URINARY TRACT

INFECTIONS

Professor Knigavko Alexander

CLASSIFICATION BY CONDITION OF THE
URINARY TRACT AND THE KIDNEYS

· Uncomplicated Urinary Tract Infection

· (Urethritis, Cystitis, serous Pyelonephritis)
· Every doctor can treat it
· Complicated Urinary Tract Infections
· Only urologist
 CLASSIFICATION BY LOCATION

· PYELONEPHRITIS
· Paranephritis
· CYSTITIS
· URETHRITIS
· PROSTATITIS
· EPIDIDYMO-ORCHITIS
 ORGANISMS THAT CAUSE
URINARY TRACT INFECTION
· Non-specific organisms:
– E. coli (common)
– Staph. aureus
– Ps. aerogenosa
– Proteus
– Klebsiella (common)
– L-form bacteria or viruses
– microorganism associates
– Conditionly specific: Trichomonas and mycoplasma

· Specific organisms:
– Gonococci (not uncommon)
– Schistosoma hematobium (rare)
– Mycobacteria tuberculosis (rare)
 ROUTES OF INFECTIONS
· Ascending Infection
– Through the urethra
· Hematogenic
– Through the kidneys
– Through the prostate
· Limphogenic
– Through the kidneys
– Through the prostate
 ASCENDING INFECTION

· More common in females because of

– The short urethra
– Close proximity of the urethra to the vagina

· Organisms that cause ascending infection

– Non-specific (E. coli, Klebsiella)
– Specific (mycoplasma, chlamydia, trichomonas)
 HEMATOGENOUS INFECTION
(rare)
· Non-Specific Organisms
– Staph. aureus (commonest)
• Kidney  renal cortical abscess (renal
carbuncle)
• Prostate  prostatitis
· Specific Organisms
– Schistosoma hematobium
– Tubercle bacilli
 Cystitis
· Inflammation of mucosa urinary bladder
· Most common UTI
· Sexually active women (15-50 years) mostly
suffer
· At least one episode of cystitis has been observed
by almost every woman in her lifetime

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 Ethiopathogenesis

· Infection agent arrives to bladder through wide

urethra
· Risk factors: bad hygiene , open sexual
intercourse, coldness, Low immunity, damage
urine outflow
· Agents: E.coli (80%), Enterococcus,
Mycoplasma, Ureaplasma, Trichomonas
· Types: infectious, chemical, post radiation, drug-
connected, thermal

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Causes of cystitis

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 Clinical signs of cystitis
· Often and painful, burning urination,
· urgency, urinary incontinence
· Suprapubic pain
· Macrohematuria

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 Diagnostic

· Urine test: pyuria,

Leycocituria, hematuria, proteinuria
· Blood test – usually N
· USD – enlargement of mucosa
· Urine culture – in chronic
· Cystoscopy in chronic
· IVU or CT if chronic 12
 Treatment

· Antibacterial drugs:
· Fluoroquinolone (possible combination with
ornidasol) Ciprofloxacin, Levo… or cefalosporin,
Trimetoprim, Phosphomicin
· Phytotherapy (herbal medicines…)
· Analgetics if need
· Hemostatic if hematuria (tranexam)

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 Chronic cystitis

– Mild but persistent symptoms

– Predisposed by presence of chronic
infravesical obstruction with retained
urine in the bladder (chronic retention);
e.g. BPH in aging men
– Treatment must include removal of
infravesical obstruction
– Antibacterial treatment according
sensitivity of vaginal infection and partner
if STD suspicion
 Interstitial cystitis
· Nonspecific non-inflammatory bladder disease
with constant urges and suprapubic pain
(often confused with overactive bladder)
· Treatment :
· Instillation of hyaluronic acid
· Neurological medicines
· Anti histamine
· Analgesics if it need
· Cystoscopic injections of Botox for reducing of
pollaciuria
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 Complicated UTI

