Uti 2

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Uti 2

  1. 1. <ul><li>Urinary Tract Infections </li></ul>
  2. 2. Urinary Tract Infections <ul><li>Most common urinary pathology </li></ul><ul><ul><li>7million hospital visits </li></ul></ul><ul><ul><li>1million admissions complicated with UTIs </li></ul></ul><ul><li>Common in both sexes </li></ul><ul><li>More common in female </li></ul><ul><li>Among Males == neonates and elderly more affected </li></ul>
  3. 3. Urinary Tract Infections <ul><li>INFLAMATORY RESPONSE OF UROTHELIUM TO THE BACTERIAL INVASION THAT IS USUALLY ASSOCIATED WITH BACTERIURIA AND PYURIA </li></ul>
  4. 4. <ul><li>BACTERIURIA </li></ul><ul><ul><li>( bacteria in urine. Normally free of) </li></ul></ul><ul><ul><li>Not contamination from vagina,introitus, prepuce, skin </li></ul></ul><ul><ul><li>Collection technique ( suprapubic aspirate, cath, vioded, MSU) </li></ul></ul><ul><li>SIGNIFICANT BACTERIURIA </li></ul><ul><ul><li>( # that exceeds that caused by contamination) ( 10 5 ) </li></ul></ul><ul><li>Symptomatic and Asymptomatic Bacteriuria </li></ul><ul><li>PYURIA </li></ul><ul><ul><li>( white blood / pus cells in urine. Indicates inflammation) </li></ul></ul><ul><li>BACTERIURIA WITHOUT PYURIA </li></ul><ul><ul><ul><li>(colonization) </li></ul></ul></ul><ul><li>PYURIA WITHOUT BACTERIUTIA </li></ul><ul><ul><ul><li>Tuberculosis, stones and cancer </li></ul></ul></ul>Urinary Tract Infections
  5. 5. CLASSIFICATION <ul><li>Acute - chronic </li></ul><ul><li>Non – Specific </li></ul><ul><ul><ul><li>Gram –ve rods </li></ul></ul></ul><ul><ul><ul><li>Gram +ve cocci. </li></ul></ul></ul><ul><li>Specific </li></ul><ul><ul><ul><li>T.B </li></ul></ul></ul><ul><ul><ul><li>Candidiasis </li></ul></ul></ul><ul><ul><ul><li>Actinomycosis </li></ul></ul></ul><ul><ul><ul><li>Schistosomiasis </li></ul></ul></ul><ul><li>3 Site </li></ul><ul><ul><li>Upper </li></ul></ul><ul><ul><ul><ul><ul><li>Pylonephrit </li></ul></ul></ul></ul></ul><ul><ul><li>Lower </li></ul></ul><ul><ul><ul><ul><ul><li>Cystits </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Urethritis </li></ul></ul></ul></ul></ul><ul><li>4 Uncomplicated </li></ul><ul><ul><ul><li>Structurely and functionally normal tract </li></ul></ul></ul><ul><li>Complicated </li></ul><ul><ul><ul><li>Structural / functionall abnormality, decreasing antimicrobial efficacy </li></ul></ul></ul>
  6. 6. CLASSIFICATION <ul><li>1 st infection </li></ul><ul><ul><ul><li>Nonhospitalized pt, Structurely and functionally normal tract </li></ul></ul></ul><ul><li>Isolated </li></ul><ul><ul><ul><li>If occur at least 6 months apart </li></ul></ul></ul><ul><li>Unresolved bacteriuria </li></ul><ul><ul><ul><li>Culture during treatment ------ original pathogen not eradicated </li></ul></ul></ul><ul><ul><ul><ul><li>Resistent to the drug </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Azotemia / papillary necrosis / </li></ul></ul></ul></ul><ul><ul><ul><ul><li>mass of bacterial groth too great for antimicribial inhibition / deception </li></ul></ul></ul></ul><ul><li>Recurrence </li></ul><ul><ul><ul><ul><li>Re-emergence of infection after documented sterilization </li></ul></ul></ul></ul><ul><ul><li>Bacterial persistence </li></ul></ul><ul><ul><ul><ul><li>Same bacteria from within the urinary tract </li></ul></ul></ul></ul><ul><ul><ul><ul><li>12 urologic abnormalities </li></ul></ul></ul></ul><ul><ul><li>Re-infections </li></ul></ul><ul><ul><ul><ul><li>New infection with Different bacteria from outside urinary tract (susceptibility factors) </li></ul></ul></ul></ul>
