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URINARY TRACT INFECTION

 2 general anatomic categories:
1. Lower tract infection: urethritis and cystitis
2. Upper tract infection: acute pyelonephritis, prostatitis, intrarenal and perinephric abscesses
 Infection is indicated with growth of >10
5
organisms per mL from a properly collected
midstream “clean catch” urine sample
o Some cases though of true UTI lack in significant bacteriuria (i.e. in suprapubic aspirated
urine, samples from indwelling catheter)

ACUTE UTIS: URETHRITIS, CYSTITIS AND PYELONEPHRITIS
 Catheter (nosocomial) or non-catheter (community-acquired) infection
 Symptomatic or asymptomatic
 Annual incidence of 0.5-0.7 infections per patient-year in young women
 In males, acute symptomatic UTIs occur in the first year of life (urologic abnormalities)
o UTI is unusual in male patients under age of 50
 Asymptomatic bacteriuria is more common among elderly men and women by 40-50%
 28 cases per 10,000 women : incidence of acute uncomplicated pyelonephriti among
community-dwelling women 18-49 years of age

 Etiologic Causes:
1. Gram negative bacilli – most common agents
a. Escherichia coli – 80% of acute infections
b. Proteus and Klebsiella spp. And Enterobacter spp PEK. – account for uncomplicated
UTIs
 Proteus (through production of urease) and Klebsiella (through the production of
extracellular slime and polysaccharides) predispose to stone formation and are
isolated more frequently in patients with calculi.
c. Serratia spp. and Pseudomonas spp. plus organisms in letter b – recurrent infections and
infections associated with urologic manipulation, calculi or obstruction/nosocomial,
catheter-associated infections
2. Gram-positive cocci – lesser role in UTIs
 Staphylococcus aureus – cause infections in patients with renal stones or with
previous instrumentation or surgery
 Staphylococcus epidermidis – common cause of catheter-associated UTI
3. Neisseria gonorrhea and Herpes simplex virus – found in sexually active women with new
sexual partners
4. Ureaplasma urealyticum and Mycoplasma hominis – have been isolated from prostatic and
renal tissues of patients with acute prostatitis and pyelonephritis
5. Adenovirus – acute hemorrhagic cystitis in children and in some young adults, often in
epidemics
6. Candida – catheterized or diabetic patients


 Mechanisms of infection
o Ascent of bacteria from the bladder – probably the pathway for most renal parenchymal
infections
o Periurethral colonization
 Predisposed by alteration of the normal vaginal flora by antibiotics, other genital
infections or contraceptives (especially spermicide)
o Urethral massage during intercourse can facilitate entry of small numbers of periurethral
bacteria to the bladder
o Hematogenous pyelonephritis occurs most often in debilitated patients who are either
chronically ill or receiving immunosuppresants
o Metastatic staphylococcal or candidal infections of the kidney may follow bacteremia or
fungemia spreading from distant foci or infection in the bone, skin or vasculature

 Predisposing Conditions
1. Gender and sexual activity:
 Female urethra is prone to colonization due to its proximity to the anus, short length
and its termination between the labia
 Insertive rectal intercourse is associated with increased risk of cystitis for men
 Lack of circumcision is a risk factor for UTI in both male neonates and young men
2. Pregnancy: 2-8% UTIs detected among pregnant women due to:
 decreased ureteral tone
 decreased ureteral peristalsis
 temporary incompetence of the vesicoureteral valves
3. Obstruction
o Tumor, stricture, stone or prostatic hypertrophy can result in hydronephrosis and
increased frequency of UTI
4. Neurogenic bladder dysfunction
o Bladder enervation as in spinal cord injury, tabes dorsalis, multiple sclerosis, diabetes
o Bone demineralization due to immobilization causing hypercalciuria, calculus formation
and obstructive uropathy
5. Vesicoureteral reflux
6. Bacterial virulence factors:
 E. coli O, K and H serogroups causes symptomatic UTI
 Fimbriae of E. coli and Proteus
 Cytotoxins, hemolysins and aerobactins
7. Genetic factors:
 Maternal history of UTI is more often found in women who have experienced
recurrent UTI
 P fimbriae mediate attachment of E. coli to P-positive erythrocytes