· Men
· Age >60
· Hospital infections
· Pregnancy
· Presence of urethral catheter
· Anomalies of UT
· Diabetes Mellitus
· Presence symptoms after 5-7 days of treatment
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 PYELONEPHRITIS

Infectious inflammation of pelvic system and kidney

parenchyma
is observed in 20-40% of patients with affection of the
kidneys and upper urinary tracts.
- Females are more frequently affected than males
Females largely fall ill with cystitis after defloration,
during pregnancy, due to genital infections.
In primary pyelonephritis the urine outflow is not
disturbed and secondary process occurs under the
conditions of urostasis.
 PYELONEPHRITIS
· Acute pyelonephritis
– Acute onset of severe symptoms
– it usually resolves completely within 4-8 days
with adequate antimicrobial therapy

· Chronic pyelonephritis
– Mild but persistent symptoms
– Predisposed by presence of chronic
obstructive uropathy in the ureter, bladder
neck or urethra
– Treatment must include removal of any
obstructive lesion
 PYELONEPHRITIS (cont.)
· Clinical presentation
– Dull aching renal pain
– Fever, malaise, nausea, vomiting (only in acute
pyelonephritis)
· Diagnosis
– Urine analysis: pyuria (WBC in significant amount)
– Positive Pasternatskiy symtom
– Leykocytosis with shift to the left
– Enlargement hypoechogenig kidney perenchyma on
USD
Infections processes Acute renal
in the urinary tract pyo-inflammatory diseases
 Stage of the inflammatory process
I. Serous pyelonephritis one may see enlargement of
the kidneys, oedema of the surrounding cellular tissue. Numerous
inflammatory infiltrates are revealed during the microscopic study.

II. Purulent pyelonephritis

Apostematous nephritis is characterized by formation of
numerous minute foci under the kidney capsule and in the areas of its
cortical layer. Purulent infiltrates spread to the renal papillae. Dense
infiltrate is formed near the papillary base in some patients, which
then transforms into abscess that impairs renovation of the
papilla and causes its rejection. Fusion of minute purulent foci results
in necrosis — renal carbuncle or abscess. Formation of
carbuncle is associated with development of septic emboli,
which close the vessel lumen.
II. Purulent pyelonephritis (cont.)
Pyonephrosis is a terminal stage of specific or nonspecific
purulent destructive pyelonephritis.
The kidney looks like a big thin-walled cavity – socks with pus.
Two factors are necessary for development of pyonephrosis:
disturbed urine outflow out of the kidney and
penetration of pathogenic microflora in it.
Pyonephrosis may be primary (as a result of purulent
pyelonephritis) and secondary (due to infected hydronephrosis).
Pyonephrosis is always accompanied by marked sclerotic peri- and
paranephritis.
Clinical picture. The clinical picture of pyonephrosis is dull pain on
the side of affection, loss of weight, enlargement of the kidney, its
tenderness on palpation, pyuria, subfebrile temperature. Elevation of
the temperature, intoxication, increased pains and disappearance of
pyuria are symptoms of the ureter obstruction.
Treatment of patients with pyonephrosis is only surgical.
 Chronic pyelonephritis
- characterized by foci and
variety (polymorphism) of
changes in the renal tissue;
- in bilateral process there is
affection asymmetry of
different degree. Inflammatory
areas are gradually substituted
for areas of sclerotic
connective tissue. At first the
renal tubules become
extended (shield-like kidney),
then the affected kidney
shrinks. In case of bilateral
shrinkage chronic renal
 Acute pyelonephritis.
Manifestations of primary inflammation
General
Chill, significant fever, excessive
sweating, headache, pain in the
muscles and joints, nausea,
vomiting, general malaise. The
body temperature is of constant
or intermittent character.
Elevated temperature is
followed by marked adynamia,
arterial hypertension.
Local
Pain in the lumbar area,
irradiates into the hip, rarely —
in the upper part of the
abdomen or back. Palpatory
pain is determined in the area of
the affected kidney, the
Pasternatsky
symptom is positive. There
is observed tension of the
lumbar and epigastric areas (the
Pittel's symptom).
 Acute pyelonephritis.
Manifestations of secondary inflammation

-Palpated an enlarged painful kidney.