  7. 7. CLASSIFICATION <ul><li>DOMICILIARY </li></ul><ul><ul><ul><li>ENTERO </li></ul></ul></ul><ul><ul><ul><li>STAPH </li></ul></ul></ul><ul><li>NOSOCOMIAL </li></ul><ul><ul><ul><li>PSEUDOMONA </li></ul></ul></ul>
  8. 8. ROUTES OF INFECTION <ul><li>Ascnding </li></ul><ul><ul><li>Both men & women </li></ul></ul><ul><li>Hematogenous </li></ul><ul><ul><li>Tuberculosis, staphlococci </li></ul></ul><ul><li>Lymphatogenous </li></ul><ul><ul><li>Not well esteblished </li></ul></ul><ul><li>Direct extension </li></ul><ul><ul><li>Neighboring organs. IBD, PID, VVF, VIF </li></ul></ul>
  9. 9. URINARY PATHOGENS <ul><li>Predictable </li></ul><ul><li>Most UTIs == Aerobic gram negative rods </li></ul><ul><ul><li>E.Coli, </li></ul></ul><ul><ul><li>Proteus, </li></ul></ul><ul><ul><li>Klebsiella </li></ul></ul><ul><ul><li>Pseudomonas </li></ul></ul><ul><ul><li>Citrobactor </li></ul></ul><ul><ul><li>Serratia </li></ul></ul><ul><li>Gram positive cocci , == </li></ul><ul><ul><li>Enterococci </li></ul></ul><ul><ul><li>Staph. Aureus, Epidermidis and Saprophyticus </li></ul></ul><ul><ul><li>Strept. Group B&D </li></ul></ul><ul><li>Gram negative cocci == Neisseria Gonorrhoeae </li></ul><ul><li>Gram positive rods and anaerobes == rarely implicated </li></ul><ul><li>Others == special identification technique </li></ul><ul><ul><li>Chlamydiae ( C. Tracomatous), </li></ul></ul><ul><ul><li>Mycoplasmas ( ureaplasma urealyticum) </li></ul></ul>
  10. 10. DIAGNOSIS <ul><li>URINE ANALYSIS </li></ul><ul><ul><li>Microscopic exam high power </li></ul></ul><ul><ul><li>3 or more (5-8 in females) pus cells </li></ul></ul><ul><ul><li>NITRITE (bacteria) </li></ul></ul><ul><ul><li>LEUKOCYTE ESTRASE (LEUKOCYTEs) </li></ul></ul><ul><li>URINE CULTURE </li></ul><ul><ul><li>Qualitative </li></ul></ul><ul><ul><li>Quantified (CFU/ML) </li></ul></ul><ul><ul><li>10 5 == significant bactereuria // sumptomatic bactereuria </li></ul></ul><ul><li>COLLECTION </li></ul><ul><ul><li>Suprapubic </li></ul></ul><ul><ul><li>Catheter </li></ul></ul><ul><ul><li>Segmented voided </li></ul></ul>
  11. 11. RADIOLOGIC STUDIES <ul><li>Indications </li></ul><ul><ul><ul><li>Calculi </li></ul></ul></ul><ul><ul><ul><li>Ureter reflux </li></ul></ul></ul><ul><ul><ul><li>Poor response </li></ul></ul></ul><ul><ul><ul><li>Papillary necrosis </li></ul></ul></ul><ul><ul><ul><li>Neuropathic bladder </li></ul></ul></ul><ul><li>PLAIN FILM </li></ul><ul><li>IVU </li></ul><ul><li>MCG </li></ul><ul><li>CYSTOSCOPY & URS </li></ul><ul><li>CT-MRI </li></ul><ul><li>RADIONUCLIDE SCANES </li></ul>
  12. 12. Localization studies <ul><li>Stamey’s technique of ureteric catheterization under cystoscopic guidance </li></ul><ul><li>Immunological techneques </li></ul><ul><ul><li>Agglutination tests and ELISA </li></ul></ul><ul><li>Prostatic and urethral localization </li></ul><ul><li>Tissue and stone cultures </li></ul>
