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INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM Urinary tract infections Definition It is the inflammation and the

infection of the urinary tract. UTIs are generally classified as infections involving the upper or lower urinary tract Lower UTI  Cystitis  Prostatitis  Urethritis Upper UTI  Acute pyelonephritis  Chronic pyelonephritis  Renal abscess  Interstitial nephritis  Perirenal abscess Incidence UTI are the second most common bacterial infection in woman, with at least one third of women developing a UTI before the age of 24. Pregnant women are under risk. And more than 10,000 people are admitted every year in the hospital. Etiology  Escherichia coli  Enterococcus  Klebsiella  Enterobacter  Proteus  pseudomonas  staphylococcus  Candida albicans Predisposing factors to urinary tract infections  Factors influencing the urinary stasis (Intrinsic obstruction, extrinsic obstruction, urinary retention and renal impairment)  Foreign bodies (urinary tract calculi, catheters, shorter female urethra, obesity)  Factors compromising immune response (aging, HIV, diabetes mellitus)

poor personal hygiene) Pathophysiology Due to the etiology pH of the urine. multiple sex partners.  Dysuria – difficulty voiding  Pain on urination Storage symptoms  Urinary frequency – An abnormally frequent (usually more than 8 times in a 24 hour period) desire to void. hypoestrogenic state. often of only small quantities (less than 200 ml)  Urgency – a sudden. high urea concentration. In children it is called bedwetting General symptoms  Dysuria  Frequent urination  Urgency . voiding dysfunction with detrusor sphincter dyssynergia)  Other factors (pregnancy. Can be acute or chronic. which can be caused by atonic bladder or obstruction of the urethra. usually accompanied by frequency  Incontinence – involuntary or unwanted loss of leakage of urine  Nocturia – waking up 2 or more times at night because of the need or urge to void  Nocturnal enuresis – complaint of loss of urine during sleep. Functional disorders (constipation. and abundant glycol proteins interfere with the growth of the bacteria An alteration of any of these defence mechanism may lead to UTI Clinical manifestations Emptying symptoms  Weak urinary stream  Hesitancy – difficulty starting the urine stream resulting in a delay between initiation of urination by relaxation of the urethral sphincter and when urine stream actually begins  Intermittency – interruption of the urinary stream while voiding  Post void dribbling – urine loss after completion of voiding  Urinary retention or incomplete emptying – inability to empty the urine from the bladder. strong or intense desires to void immediately. use of spermicidal agents or contraceptive diaphragm.

In case of monolial infection nystatin and fluconazole may be prescribed  Analgesics  Warm sitz bath to relieve the symptoms .sulfamethoxazole. norfloxacin. Suprapubic discomfort or pressure  Hematuria  Flank pains. Etiology  Trichomonas  Monilial  Chlamydia  Gonorrhoea Clinical manifestations  Purulent discharge  Dysuria  Urgency  Frequent urination Diagnostic evaluation  History collection  Physical examination  Urine analysis & culture  Blood studies Treatment  Anti bacterial agents: sulfamathoxazole (trimethoprim and nitrofurantoin) In case of trichomonas metronidazole and clotrimazole. WBC. nitrofurantioin. ofloxacin  Adequate fluid intake  Urinary analgesics: phenazopyridine (pyridium) Urethritis Definition It is the inflammation of the urethra. trimethoprin. chills and fever  Fatigue or anorexia Diagnostic evaluations  Urinalysis (presence of nitrates. floxacin. leucocyte esterase)  Urine culture  Intra venous pyelography  Abdominal computer tomography Treatment  Antibiotic therapy: trimethoprin.