-The pain syndrome resembles the attack of
renal colic.
-The temperature is of septic character.
 Diagnosis
 Bacteriuria. (the number of microbes in 1 ml of urine
("microbial number of urine"), character of microflora, presence of
leucocyturia, active leucocytes and Sternheimer—Malbin cells.)

 Proteinuria. (no more than 1 g/l) and leucocyturia are revealed

in urine. Later on leucocyturia increases.

 Clinical study of blood in patients with acute serous pyelonephritis

moderate reduction of hemoglobin,
shows
leucocytosis, left shift of leucogram
(increased number of stab neutrophils and development of young
forms of leucocytes, elevated ESR, toxic granularity of neutrophil
granulocytes).

 In severe forms of the disease with affection of the opposite kidney

azotemia,
and liver there may be
hyperbilirubinemia, hyperglycemia,
hypo- and disproteinemia.
 Diagnosis

 Ultrasound scanning
 Examination urography
 Excretory urography (IVU)
 Computer Tomography
 Magnetic Resonance Tomography
 Chromocystoscopy
 Radionuclide scintigraphy
 Differential diagnosis

 Acute cholecystitis
 Appendicitis
 other acute infections (leptospirosis)
 PYELONEPHRITIS

· Treatment
– Wide spectrum antibiotic (ampicillin,
quinolones, cephalosporin, nitroimidazol are
usually effective) not less 14 days
– In chronic pyelonephritis, any obstructive
lesion must be removed
– Appropriate antibiotic based on urine culture
and sensitivity in chronic
– Phytotherapy, diet
 Treatment
 The main scheme of treatment includes the
regimen, diet, hydration, detoxication, general
strengthening of the organism, antibacterial and
vitamins therapy, bed regimen.
 When the glomerular filtration is kept, it is allowed
to take some salt and the amount of liquid taken
may be increased.
 Cephalosporins and fluoroquinolones of III-IV
generation are the most effective drugs.
 Secondary pyelonephritis
-combination of antibiotic therapy with drainage
of the kidney (ureteric catheterization, puncture
nephrostomy or open nephrostomy)
 ACUTE PROSTATITIS
· Symptoms
– Acute onset of fever with severe irritative and obstructive
urinary symptoms
– DRE (digital rectal examination): a very tender, firm and
swollen prostate
 ACUTE PROSTATITIS (cont.)
· Diagnosis
– Urine analysis: pyuria (WBC in significant amount)
– Prostatic secretions obtained by prostatic massage:
many leucocytes, pus
· Treatment
– Appropriate antibiotic (ampicillin, quinolones,
cephalosporin, nitroimidazoles)
– Tamsulosin
– Analgetics
– Desintoxication
– Massage from day of normal temperature
 CHRONIC PROSTATITIS
· Etiology
– Same organisms as for acute prostatitis and STI
– Chronic low grade and persistent bacterial infection
· Clinical Presentation
– Mild irritative urinary symptoms
– Pain referring to the anterior urethra, lower abdomen, peri-anal
region, testis or perineum
– DRE: prostate is very firm and mildly painful
– ED, PE
· Diagnosis Prostatic secretions by prostatic massage: WBC
>15WBC/HPF and prostatic cells with lipid dystrophy
· Treatment
– Antibiotics based on culture and sensitivity of the expressed
prostatic secretions
 EPIDIDYMO-ORCHITIS
· Acute epididymo-orchitis
– Bacterial spread from the urethra and along the vas to the
epididymis and testis
– Acute onset of severely painful huge tender firm scrotal
swelling
– Differential diagnosis with testicular torsion by Doppler
ultrasound
– Treatment: antibiotics, pain killers, suspensorium and bed
rest
· Chronic epididymo-orchitis
– Chronic non-specific epididymo-orchitis does not occur
– Chronic specific epididymitis: T.B. (review under Specific
Infections)
Exacerbation of chronic orchoepididymitis