  13. 13. PRINCIPLES of MANAGEMENT <ul><li>INITIAL ELEMINATION </li></ul><ul><ul><li>Medical measures </li></ul></ul><ul><ul><ul><li>SERUM/URINARY LEVELS </li></ul></ul></ul><ul><ul><ul><li>BACTERIAL RESISTENCE </li></ul></ul></ul><ul><ul><li>Surgical measures </li></ul></ul><ul><li>Identification of underlying cause </li></ul><ul><li>Treatment of underlying abnormality </li></ul><ul><li>Prophylactic and suppressive treatment </li></ul>
  14. 14. <ul><li>Recurrent attacks in women and single episode in men or children either sex should be evaluated further to find the underlying cause </li></ul>
  15. 15. ANTIBIOTICS <ul><li>TMP-SMX </li></ul><ul><li>NITROFURANTION </li></ul><ul><li>CEPHALOSPORINS </li></ul><ul><li>AMINOPENICILLINS </li></ul><ul><li>AMINOGLYCOSIDES </li></ul><ul><li>AZTREONAM </li></ul><ul><li>FLUOROQUINOLONES </li></ul>
  16. 16. CHOICE <ul><li>COMLICATED </li></ul><ul><li>SPECTRUM </li></ul><ul><li>SIDE EFFECTS </li></ul><ul><li>COST </li></ul><ul><li>DURATION </li></ul>
  17. 17. Acute Pyelonephritis <ul><li>Inflammation of parenchyma & pelvis of Kidney </li></ul><ul><li>Bacteriology - E. Coli 80% </li></ul><ul><li>- Klebsiela, </li></ul><ul><li>- Proteus, pseudomonas </li></ul><ul><li>- Enterobacter, Staph. </li></ul><ul><li>Clinical features </li></ul><ul><li>prodronal symptoms= Nausea, vomiting, malaise </li></ul><ul><li>Abrupt onset of fever </li></ul><ul><li>Chills, flank pain </li></ul><ul><li>LUTS – frequency, urgency, dysuria </li></ul><ul><li>Signs: </li></ul><ul><li>Tachycardia, temperature 101 - 104 0 F, Renal angle tenderness, Abdominal signs. </li></ul>
  18. 18. Acute Pyelonephritis <ul><li>Diagnosis: </li></ul><ul><ul><ul><li>Bld. C/P- Leucocytosis-Neutrophils </li></ul></ul></ul><ul><ul><ul><li>Urinalysis – Pyuria, bactiuria, haematuria </li></ul></ul></ul><ul><ul><ul><li>Urine C/S – 100,000 CFU/ml </li></ul></ul></ul><ul><ul><ul><li>Blood culture – Bacteraemia / Septicemia </li></ul></ul></ul><ul><ul><ul><li>Doppler USG – CT, Isotope Scan </li></ul></ul></ul><ul><li>Dif diagnosis </li></ul><ul><ul><li>Pnumonia,appendicitis, cholecystitis </li></ul></ul><ul><ul><li>PID.renal & perirenal abscesses </li></ul></ul>
  19. 19. Management <ul><li>Hospitalization </li></ul><ul><li>Antibiotics culture reports </li></ul><ul><li>Antipyretics </li></ul><ul><li>Antiemetics </li></ul><ul><li>I/V & oral fluids </li></ul><ul><li>Urinary alkalinisation </li></ul><ul><ul><ul><li>EColi , strept------acidic </li></ul></ul></ul><ul><ul><ul><li>Staph, protes, psodoonas, klebsiella, provodentia= alkaline </li></ul></ul></ul><ul><li>Correction of anatomical / functional anomalies </li></ul>
  20. 20. Chronic Pyelonephritis <ul><li>Interstitial inflammation = patchy scaring of parenchyma==renal insufficency </li></ul><ul><ul><ul><li>Tubules atrophic & dilated </li></ul></ul></ul><ul><ul><ul><li>Glomeruli retain structure till late </li></ul></ul></ul><ul><li>Reflux nephropathy </li></ul><ul><li>Clinical feature </li></ul><ul><ul><ul><li>Pain, LUTS,dysurea, constitutional symptoms </li></ul></ul></ul><ul><ul><ul><li>hypertention, pyrexia, anemia </li></ul></ul></ul>