physical exertion. urgency)  Pain depends on the bladder filling. Incidence The average age of onset is 40 years. Nortryptyline .Interstitial Cystitis/ Painful Bladder Syndrome Definition IC is a chronic. painful inflammatory disease of the bladder characterised by the symptoms of urgency/frequency and pain in the bladder or pelvis. post ponding urination. pressure against the intra pubic area and emotional distress Diagnostic evaluations  History collection  Physical examinations  Urine culture  Cystoscopic examinations Treatment  Dietary and the life style modification which include the avoidance of the foods and beverages likely to exacerbate the symptoms.  Calcium glycerophosphate alkalizes the urine  Relaxation techniques  Tricyclic anti depressants eg. PBS is a Suprapubic pain related to bladder filling accompanied by other symptoms such as frequency. The ratio of women to men with IC/PBS is 10:1 to 12:1 Etiology  Etiology remains unknown  Defects of the glycosaminoglycan layer that protects the bladder mucosa from the irritating effects of urine exposure  Abnormal constituents of the urine  Dysfunction of the sympathetic innervations of the lower urinary tract  Reflex sympathetic dystrophy Other predisposing factors may be:  Chronic inflammation Clinical manifestations  Two primary clinical manifestations are pain and bothersome ( frequency. Amitriptyline. in the absence of UTI or other obvious pathology.

BPH. malaise. heparin. Etiology  Bacterial infections  Fungi  Protozoa  Virus  Bacterial organisms are E. flank pain and LUTS characterised by the cystitis  Dysuria  Urgency and frequency  Costovertebral tenderness (pain in the affected side) Diagnostic evaluations  Urinalysis (Pyuria. Instilling dimethyl sulfoxide. WBC found in urine)  CBC (leucocytosis)  Urine culture  Blood culture . kidney stones. Bacteuria and Hematuria. Klebsiella/ Enterobacter Pathophysiology Due to the etiology Colonization and the infection of the lower urinary tract via the asending urinary tract Pre-existing factors aggravates the condition (urinary backflow. hyaluronic acid into the bladder to desensitize the bladder discomfort  Surgical procedure include the urinary diversion Acute Pyelonephritis It is an inflammation of the renal parenchyma and collecting system. Proteus. Coli. indwelling catheters) Scarring of the renal tissues Poor functioning of the kidney Clinical manifestations  Starts with mild fatigue  Sudden onset of chills fever vomiting.

Klebsiella/ Enterobacter Repeated infections Diagnostic evaluation  Radiological imaging  Histological examination  Renal function test Treatment  Treat hyperkalemia (IV glucose. calcium channel blockers)  Treat anemia  Reduce the lipid level Renal tuberculosis It is rarely a primary lesion. atrophic. Etiology       Bacterial infections Fungi Protozoa Virus Bacterial organisms are E. Coli. Proteus. shrunken and lost functioning owing to the scarring or fibrosis. ultrasonography  IVP and CT scanning Treatment Parentral antibiotics (ampicillin. vancomycin) IV fluids Nonsteroidal anti inflammatory drugs Antipyretics Urinary analgesics Chronic Pyelonephritis This term is used when the kidney has become small. Clinical manifestation Fatigue Low grade fever Infection of the bladder and the genitor urinary tract Frequency and burning sensation on voididng . It is usually secondary to the TB of the lung. insulin/10 % calcium gluconate)  Treat hypertension ( diuretics.

Classification i. Scleroderma/ streptococcal infection) iii. The extend of the damage (diffuse or/ focal) ii. The initial cause of the disorder (SLE. which may affect both the kidney equally and it is one of the major cause of the renal failure.Epididymitis (in men) Renal colic Lumbar region pain Iliac pain Hematuria Treatment Treatment include the anti tuberculosis therapy and the symptomatic treatment. IMMUNOLOGIC DISORDERS OF THE KIDNEY Glomerulonephritis Glomerulonephritis is the inflammation of the glomeruli. The extend of changes (minimal/widespread) Etiology  Bacterial  Viral  Chemical  Drugs  Antigen – antibody reaction Pathophysiology I Antibodies have specificity of the antigen within the glomerli basement membrane Immunoglobulins and the complements get deposited on the basement membrane Production of the autoantibodies Structural changes of the glomerular basement membranes II Antibodies react with the circulating nonglomerular antigens .

Clinical manifestations  Protenuria  Hematuria  Slow development of uremia Diagnostic evaluations  Renal biopsy  Ultrasonography  CT Scans are used for the confirming the condition .Gets deposited as immune complexes along the glomerular basement membrane Causes a tissue injury Inflammatory reactions Clinical manifestations  Varying degree of Hematuria  Urinary excretion of various formed elements  Protenuria  Renal insufficiency Diagnostic studies  History collection  Physical examination  Urine culture and urinalysis  Blood analysis (elevated creatinine & BUN)  Ultrasonography  CT Scan Management  Symptomatic treatment  Restriction of the sodium and fluid intake  Antihypertensive drugs  Antibiotic therapy in case of a streptococcal infection Chronic glomerular nephritis It is a syndrome that reflects the end stage of the glomerular inflammatory diseases.

