Seminar 15:

Urinary Tract Infections

Presented by: Supervised by:
Bong Jen Nee Dr. Arsath
Chong Kel Liang
Babu Akash Date: 22.03.2022
Baviethra Time: 8 a.m.
 Contents

• Surgical anatomy of urinary system

• Aetiology, pathophysiology of UTI
• Clinical features of UTI
• Investigations and treatment for UTI
Surgical Anatomy
of Urinary System
Bong Jen Nee
BMS 17091121
Kidneys
• Retroperitoneal Organs
• Extend from T12 – L3

Perinephric fat appear

‘whiter’ than colonic
mesenteric fat

Thicker perinephric fat ass/w

increased estimated blood
loss & operative time for
partial nephrectomy
Tenderness over costovertebral angle (CVA)
• Acute pyelonephritis
• Renal calculi
• Renal artery occlusion
• Perinephric abscess
5 Segmental arteries
• Anatomical end branches
• Any trauma/ obstruction  lead to ischemia &
necrosis of renal parenchyma
• Used for partial nephrectomy

Renal artery  anterior & posterior division 

5 segmental arteries  interlobar arteries 
arcuate arteries  interlobular arteries 
afferent arterioles  glomerulus  efferent
arteriole  vasa recta

Accessory Artery [in 25% of

patient]
• Artery that reach the kidney

Aberrant Artery
• Artery that not enter the
kidney through hilum
Avascular Plane of Brodel
• Between posterior and anterior segmental
artery
• Posterior to lateral aspect of kidney
• Results in significantly less blood loss – safe
route for nephrostomy
• Right renal vein  drain into vena
cava
• Left suprarenal & gonadal vein 
drain into left renal vein

• Renal cell carcinoma – can lead to

left sided varicocele

• Longer left renal vein – left kidney is

preferred for organ transplantation
Ureters

Cross common iliac/ Male

external iliac artery
• Posterior to vas deferens
Female • Ex: radical prostatectomy [whole
Enter posterior wall of
• Posterior to uterine artery prostate, seminal vesicle, vas
urinary bladder • Ex: hysterectomy [uterus & uterine deferens are removed]
artery are removed]
 Urinary Bladder

Sympathetic : Hypogastric nerve [T12 – L2]

• Cause relaxation of detrusor muscle  urine retention

Parasympathetic : Pelvic nerve [S2-4]

• Cause contraction of detrusor muscle  stimulate
micturition

Detrusor muscle Somatic: Pudendal nerve [S2-4] – innervate external

• Become hypertrophy [prominent trabeculae] to sphincter
compensate for increased workload of bladder emptying • Provide voluntary control of micturition
• Ex: obstruction in urine outflow • Ex: in vaginal delivery, prostatectomy  cause urinary
incontinence
 Detected by sensory nerve
Parasympathetic
 afferent signal to spinal
efferent contract
Bladder wall stretch cord
detrusor muscle

Internal urethral sphincter

contract, external sphincter
voluntarily relax
Spinal Cord Transection above T12: Spinal Cord Transection below T12:
Reflex bladder Flaccid bladder

• Afferent signal unable to reach brain • Damaged parasympathetic to bladder

• External urethral sphincter constantly
relaxed
• Bladder automatically empty as it fills
• Frequent, small volume urine  urge
incontinence
• Detrusor muscle paralysed, unable to
contract
• Bladder is filled uncontrollable,
become distended  until overflow
incontinence occur
Urethra Male urethra: ~20cm long
• Transport urine from bladder to external opening in perineum
• Lined by stratified columnar epithelium (protected from
corrosive urine)

Prostatic Urethra
• Can be compressed by BPH

Membranous Urethra
• From apex of prostate to bulb of penis
• Posterior urethral injury (d/t pelvic fracture)
• Cause extravascation of urine into deep
perineal space

Penile Urethra
• From bulb of penis (through corpus spongiosum)
to urethral meatus
• Anterior urethral injury (perineal straddle injury)
• Cause extravasation of urine into superifical
perineal space: scrotum, around penis, lower
abdominal wall
 ~20cm

~4cm

Female Urethra: ~4cm long

• Begin at neck of bladder – pass inferiorly through perineal membrane & muscular
pelvic floor – open directly into perineum
• Short length of urethra in female
• more susceptible to UTI
 Foley catheter should be AVOIDED in
patient w suspected urethral injury:
• Blood in meatus
• Perineal hematoma

References
• Norman S Williams. Bailey & Love’s Short Practice of Surgery. 27th Edition.
• Oliver Jones. 2020. Organs of the Plevis. Teachmeanatomy.info
Etiology & Pathogenesis of
Urinary Tract Infection
Prepared By: Chong Kel Liang (BMS 17091112)
Etiology
In acute uncomplicated cystitis
E. coli accounts for 75-90 % of cases
Staphylococcus saprophyticus for 5-15% (with particularly frequent isolation from
younger women)
Klebsiella species, Proteus species, Enterococcus species, and other organisms for 5-
10 %

