos and sinsin infants and c!ildren Zit! UTI

NICE uidelines Cgh and !tt"sjkkZZZQuroloyQZiscQeduksystekassetskm^kodule"ediatricutiQ"dfpqmg^q

&acteriuria andfever of ^`C or!i!er

fever loZer t!an ^`CZit! loin "ainktenderness and &acteriuria

acute pyelonep"ritis/upper urinary tractinfection.

6acteriuria 6ut no systemic symptoms or signss"ould 6e considered to "ave cystitis/lo;er '7I


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P!ysical Exaination eneral a""earance *ost infants and c"ildren are uncomforta6le and appear ill.

Vital sins Fever may 6e present ;it" B7 more t"an %„: and oftenmore t"an %|„:.

7ac"ycardia may 6e present secondary to fever and pain. Blood pressure is usually normal. Hypertension s"ould

raise concern for clinically significant o6struction or renalparenc"ymal disease.

Hypotension may occur if se"sis and s!oc are present.


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P!ysical Exaination A&doinal findins A6dominal pain may 6e present. A mass may indicate o6struction

"ydronep"rosis or anot"er anatomica6normality. Suprapu6ic pain may 6e present.

A palpa6le 6ladder indicates o6struction orfunctional difficulty in starting or completingvoiding.

Adolescent girls may "ave rig"t upper ?uadrantpain


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P!ysical Exaination [ac findins Tenderness in t!e costoverte&ral anle #CVA%$ or flan

liely to &e "resent in older c!ildren and adolescentsQ

acral di"le or &irt!ars overlyin t!e s"ine ay &eassociated Zit! an underlyin anoaly of t!e s"inal cordQ Verte&ral a&noralities ay &e evidentQ

enitourinary findins

Assess for irritation$ "inZors$ vainitis$ traua$ orsins of sexual a&useQ A &ulin !yen suests an i"erforate !yen and

uret!ral o&structionQ

Neuroloic findins


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U_ TU[][\KG`MÊ]PJOOZGXhEOW CYO`WJT CYO_T`QCYOLJREY [JLhEOGZ[̂GY]G 0-) C\ YG[jNOCMNTG]GZCJKKGYX P]E CJKKGYXKLJO CJKKGYX

WkGLG CJKKGYXL]Z WJRECJKKGYXU[]UO_ `Q PLJRECJKKGYX WJ…bXCJKKGYX P]E ] Ê OT [\WN EjNOCMN CJKKGYXO\ EELL^MNZx[N CXYJMNGÔJREhEGTONECJKKGYX P]E CJKKGYXM_TL]T CJKKGYX

U[]] T̂ WXCE`ZOw EGOTWkGCJKKGYX [\_EEN Y`WÔ[G W\ RZTU[] M CXYJMNZ[\GMNOPQ RhEGTONECJKKGYX CXYJMNG]GẐGX P]E _TjxL]Z WJRE^GXU[] UO_

(encopresis# hEONO GGWXGGKOT[JU[]kGGX TM_TJ


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0>.,.G.>50>/ Ek RGÈJWXK]YEKxT KJ††GbP\ OZGX U_ WXYG[OJEW ǸM _EhE_T P]E LNYbLJREY `Q ÈQ`JYÈ]GY

GXL\ costoverte6ral angle lipoma "air patc" dimple sinus tract LNYblum6osacral GPG`Q]ET YJZYXjNOCMN P] E p"imosis vaginitis la6ial ad"esion

_GCXYJMNWXGMY]GTGZ_GUO_JL neurogenic 6ladderYMYGTYGÈJQ CX[NEGkGTGET rectalsp"incter O_YZ


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0>.,.G)>52H15F=,=0>. .$ GMYCJKKGYX (urinalysis# OZhP_LMY

(dipstic4# ]Y[JLmicroscopic eam Q MYJOTj_ xC] YZ\ G[\ MNOPQ RGTONECJKKGYX

.$.$ GMY leu4ocyte esterase (LY]G[\ pyuria OZ detect esterases hE neutrop"ils# WX nitrite (OZGJZ`WJGY]GL\\ZXCW\ ZE nitrate \ [\ hECJKKGYXCE nitrite# OZL dipstic4 QY]GjNOCMǸ Gh`_jWLY

.$. GMYEJL[OWQOGY QY]GjNOCMN `G@B:[GY]G ) WWz/H2F(pyuria# .$.% GZ_[[CJKKGYX (hP_CJKKGYX\ N TLh`[]