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Abscesses of epididymis

36
 MALE GENITAL GONORRHEA
· Cause
– Ascending infection of gonococcal bacilli in the urethra
following sexual intercourse with an infected partner
· Presentation
– Yellow urethral discharge in the acute stage (differential
diagnosis: prostatorrhea: colorless urethral discharge; not a
disease)
· Complications
– Chronic urethritis, chronic prostatitis
– Stricture of the bulbous urethra
· Treatment
– Medical treatment: tetracyclines, quinolones
– Surgical treatment of urethral stricture: endoscopic visual
urethrotomy, or excision of the strictured urethral segment
 BALANITIS AND BALANOPOSTITIS
· Balanitis is the inflammation of the outer layer of the
prepuce tissues.

· Balanoposthitis is the inflammation of the prepuce is

usually combined with inflammation of glans penis.
· Treatment consists of a careful toilet of the penis, hot
bathing (35°C) with chamomile, by furacilin 1:5,000,
Triacutan, Triderm
· If balanoposthitis is developed in a patient with phimosis or
narrow forescin — the surgical treatment (circumcisio—
circumferential dissection ) is recommended
 UROGENITAL BILHARZIASIS

· Bilharzial cystitis (commonest)

· Bilharzial ureteritis (2nd common; only in the
lower third)
· Bilharzial urethritis (rare)
· Bilharzial genital lesions (esp. the seminal vesicles;
very rare)

· The kidneys and upper 2 thirds of the ureters are

NEVER directly affected by bilharzia
 ACUTE BILHARZIAL CYSTITIS
· Symptoms
– Symptoms of cystitis (burning, frequency, urgency)
– Terminal hematuria
· Urine analysis
– Living bilharzial ova
· Treatment
– Oral tablets (Praziquantel -Biltricid; 40mg/kg in a
single or double dose)
– Good prognosis
 CHRONIC BILHARZIAL
CYSTITIS (AND URETERITIS)

· Thousands of bilharzial ova are retained in the

suburothelium and die

· The dead bilharzial ova in the suburothelium

undergo calcification, and appear as “linear
calcification”
 CHRONIC BILHARZIAL CYSTITIS
“COMPLICATIONS”
· Fibrosis of the bladder muscles
– Chronic bladder ulcer (localized fibrosis in the detrusor
with ischemic atrophy of the overlying mucosa)
– Contracted bladder (fibrosis of the entire detrusor)

· Chronic irritation of the urothelium

– Metaplasia (to squamous epithelium)
– Leukoplakia (squamous metaplasia with
hyperkeratosis)
– Carcinoma
 CHRONIC BILHARZIAL URETERITIS
“COMPLICATIONS”

· Stricture of the lower third of the ureter

– Caused by fibrosis of the ureteral muscle by the
bilharzial reaction

· Vesico-ureteral reflux
– Caused by derangement of the uretero-vesical
junction by the bilharzial reaction
 TREATMENT OF COMPLICATIONS

· Chronic bladder ulcer: partial cystectomy

· Bladder neck obstruction: endoscopic incision of the
bladder neck
· Contracted bladder: ileocystoplasty or colocystoplasty
· Bladder cancer: radical cystectomy
· Stricture of the ureter: resection of the strictured
segment, and anastomosis of the 2 healthy ends of the
ureter
· Vesico-ureteral reflux: re-implantation of the ureter in
the bladder by an anti-reflux technique
 UROGENITAL TUBERCULOSIS