In complicated UTI
E.coli (predominant organism)
Other aerobic gram-negative rods(Klebsiella species, Proteus spp.)
Gram positive bacteria(Enterococcus & Staphylococcus aureus)
Yeast
Pathogenesis
Most cases bacteria ascends from the urethra to the bladder (cystitis)
• Bacterial organisms can further ascend through the ureter and infect the kidney
causing a renal parenchymal infection (pyelonephritis)

• Infection and symptom development depends on the

Host- e.g., genetic background, behavioral factors and underlying disease
Pathogen
Environmental factors- e.g., vaginal microflora, medical devices
Indwelling catheter, stone, or any other foreign body
Hematogenous spread to the urinary tract (rare)- e.g., Salmonella, S. aureus and
Candida
Stages of Urinary Tract Infection
References

• Bailey & Love’s Short Practice of Surgery; Edited by Norman S Williams, P. Ronan O
Connel, Andrew Mac Casksie, 26th Ed, CRC Press. 2013.
• Wong, E., 2012. Urinary Tract Infection- Pathogenesis of Urinary Tract Infection.
[Online] Available at: http://www.pathophys.org/uti/uti-patho/[Accessed 17
March 2022].
• Roy, D. K., 2014. Urinary Tract Infection. [Online] Available at:
https://www.slideshare.net/doctornobel/urinary-tract-infections-
33422292[Accessed 17 March 2022].
CLINICAL FEATURES
AKASH BABU
BMS17091688
 CLINICAL FEATURES
●Dysuria, frequency, urgency
●Suprapubic pain
●Gross hematuria may be present
●Fever is usually absent in lower UTIs; therefore, fever and
flank pain should be taken as a sign of more serious
infection, such as pyelonephritis.
 REFERENCES

●Norman S Williams, Christopher J.K Bulstrode, P.Ronan

O’Connell, Hodder Arnold, Bailey and Love’s Short
Practice of Surgery, 25th Edition.
 MANAGEMENT
BAVIETHRA
BMS17091043
 DIAGNOSIS
Uncomplicated lower UTI in women

● Typical symptoms: Treatment may be initiated without further diagnostics.

● Unclear history or symptoms: Perform urinalysis
 a urine dipstick test / microscopy

● Positive urinalysis (proof of pyuria and bacteriuria): Initiate treatment

● Negative urinalysis but persisting suspicion: Obtain urine culture
Urinalysis
Indications: best initial test for all patients
● Procedure: visual, chemical (dipstick), and microscopic examination of urine
● Specimen collection method
 Clean-catch midstream sample: thought to reduce contamination with vaginal or skin flora
 Straight catheterization of the bladder: may be considered if the risk of contamination is
high
 Suprapubic aspiration: no contamination if performed correctly but rarely used due to its
invasive nature
● Typical findings Pyuria: presence of white blood cells (WBCs) in the urine
● Positive leukocyte esterase: an enzyme produced by WBC≥ 5 WBC/HPF or ≥ 8–10 WBC/mm3
● Bacteriuria: presence of bacteria in the urine
● Positive urinary nitrites: indicate bacteria that convert nitrates to nitrites (most commonly
gram-negative bacteria; e.g., E.coli

Other findings;
● Leukocyte casts (pyelonephritis)
● Micro- or macroscopic hematuria may be present.
● Alkaline urine (pH > 8)
● struvite crystals in sediment: indicate urease-producing organisms
Proteus, Klebsiella, Staphylococcus saprophyticus
Urine culture
Collected urine should be sent for culture immediately; if not, it should be refrigerated
at 4°C
● Cultures are considered positive if either of the following is present:
 Significant bacteriuria: defined as ≥ 10^5 CFU/mL in a clean-catch specimen
 Any organisms in a specimen obtained by suprapubic aspiration
● In patients with a normal urinary tract
(normal renal imaging), outcomes are very
good
● Persistent or recurrent infection seldom
results in serious kidney damage
(uncomplicated UTI).
● In those with abnormal urinary tracts (stones
or stasis), recurrence is more common and
outcomes are less good.
● combination of infection and obstruction
results in severe, sometimes rapid, kidney
damage (obstructive pyonephrosis)
 major cause of Gram-negative
septicaemia from Pseudomonas and
Enterobacter spp.
Imaging
 CT abdomen and pelvis with or without IV contrast
● Most sensitive for initial imaging
● Noncontrast CT is useful to diagnose urolithiasis.
● IV contrast is indicated if complications (abscess) or other causes of obstruction are
suspected.