Etiology  Primary glomerular disease  Membraneous proliferative glomerulonephritis  Primary nephrotic syndrome  Focal glomerulonephritis  Inheritied nephrotic disease Extrarenal causes  Multisystem diseases  SLE  DM  Amyloidosis  Infections  Bacterial ( streptococcal. syphilis)  Viral (hepatitis. causing proteinuria that leads to low plasma albumin and tissue edema. HIV)  Protozoal (malaria)  Neoplasm  Hodkins lymphoma  Solid tumors of the lungs. Hypertension and UTI are treated vigorously.Treatment The treatment is the supportive and symptomatic treatment. cancer. Nephrotic syndrome It results when the glomerulus is excessively permeable to the plasma proteins. breast  Leukemia  Allergens  Drugs  Penicillamine  NSAIDS  Captopril  Heroin Pathopysiology Increases permeability of the basement membrane Massive excretion of the protein through urine . colon.

decreased total serum protein and elevated serum cholesterol. it may or may not obstruct the flow of urine flow Incidence Majority of the cases are found in between the age of 22 and 55 years .Results in the clinincal manifestations Clinical manifestations  Peripheral edema  Massive proteinuria  Hypertension  Hyperlipidemia  Hypoalbuminemia  Ascites & anasarca  Skeletal abnormalities  Calcium imbalances Diagnostic studies  History collection  Physical examination  Blood studies (decreased serum albumin. triglyceride level also increases)  Urinalysis Treatment  Angiotensin coverting enzymes inhibitors  Non steroidal anti inflammatory drugs  Low sodium  Loop diuretics  Lipid lowering agents  Anticoagulant therapy if in case of thrombosis  Corticosteroids  Cyclophosphamides OBSTRUCTIVE UROPATHIES Urinary Tract Calculi Definition It is the development of the stones in the urinary tract.

large intake of calcium and oxalate . excessive amount of tea or fruit juices that elevate the oxalate level. Uric acid 4. Struvite (magnesium ammonium phosphate) Etiology  Metabolic: Abnormalities that result in increased urine levels of calcium. and the five major categories of the stone are: 1. low fluid intake that increases the urine concentration  Genetic history: Family history of stone formation. Calcium phosphate 2. Cystine 5. pseudomonas and staphylococcus Pathophysiology Due to etiology Increased concentration of the urine Mucoproteins may form the stone or crystals Causes the obstruction of the urinary path way Clinical manifestations:       Abdominal or flank pain Hematuria Renal colic Pain may be associated with nausea and vomiting Pain depends on the site of the obstruction Mild shock with cool and the moist skin . Klebsiella. Calcium oxalate 3.Types: The term calculus refers to the stone. low urine volume and increased solute concentration in the urine  Diet : Large intake of the dietary protein. uric acid or citric acid  Climate: Warm climates that increases the fluid loss. oxaluric acid. gout or renal acidosis  Lifestyle : Sedentary occupation & immobility  Micro organisms : Proteus. cystinuria. lithiasis refers to the stone formation.

potassium. Cystomy. BUN and creatinine levels are also measured Treatment  Initial treatment include the pain management. laser lithotripsy. sodium. Hydronephrosis Definition The urinary tract may be obstructed at any point between the kidney and the urethral meatus. infection control and the prevention of the obstruction  Opoids are administered to reduce the pain  Adequate hydration  Sodium restriction  Dietary modification (Purine. This results in the dilation of the tract above the obstruction. extracorporeal shock wave lithotripsy  Surgical therapy: Pyelolythotomy. Ureterolithotomy.  Lithotripsy: percutaneous ultrasonic lithotripsy. electro hydraulic lithotripsy. Dilation of the renal pelvis is known as Hydronephrosis. bicarbonates. calcium and oxalate containing foods are to be controlled according to the extend and the severity of the condition)  Antibiotic therapy may be given in case of any infections  Endourogenic procedure: cystolitholapaxy. phosphorus. uric acid. Urinary infections with fever and chills Diagnostic evaluations          History collection Measurement of the pH of the urine Urinalysis Urine culture Intravenous pyelography Retrograde pyelogram Ultrasound Cystoscopy Serum calcium. percutaneous nephrolithotomy. .