Z_[ 5ram‡s stain OZU[]CJE# QY]G jNOCMǸ GLPQ RL\\Z[GY]G`Q]GJL $ MJY/oil po;er field

GMYLQ RTM_ECEGMYJOT M]̀ GLYG[jNO


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0>.-X>;-67@1?3SS>G; . GGXPQ RhECJKKGYX QY]G[\YG[KkGJ†\ KÔ

hEGYNEN JZ (gold standard# Q ZQEZJEGYNEN JZ WXGWQhP_ZGM_GEŴP\ _L]TP\ ROJTE\R

a# j_ xC]YZOW\ [\ U_KxTU[]GLKG`M^]Y[JL[\WJ…bXC] YZ`EJ (ill appearance# `QkGCEM_Th _̀ZGCˆNP\YEXZ]GT]TO]YE h _̀LCJKKGYXMY urinalysis _ [JLGGXPQ R]Eh _̀ZGM_GEŴP\

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MNOPQ RGTONECJKKGYXUO_E]PJO YK]TMYGX

PQRhECJKKGYX ]Eh _̀GJ…GO_YZZGM_GEWP\


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G=(0>.-0,G1/>5SS>G;S>2.-X>;-67@1

G=(0>.-0,G1/>5SS>G;S>2.-X>;-67@1 a% u"ra"u&ic as"iration -67 *171+BH0)( *SDB 93;3>

?2H ?6H ?3-B01>/D, *>0G> m ( B/-X>;-B06>/)( *.

3>+,.G8B0.15 #urinalysis% +BH 9,+.-X>;-67@1 S3-7@ 13-67@1>0=G2352.71 H

@


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SS>G;-0B/G=( su"ra"u&ic

as"iration -X>;-67@1K4@3#+0( * colonyk


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0>.BM9:.0> 90H +K>G; de!ydration OZh`_KGEk RGGTCG`QGT`WO

WQOOkG _GkGCE e"irical anti&iotics (GCW\ ZECWTMG[ sensitivity#

]EUO_jWGXPQ R GNO EXEkGh`_ Ampicillin )1-$11 [././YJE

GT`WOWQOOkG WX 5entamicin %-) [././YJE GT`WOWQOOkG`Q_GW_G[ `Q %rd generation:ep"alosporins

OM\ [\GGÊT h`_ZGGT`WOWQOOkG`Q_GW_G[ UO_] aminoglycosides P] E 5entamicin ) [././YJE (XYJThEj_ xC]YZ\ [\GkGTGETUMjNOCMN# `Q %rdgeneration :ep"alosporins P]E :efotaime $11-11

[././YJE :eftriaone )1-$11 [././YJE \ \ ] Q N QR


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0>.BM9:.0> .;-..0>B/,.GSS>G;@>?3

hm 63 qJqh G3?3H M

G/ acute "yelone"!ritis EXEkGkG circumcision hEj_ xC]YZ\ [\ p"imosis 0>.,.G2>8G>5-B=3

SS>G; \ GL]Y[O_YZhEj_ xC]YZ (OxjEx[N#


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0>.BM9:.0> 0>.,.G,=B,>H MG/.,=B-67@1@>1/ ( % JR T//C\ # EXEkG

h _̀ prop"ylais O_ YZZG :otrimoa8ole $- [././YJE T trimet"oprim `Q 9itrofurantion $-[././YJE CEYWGEGEZ]GTE_Z }-$ OQE

9:;90H +K/-S( */5\ LUO_L]Z UO_] EXEkG

h _̀OQ[EkRG[Gw U[]WJRECJKKGYX ]GZCJKKGYXEKOQ ] _ _ J N


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VEICULOURETERALRELUz #VUR%


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Vesiculoureteral reflux

3etrograde flo; of urine from t"e 6ladder tot"e ureter and 4idney Flap valve mec"anism Š 'reteral attac"ment

to t"e 6ladder normally is o6li?ue

preventreflu


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E"ideioloy• $1& of c"ildren• V'3 is t"e most common urologic anomaly in

c"ildren

7"e incidence decreases as age increases (uncommon aftert"e age of ) years Boys tend to present at a younger age Among older c"ildren girls are affected approimately four

times more fre?uently t"an 6oys |& of males and $0& of females ;it" a '7I go on to "avea diagnosis of V'3 1& to 01& of c"ildren Š ‰1& of infant ;it" '7Is "ave V'3