 Ultrasound of the kidneys and bladder

● Perform if there are contraindications to contrast or radiation.
● Useful for measuring postvoid residual volume if obstruction is suspected (BPH)

 MRI of the abdomen and pelvis

 voiding cystourethrography
 retrograde cystography
 TREATMENT
General principles
● Antibiotic treatment is recommended for all patients with symptomatic
UTI.

Consider the need for supportive treatment.

● Phenazopyridine; a urinary analgesic, can be used for symptomatic
relief for a maximum of 2 days.
● Oral analgesia with NSAIDs, can provide additional relief.
Uncomplicated lower UTI
● Symptom relief can be expected to occur after an average of 36 hours. 
● Persistent symptoms despite antibiotic therapy suggest complicated UTI
and/or indicate the need to change the empiric therapy.
Antibiotic treatment
First-line treatment
 Nitrofurantoin for 5 days
 Trimethoprim/sulfamethoxazole (TMP-SMX) for 3 days
 Fosfomycin (single dose)
● Second-line treatment: beta-lactam antibiotics for 5–7 days
 Aminopenicillins plus beta-lactamase inhibitors(amoxicillin/clavulanic acid)
 Oral cephalosporins, e.g., cefpodoxime, cefdinir , or cefaclor
● Alternatives: Consider fluoroquinolones (ciprofloxacin for 3 days) for patients with previous
infections with bacteria resistant to other drug classes
Complicated lower UTI
● Empiric antibiotic therapy should have
broad-spectrum activity against the Hospitalization and initial intravenous
expected uropathogens. treatment may be necessary in the
● Antibiotic therapy must be adapted to following cases:
culture results and is commonly given for  Severe systemic symptoms(signs of
7–14 days. shock)
● In addition to antibiotic therapy,  Inability to tolerate oral antibiotics
complicating factors (obstruction) should  Severe comorbidities
be treated (immunocompromise or heart
● For UTI in men, referral to urology can be failure)
warranted especially in the following cases:
 Treatment failure or recurrent UTIs
 Symptoms of UTI and hematuria
 Voiding difficulties or acute urine retention
 Suspected acute bacterial prostatitis
Antibiotic treatment of complicated lower UTIs

● Fluoroquinolones PO or IV: (ciprofloxacin or levofloxacin )

● Beta lactams
 Second-generation or third-generation cephalosporins: e.g., ceftriaxone
 Extended-spectrum penicillins: e.g., ampicillin/sulbactam
● Aminoglycosides (gentamicin ): treatment option if fluoroquinolones or beta lactams
are contraindicated or as an addition to beta lactams

● Reasonable options if the pathogen is susceptible include

 Nitrofurantoin
 TMP-SMX
 Fosfomycin
Management of complicating factors
● Nephrolithiasis: In UTI with renal obstruction, urgent urology
consultation is required for drainage.
● Indwelling medical devices (e.g., ureteral stents, percutaneous
nephrostomy tubes)
 Management of infections may require exchange or removal of the
device, especially when it is obstructed.
 Urology should be consulted urgently for further management.
● Other treatable factors should be addressed: optimal blood sugar
control for diabetics.
Chemoprophylaxis
● Indication: may be considered in all women with recurrent uncomplicated UTIs
● Continuous prophylaxis
 Typically taken for 3–12 months with periodic reassessment
 Regimens
 Trimethoprim (TMP) daily
 TMP-SMX daily
 Cephalexin daily
 Nitrofurantoin daily
 Fosfomycin every 10 days

● Intermittent or postcoital prophylaxis

 Recommended for women who have recurrent UTIs associated with sexual activity
 Substances
 TMP-SMX
 Cephalexin
 Nitrofurantoin
Prophylactic measures to be adopted by women with recurrent urinary
infections
● Fluid intake of at least 2 L/day
● Regular complete emptying of bladder
● Good personal hygiene
● Emptying of bladder before and after sexual intercourse
● Cranberry juice/tablets may be effective
● Topical estrogen therapy should be considered in postmenopausal
women
Candiduria
● Candida isolated from the urine rarely indicates systemic infection, but
it may be a marker for greater mortality in severely ill patients.
● Predisposing factors should be treated in all cases of candiduria, by
removing indwelling catheters whenever possible.
● Indications for antifungal treatment include symptomatic cystitis or
pyelonephritis, neutropenia, or a planned urologic procedure.
● Commonly used antifungals include fluconazole and amphotericin B
 References

● https://www.amboss.com/us/knowledge/Urinary_tract_infections
● https://emedicine.medscape.com/article/233101-overview
● Kumar &Clark Clinical Medicine ; edited by Parveen Kumar,
Michael Clark ,9th ed, 2017.
● Davidson’s Principles and Practice of Medicine; Edited by Stuart H
Ralston, Ian D Penman, Mark WJ Strachan, Richard P Hobson, 23th
ed.