sickle cell disease) Tumour of the renal pelvis or ureters Bladder tumour Within the wall          Pelviuretric neuromuscular dysfunction (congenital) Uretric stricture(tuberculosis.Etiology Within the lumen      Calculus Blood clot Sloughed papilla (diabetes. ureterocele. analgesic abuse. calculus) Congenital megaureter Congenital bladder neck obstruction Neuropathic bladder Urethral stricture Congenital urethral valve Pin hole meatus Pressure from outside          Pathophysiology Obstruction with continuing urine formation results in:  Progressive rise in intra luminal pressure Pelviuretric compression Tumours Diverticulitis Aortic aneurysm Retroperitoneal fibrosis Accidental ligature of ureters Retrocaval ureters (right sided obstruction) Prostatic obstruction Phimosis . calculus) Ureterovesical stricture (congenital.

Diagnostic studies  History collection and physical examination  Routine blood and biochemical investigations  Ultrasonography . urge incontinence. Ischemic interstitial damage develops and an inflammatory process also develops. It may be provoked by the increases urinary output. Clinical features Symptoms of upper tract obstruction  Loin pain (dull/sharp. in acute or chronic retention Examination of the genitals. fever and septicaemia) Symptoms of the bladder outflow obstruction     Signs     Loin pain Enlarged Nephrotic kidney which is palpable Bladder can be percussed. constant or intermittent). Acute obstruction is followed by the transient renal arterial vasodilatation succeeded by vasoconstriction. Eventually there is a damage which is induced by the compression of the renal substances.  Polyuria may occur in partial obstruction  Infection complication (malaise. Distal proximal to the site of the obstruction  Compression and thinning of the renal parenchyma. narrowing and diminished force of urinary stream Terminal dribbling and sense of incomplete bladder emptying Overflow incontinence or retention with overflow Infection occurs (increased frequency and urgency. eventually reducing it to a thin rim and resulting in a decrease in size of the kidney. Dysuria and passage of cloudy smelly urine. vagina and the rectum in case of prostatic enlargement or in case of pelvic malignancies Hesitancy.

Antibiotic therapy for the infections.      Treatment Radionuclide studies Excretion urography CT scanning Cystoscopy Urethroscopy Urethrography The treatment includes:      Relieving the obstruction Treating the underlying cause Preventing and treating infection Temporary external drainage of urine by nephrostomy. Surgical management: surgical management is done to correct the congenital defects or to correct the complication which are aroused after the hydronephrosis.  Ureterocystostomy (reimplantation of the ureters into the bladder wall) . Treatment  Temoraty bypassing by placing a stent under endoscopic control  Diverting the urinary flow via nephrostomy  Correction of the dialated portion using a balloon catheter  Open surgery – excise the stenotic area and reanastomose the ureters to the contralateral ureters or to the renal pelvis. Strictures A stricture is a narrowing of the lumen of the ureters or the urethra. Calculus or nephrostomy tube etc. Ureteral stricture Etiology  Surgical intervention / scar formation  Adhesion Clinical manifestations  Mild to moderate colic  In some cases infection eg.

Urethral Strictures Etiology  Trauma  Urethritis (gonococcal infections)  Iatrogenic (repeated catheterization)  Congenital defect Clinical manifestations  Diminished force of urine  Straining to void  Sprayed stream  Post void dribbling  Slit urine stream  Urinary frequency  Nocturia  Urinary retention  Unable to do the catheterization Diagnostic evaluation  History collection (H/O UTI)  Physical examination  Retrograde urethrography  Voiding cystourethrography ( identify the stricture length. . location and calibre) Management  Dialation of the urethra  Stets can be used to dialate the urethra  Urethroplasty  Longer stricture may require auto transplantation of the substitute segment such as skin flap.

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