DISORDERS OF THE

URINARY SYS

TEM

URINARY T

RACT

INFECTIO

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DR. ASMATULLAH SAPANDGENERAL MEDICAL SPECIALIST

A H M A D S H A H A B D A L I I N S T U T U T E O F H I G H E R

E D U C A T I O N

D E P A R T M E N T O F I N T E R N A L M E D I C I N E K H O S T

A F G H A N I S T A N

02 . 04 . 20 17

URINARY TRACT INFECTION (UTI)OR GENITOURINARY TRACT INFECTION:• Definition: Presence and multiplication of infectious

organism in the urinary tract as evidenced by presence of >100000 infectious agents per 1ml of the midstream urine is called UTIs.

• Prevalence of UTIs is common in women ((3% at age 20 and increasing by about 1% in each subsequent decade)), but uncommon in males except of first year of age and men of over 60 years old.

ETIOLOGY OF UTI:• E.coli 75-90%• Proteus 5-10%• Klebsiella 5-10%• Enterococcus fecalis 5-10%• Staphylococcus saprophyticus or epidermidis 5-15%

RISK FACTORS FOR UTI:

PATHOGENESIS OF UTI:1. ROUTE OF SPREAD:• Ascending transurethral route• Blood stream• Lymphatics• Direct extension

2.Periurethral area is heavily colonized with bacteria derived from fecal flora. This may be facilitated by lack of personal hygiene and local infections e.g. vaginitis.

TYPES OF UTI:1. Uncomplicated UTI: when infection occurs in a

patient without any functional and anatomic abnormality or instrumentation of the urinary tract is called UcUTI.

2. Complicated UTIs: when infection occurs in a patient with abnormal urinary tracts e.g. with stones or associated disease e.g. DM or others is called CUTI.

3. Recurrent UTIs: Repeated episodes of UTIs either complicated or uncomplicated.

4. Catheter-associated UTIs (CAUTI)5. According to Location: Upper UTI

(kidneys&ureters) and Lower UTI (urinary bladder, Prostate and urethra)

CLINICAL SYNDROMES OF UTI:The most important issue to be addressed when a UTI is suspected is the characterization of the clinical syndrome as:• ASB (Asymptomatic bacteruria)• Uncomplicated Cystitis, Pyelonephritis, Prostatitis• Epididymitis• Complicated UTI.This information will shape the diagnostic and therapeutic approach.

CLINICAL SYNDROMES OF UTI:1. ASYMPTOMATIC BACTERURIA:

A diagnosis of ASB can be considered only:• when the patient does not have local or systemic

symptoms referable to the urinary tract.

• The clinical presentation is usually that of a patient who undergoes a screening urine culture for a reason unrelated to the genitourinary tract and is incidentally found to have bacteriuria (>100000/ml)

CLINICAL SYNDROMES OF UTI:2. ACUTE CYSTITIS:

The typical symptoms of cystitis are: • Dysuria, Urinary frequency, and Urgency. • Nocturia, hesitancy, suprapubic discomfort, and

gross hematuria are often noted as well. • Unilateral back or flank pain is generally an

indication that the upper urinary tract is involved. Fever also is an indication of invasive infection of either the kidney or the prostate.

CLINICAL SYNDROMES OF UTI:3. PYELONEPHRITIS (Acute/Chronic):

• Mild pyelonephritis can present as: low-grade fever with or without lower-back or costovertebral-angle pain.

• Severe pyelonephritis can manifest as high fever, rigors, nausea, vomiting, and flank and/or loin pain. Symptoms are generally acute in onset, and symptoms of cystitis may not be present.

• Fever is the main feature distinguishing cystitis and pyelonephritis.

• The fever of pyelonephritis typically exhibits a high spiking “picket-fence” pattern and resolves over 72 h of therapy.

• Complications: Chronic pyelonephritis, emphysematous-pyelonephritis and intraparenchymal abscess.

CLINICAL SYNDROMES OF UTI:4. PROSTATITIS (Acute/Chronic):• Prostatitis includes both infectious and noninfectious

abnormalities of the prostate gland. Infections can be acute or chronic, are almost always bacterial in nature, and are far less common than the noninfectious entity chronic pelvic pain syndrome (formerly known as chronic prostatitis).

• Acute bacterial prostatitis presents as dysuria, frequency, and pain in the prostatic pelvic or perineal area.

• Fever and chills are usually present, and symptoms of bladder outlet obstruction are common.

CLINICAL SYNDROMES OF UTI:5. ACUTE EPIDIDYMITIS:

The typical symptoms of epididymitis are:

• Dysuria, Urinary frequency, and Urgency• Fever • Scrotal pain that radiates along the spermatic cord or

to the flank

CLINICAL SYNDROMES OF UTI:6. COMPLICATED UTI:

Complicated UTI presents as:• Symptomatic episode of cystitis or pyelonephritis in a

man or woman with an anatomic predisposition to infection, with a foreign body in the urinary tract, or with factors predisposing to a delayed response to therapy.

DIAGNOSIS OF UTI:

• Urine dipstick test• Urinalysis• Urine culture• STD evaluation• Pelvic exam• U/S

DIAGNOSIS OF UTI: First part

DIAGNOSIS OF UTI: Second part

DIFFERENTIAL DIAGNOSIS OF UTI SYNDROMES:1. DDX of CYSTITIS:• Vulvovaginitis • Pelvic inflammatory disease (PID)• Urethritis and prostatitis• Noninfectious causes of cystitis-like symptoms

(irradiation, chemotherapy, bladder carcinoma)

• DDx of cystitis from above conditions is done by U/S and Urinalysis.

DIFFERENTIAL DIAGNOSIS OF UTI SYNDROMES:2. DDX of PYELONEPHRITIS:• Cystitis• Prostatitis• Urethritis• Epididymitis • Acute appendicitis• Acute cholecystitis• Acute pancreatitis• diverticulitis

DIFFERENTIAL DIAGNOSIS OF UTI SYNDROMES:3. DDX of BACTERIAL PROSTATITIS:• Prostatic enlargement• Pyelonephritis• Epididymitis• Diverticulitis

DIFFERENTIAL DIAGNOSIS OF UTI SYNDROMES:4. DDX of NON-BACTERIAL PROSTATITIS:• Chronic bacterial prostatitis• Bladder cancer

DIFFERENTIAL DIAGNOSIS OF UTI SYNDROMES:4. DDX of EPIDIDYMITIS:• Testicular Tumor• Testicular torsion

TREATMENT OF UTI SYNDROMES:• The choice of antimicrobial agent and the dose and

duration of therapy depend on the site of infection and the presence or absence of complicating conditions.

• Patients should be advised to take about 2 liters of fluid daily and empty their bladder before retiring and before and after intercourse.

• For Drug therapy, Refer to the Next Slides…………

TREATMENT OF UTI SYNDROMES:

TREATMENT OF UTI SYNDROMES:

REFERENCES:• Harrison’s principles of internal medicine 19th 2015-2018• Current medical diagnosis and treatment 56th 2017• Short text book of medical diagnosis and management 11th e• Davidson’s principles and practice of medicine 22nd 2015-2018