 Clinical Presentations
1. CYSTITIS
 Sx: dysuria, frequency, urgency and suprapubic pain
 Urine: grossly cloudy, malodorous and bloody in ~30% of cases
 Some women may have only 10
2
-10
4
bacteria per mL of urine
 P.E.: tenderness of urethra or the suprapubic area
 Prominent systemic manifestations like fever, nausea and vomiting indicate
concommittant renal infection
2. ACUTE PYELONEPHRITIS
 Sx: develop rapidly over a few hours or a day – fever, shaking chills, nausea and
vomiting, abdominal pain, and diarrhea
 Symptoms of cystitis are sometimes present
 P.E.: febrile, tachycardia, generalized muscle tenderness, costovertebral angle
tenderness
 Urine: leukocyte casts detection – pathognomonic; hematuria – acute phase (if
persistent after manifestations subside, consider stone, tumor or TB)
 Usually responds to antimicrobial therapy within 48-72 hours
 Persistence of fever or of s/sx beyond 72 hours suggests the need for urologic
imaging
3. URETHRITIS
 Frequent presentation of gonococcal or chlamydial infections
 Sx: women -Mucopurulent vaginal discharge, dyspareunia and dysuria; men –
dysuria and purulent penile discharge
4. CATHETER-ASSOCIATED UTIS
 Bacteriuria develops in 10-15% of hospitalized patients with short-term indwelling
urethral catheters
 3-5% per day – risk of infection from catheterization
 Causes: E.coli, Proteus, Pseudomonas, Klebsiella, Serratia, staphylococci,
enterococci and Candida
 Gram- negative bacteremia – most significant recognized complication of catheter-
induced UTIs

 Diagnostics
1. Urinalysis
 Antiseptic solutions should not be used to wash the periurethral area before
collection of the urine specimen
 Water diuresis or recent voiding also reduces bacterial counts in urine
 In asymptomatic patients, 2 consecutive urine specimens should be examined before
therapy is instituted and both should have > 10
5
bacteria of a single specie per mL
 The leukocyte esterase “dipstick” method is less sensitive than microscopy in
identifying pyuria
2. Urine cultures
 May not be done in uncomplicated UTI
 Recommended in cases when the diagnosis of UTI is in question, in the management
of all patients suspected of upper tract infections and of those with complicating
factors (including all men).
3. Urologic evaluation (ultrasound, cystoscopy, IV pyelography)
 Should be performed for selected female patients with:
 Relapsing infection
 History of childhood infection
 Stones or painless hematuria
 Recurrent pyelonephritis
 Most male patients with UTI should be considered to have complicated infection
hence requires urologic evaluation.
 Patients showing s/sx of obstruction or stones should undergo urologic evaluation



 Treatment
Condition Characteristic
Pathogens
Mitigating
Circumstances
Recommended Empiric
Treatment
a

Acute
uncomplicated
cystitis in
women
E.coli,
Staphylococcus
saprophyticus,
Proteus
mirabilis,
Klebsiella
pneumoniae
None

Diabetes,
symptoms for .7 d,
recent UTI, use of
diaphragm, age of
>65y
Pregnancy
3 day regimens: oral TMP-
SMX, TMP, quinolone; 7
day regimen –
macrocrystalline
nitrofurantoin
Consider 7d-regimen: oral
TMP-SMX, TMP, quinolone

Consider 7d-regimen: oral
amoxicillin, macrocrystalline
nitrofurantoin, cefpodoxime
or TMP-SMX
Acute
uncomplicated
pyelonephritis
in women
E. coli, P.
mirabilis, S.
saprophyticus
Mild to mod.
Illness, no nausea
or vomiting,
outpatient therapy
Severe illness or
possible urosepsis;
hospitalization
required
Oral quinolone for 7-14d
(oral dose given IV if
desired); or single dose
ceftriaxone 1 g or
gentamicin (3-5mg/kg) ffd
by oral TMP-SMX for 14d
Parenteral quinolone,
gentamicin(+ampicillin),
ceftriaxone, or aztreonam
until defervescence; then
oral quinolone,
cephalosporin, or TMP-SMX
for 14d
Complicated
UTI in men
and women
E. coli,
Proteus,
Klebsiella,
Pseudomonas,
Serratia,
enterococci,
staphylococci
Mild to mod.
Illness, no nausea
or vomiting:
outpatient therapy
Severe illness or
possible urosepsis;
hospitalization
required
Oral quinolone for 10-14 d

Parenteral ampicillin and
gentamicin, quinolone,
ceftriaxone, aztreonam,
ticarcillin/clavulanate, or
imepenem-cilastain until
defervescence; then oral
quinolone or TMP-SMX for
10-21 d

 Treatment during Pregnancy
o All pregnant women should be screened for asymptomatic bacteriuria during the first
trimester
o Acute pyelonephritis in pregnancy should be managed with hospitalization and parenteral
antibiotic therapy, generally with a cephalosporin or an extended-spectrum penicillin
o Continuous low-dose prophylaxis with nitrofurantoin should be given to women who
have recurrent infections during pregnancy


PROSTATITIS
 Can be acute or chronic
 Acute bacterial prostatitis
o Generally affects young men
o If in older men, it is associated with an indwelling urethral catheter
o Tx: flouroquinolone
o Long-term prognosis: good
 Chronic bacterial prostatitis
o Infrequent, should be considered in men with recurrent bacteriuria
o Obstructive symptoms or perineal pain
o Caused by E. coli and other uropathogens
o Tx: flouroquinolones more successful than other antimicrobials; at least 12 weeks to be
effective