· Incidence
• Age (20-40 years); Sex (same)
· Mode of infection (hematogenous)
• From the lungs (2ry infection) or from other
organs (3ry infection)
• Kidneys and prostate are first affected (infection
then spreads to other urogenital organs)
· Pathology
• Tuberculomatous reaction
 KIDNEY INVOLVEMENT

· Acute stage
– Acute tuberculous pyelonephritis
– Usually no symptoms
· Chronic stage
– Chronic interstitial nephritis with papillary necrosis
– Autonephrectomy: kidney lost its continuity with:
• the urinary tract from complete ureteral stricture,
and
• the circulation from end arteritis obliterans
– Mild renal pain (late presentation)
 Scheme of tuberculosis spreading in renal
tissue (according to Chevassu)

1 – unchanged renal
tissue;
2 – primary tuberculous
tubercles;
3 – tuberculous infiltrate,
necropapillitis;
4 – tuberculous cavern;
5 – separated tubercular
cavern, abscess
 Changes of the urogenital system caused by
tuberculosis
1 – erosion of renal papillae;
2 – tuberculous pyocalix as a result of fibrous obstruction of the
neck of the calycle;
3 – aperture of the ureter orifice as a result of fibrosis;
4 – total replacement of renal
tissue by caseous masses
(autonephrectomy);
5 – stricture of the ureter;
6 – stricture of the pyeloureteral
segment;
7 – tuberculosis epididymitis;
8 – fibrously-changed and
shortened bladder
 ACUTE TUBERCULOUS CYSTITIS
· Tubercle bacilli move from the kidney (in the acute
stage), along the ureter, and to the bladder causing acute
tuberculous cystitis and positive urinary symptoms
· Urinary symptoms are the first complaint by the
patient:
– Frequency of micturition (+++)
– Urgency (+)
– Burning (+)
– Hematuria (+)
· Kidney pain is a late symptom that appears during the
chronic stage of pyelonephritis
CHRONIC TUBERCULOUS CYSTITIS

– Linear calcification: a symptomless condition

– Chronic ulcers: burning and frequency
– Contracted bladder: severe frequency
– Widely refluxing ureteric orifices (golf hole
appearance): hydronephrosis and UTI
 CHRONIC TUBERCULOUS
URETERITIS
· Stricture of the ureter at the lower third
– In bilharzial ureteritis: the same

· Entire ureter is dilated, rigid, straight, and has a

thick wall
– In bilharzial ureteritis, the dilated ureter is
tortuous and has a thin wall
 GENITAL TUBERCULOSIS
· Vas deferens involvement
– Very rare
– Beading of the vas

· Chronic epididymitis
– Very rare
– It is symptomless or causes mild pain
– Induration of the epididymis
 UROGENITAL TUBERCULOSIS
“DIAGNOSIS”
· Urine analysis
– Pyuria
– Urine culture for non-specific organisms:
negative (sterile pyuria)
– Urine culture for tubercle bacilli: positive

· Biopsy from the bladder or kidney

– Tuberculomatous reaction seen in biopsy
specimen
 UROGENITAL TUBERCULOSIS
“INVESTIGATIONS”
· X-Ray: calcification of the renal
parenchyma, linear calcification of the
bladder wall
· IVU: ureteral stricture, contracted bladder,
non-functioning kidney (autonephrectomy)
· Ascending cystogram: vesico-ureteral
reflux
· Cystoscopy: tubercles (confirmed by
biopsy), bladder ulcers, widely dilated (golf-
hole) ureteric orifice, contracted bladder
 UROGENITAL TUBERCULOSIS
“TREATMENT”
· Anti-tuberculous treatment
– For 6 months
· Surgical reconstruction
– Ureteral stricture (resection of the strictured
segment and re-anastomosis of the 2 healthy ends of
the ureter)
– Vesico-ureteral reflux (ureteral re-implantation in
the bladder by an anti-reflux)
– Contracted bladder (ileocystoplasty or
colocystoplasty)
· Nephrectomy if there is autonephrectomy
Thanks for attention