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Classification

qQ Priary VURmQ econdary VUR


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Priary VUR

*ost common type :ongenital anomalies Defect in development of t"e valve mec"anism

of t"e vesicoureteral unction (s"ortening ofintravesical ureter or *alformation# Spontaneous resolution can occur ;it" gro;t"!ortenin of

t!eintravesicalureter

Inco"etenceof t!e valvularec!anis UrineReflux


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econdary VUR

Associated ;it" Increased intravesical pressure


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Pat!o"!ysioloy RefluxAscendinInfectionRecurrent"yelone"!ritis

Reflux ne"!ro"at!y#carrin%

Extensive renal scarIsc!eia | Inflaation

I"airedRenal function Reninediated!y"ertension

ER


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radin of VUR

,>< International Reflux Coittee


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y"tos• ever• Irrita&ility•

Poor Zei!t ain #TT%• elly urine• A&doinal Pain• ysuria$ frebuency$ urency

\aeaturia• Enuresis and dysfunctionalvoidin• Consti"ation$ t!read Zor

infection$ sore vulva

Untreated VUR• [edZettin• \i! &lood "ressure• Proteinuria• }idney failure

Nons"ecificsy"tos

• iarr!ea• Lac of a""etite• Irrita&ility• Nausia and Voittin

Clinical anifestation


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Investiation

qQ Ultrasonora"!ymQ Voidin cystouret!rora"!y #VCU%^Q Radionuclide cystora"!y #RNC%hQ ~A scan


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Ultrasonora"!y 9on invasive met"od• :annot rule out reflu• 01& of reflu "ave a6normality on u/s

Assess for renal si8e upper tract a6normalities suc" as "ydronep"rosis and

ureteral dilatation o6vious scarring ureteral ectopia or 6ladder a6normalities suc" as

ureterocele 6ladder ;all t"ic4ening


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Ultrasonora"!y

V idi t t! !


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Voidin cystouret!rora"!y#VCU% Invasive met"od 5old standard (Detect V'3 and 5rading# ‹• :ontrast Filling and Œ-ray eamination during

voiding• 3eflu occurring during filling is termed lo;-

pressure reflu or passive reflued• 3eflu occurring during voiding is termed "ig"-

pressure reflu or active reflu• presence and etent of reflu delineates t"e

6ladder outline 6ladder nec4 and ureteral anduret"ral anatomy and 6ladder capacity

V idi t t! !


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Voidin cystouret!rora"!y#VCU%

R di lid t !


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Radionuclide cystora"!y#RNC% 9uclear scan of 6ladder *ore sensitivity 6ut


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Radionuclide cystora"!y#RNC%


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~A scan *orp"ology and structure of 4idney IV D*SA upta4e 6y t"e 4idney measure in

-0 "r.

Areas of decreased upta4e representpyelonep"ritis or scarring. epensive invasive and epose radiation• Identify ‰1& of V'3 grade III or "ig"er• 3ecommended ;"en a renal ultrasound is a6normal

greater concern for scarring (grade III-V V'3#elevated serum creatinine


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~A scan


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Persistent reflux in

ae q g yr

Natural \istory


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Natural \istory

Persistent reflux &y ae


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Treatent 5oal of treatment are

2revent pyelonep"ritis 3eflu-related renal inury and ot"er

complication urical and Nonsurical treatent 'se Aerican Uroloical Association #AUA%

Reflux Treatent uidelines


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Association #AUA% Reflux

Treatent uidelines


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Nonsurical t!eatent Pro"!ytactic Anti&iotics

Age mont"s Aoxycillin $1 mg/4g/day ƒnce daily "s. Age mont"s Cotrioxawole #[actri% Ž of dose ƒnce

daily "s

Treat voidin dysfunction and consti"ation olloZ u" Re"eat UkA $ [P easureent VCU every qmq oQ Success rate

3eflu grade $-

1& in ) yr. 3eflu grade %-) 01& in ) yr. 3eflu grade %-) 6ilat. $1& Bladder dysfunction 9o success


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urical TreatentqQ O"en "rocedure• *odifying t"e a6normal ureterovesical attac"ment Intraural

ureter lent!j ureteral diaeter hjq to gjq• ~eaureter • NarroZin to noral siwe• Poor idney function Ne"!rectoykNe"!roureterectoy

. uccess rate 2rimary reflu grades $-0 |& 2rimary reflu grades ) 1& Secondary reflu


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urical TreatentmQ Endosco"ic correction

• Bul4ing agent t"roug" cystoscope ust 6eneat"ureteral orifice creating artifical flap valve

•

9on-invasive out patient procedure• Success rate ‰1-1&

d i i


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Endoscopic correction

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UTI and Vesiculouretral Reflux