NEPHROLITHIASIS

 Types of stones:
o Calcium stones
o Uric acid stones
o Cystine stones
o Struvite stones
 Mechanisms of stone formation
o Arise due to breakdown of a delicate balance between solubility and precipitation of salts
 Supersaturation
 Reduction in ligands such as citrate can increase ion activity
 Can be increased by dehydration or by overexcretion of calcium, oxalate,
phosphate, cystine or uric acid
 Alkaline urine favors deposits of brushite and apatite
 Acidic urine of below 5.5 urine pH, uric acid crystals predominate
 Crystallization
 When urine supersaturation exceeds the upper limit of metastability, crystals
begin to nucleate
 Heterogeneous nucleation = a process where cell debris and other crystals
present in the urinary tract can serve as templates for crystal formation
 Multiple crystals can aggregate to form a kidney stone
 Common calcium oxalate kidney stones form as overgrowths on apatite plaques
(Randall’s plaques) in the renal papillae which provide an excellent surface
for heterogeneous nucleation of calcium oxalate salts
 Inhibitors of crystal formation
 Inorganic pyrophosphate – potent inhibitor
 Citrate – inhibits crystal growth and nucleation
 Glycoproteins – inhibit calcium oxalate crystallization

 Diagnostics
o Two -24 h urine collection, with a corresponding blood sample
o Serum and urine calcium, uric acid, electrolytes, creatinine, urine pH, volume, oxalate
and citrate
o Urinalysis
 Treatment
o Combined medical and surgical approach
o Depends on:
 Location of stone
 Extent of obstruction
 Nature of stone
 Function of the affected and unaffected kidney
 Presence or absence of UTI
 Progress of stone passage
 Risk of operation or anesthesia
o α1-adrenergic blockers relax ureteral muscle; shown to reduce time to stone passage and
the need for surgical removal of small stones
o general indications for stone removal: severe obstruction, infection, intractable pain and
serious bleeding
o Extracorporeal lithotripsy-in-situ fragmentation of stones
o Percutaneous nephrolithotomy requires a cystoscope
o Uteroscopy disrupts stones using a holmium laser


CALCIUM STONES
 More common in men
 3
rd
to 4
th
decade: average age of onset
 ~50% who form a single calcium stone eventually form another within the next 10 years
 Recurrent stone formers: 1 stone in every 2-3 years
o Idiopathic hypercalciuria
 MOST COMMON metabolic abnormality found in patients with nephrolithiasis
 Familial
 Diagnosed by presence of hypercalciuria without hypercalcemia
 Tx: low sodium and low protein diets superior than low-calcium diet
 Thiazide diuretics
o Hyperuricosuria
 About 20% of calcium oxalate stone formers are hyperuricosuric due to salting out
calcium oxalate by urate
 Tx: low-purine diet or Allopurinol 100 mg bid
o Primary hyperparathyroidism
 Unexplained hypercalcemia with increased parathyroid hormone
o Distal renal tubular acidosis
 A normal pH gradient is not established between blood and urine
 Leads to hyperchloremic acidosis
 Diagnosis is made by urine pH of >5.5
 Tx: Sodium bicarbonate 0.5-2.0mmol/kg of body weight per day in 4 to 6 divided
doses
o Hyperoxaluria
 Tx: diet low in oxalate with a normal intake of calcium and magnesium to reduce
oxalate absorption; resin cholestyramine 8-16 g/d
o Hypercitraturia
 20-40% of stone formers
 Tx: alkali
o Idiopathic Calcium lithiasis – no metabolic cause for stones despite a thorough metabolic
evaluation


URIC ACID STONES
 5-10% of kidney stones
 More common in men
 50% have gout
 Urine pH is usually <5.4 and often below 5.0: in gout, uric acid lithiasis and dehydration
 Myeloproliferative syndromes, chemotherapy and Lesch-Nyhan syndrome cause such massive
production of uric acid and consequent hyperuricosuria
 Plugging of renal collecting tubules by uric acid crystal can lead to acute renal failure
 Tx: low-purine diet, alkali, fluids, allopurinol

CYSTINE STONES
 Uncommon,~ 1%
 Cystinuria
o Defective transport of dibasic amino acids by the brush borders of renal tubule and
intestinal epithelial cells
o 2 types:
a. Type I – autosomal recessive; abnormal SLC3A1on chromosome 2
b. Non-Type-I – autosomal dominant; mutations in SLC7A9 gene on chromosome 9
o Tx: high fluid intake – cornerstone of tx; alkali, low-salt diet,

STRUVITE STONES
 Common and potentially dangerous
 Mainly in women or patients requiring chronic bladder catheterization
 Are a result of urinary infection with bacterial usually, Proteus species UTI
 Can grow to a large size and fill the renal pelvis and calyces to produce STAGHORN
appearance
 Tx: complete removal of stone with subsequent sterilization of the urinary tract- treatment of
choice for patient who can tolerate the procedure
o Percutaneous nephrolithotomy – preferred surgical approach
o Extracorporeal lithotripsy can be used in combination with percutaneous nephrolithotomy
o 50-90% stone-free rates post surgery















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