  21. 21. Chronic Pyelonephritis <ul><li>Investigatios </li></ul><ul><ul><ul><li>Protinurea <3g/D </li></ul></ul></ul><ul><ul><ul><li>Pus cell but no casts </li></ul></ul></ul><ul><ul><ul><li>Bact. Exam </li></ul></ul></ul><ul><ul><ul><li>IVU and US </li></ul></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Eradicate predisposing factors </li></ul></ul><ul><ul><ul><ul><li>Stones, obstruction, reflux </li></ul></ul></ul></ul><ul><ul><li>Repeated courses of antiiotics </li></ul></ul><ul><ul><li>Nephrectomy == infection, hypertention </li></ul></ul><ul><ul><li>End stage renal disease – transplantation,dialysis </li></ul></ul>
  22. 22. Pyonephrosis <ul><li>Infected hydronephrosis,calculus, pyelonephritis </li></ul><ul><li>Pus containing multilocular sac </li></ul><ul><li>Destruction of parenchyma due to obstruction & infection====septicemia </li></ul><ul><li>Clinical features </li></ul><ul><ul><ul><li>Anemia, fever, loin swelling </li></ul></ul></ul><ul><li>KUB, US, IVU—calculus, dilatation, function </li></ul><ul><li>Antibiotics, </li></ul><ul><li>Drainage==PCN, open nephrostomy </li></ul><ul><li>nephreectomy </li></ul>
  23. 23. Renal abscess <ul><li>Parenchymal abscess--encapsulated </li></ul><ul><li>Blood born </li></ul><ul><li>Coliforms, Staph aureus </li></ul><ul><li>Hematoma,DM, AIDS, drug abusers </li></ul><ul><li>Tender loin swelling, fever, </li></ul><ul><li>Leucocytosis </li></ul><ul><li>US, IVU, CT SCAN == SOL </li></ul><ul><li>Antibiotics </li></ul><ul><li>Percuteneous aspiration </li></ul><ul><li>Open drainage </li></ul>
  24. 24. Perinephric abscess <ul><li>Pus between kidney & gerota's fascia </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Rupture of renal abscess </li></ul></ul><ul><ul><li>Ascending infection in urinary stasis, </li></ul></ul><ul><ul><li>Obstruction, Calculi, neurogenic bladder, diabetes.hematoma, pyonephrosis, TB, </li></ul></ul><ul><li>Clinical features </li></ul><ul><li>Fever, flank pain, & LUTS, Tender flank mass, skin erythema, anaemia </li></ul><ul><li>Diagnosis </li></ul><ul><ul><ul><li>Bld C/P </li></ul></ul></ul><ul><ul><ul><li>Urinalysis </li></ul></ul></ul><ul><ul><ul><li>Urine C/S </li></ul></ul></ul><ul><ul><ul><li>Bld. C/S </li></ul></ul></ul><ul><ul><ul><li>P/C aspiration </li></ul></ul></ul><ul><ul><ul><li>U.s, </li></ul></ul></ul><ul><ul><ul><li>IVU & CT </li></ul></ul></ul><ul><li>Management </li></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><li>P/C aspiration -----C/S </li></ul></ul></ul><ul><ul><ul><li>Open drainage </li></ul></ul></ul>
  25. 25. <ul><li>Acute Cystitis and urethritis </li></ul><ul><li>VUR, and vesical diverticulum neurogenic bladder / decompensation of bladder Cystocele / UV prolapse vesical calculus, foreign body neoplasm of blader, urethra, prostate and penis </li></ul><ul><li>bladder neck stenosis, Post urethral,valve Urethral stricture Enlarged prostate--------- benign / malignant / inflammatory Urethral Stone / foreign body impaction Ext, meatal stenoaia Phemosis / fused synichae, </li></ul><ul><li>Detrusor sphincter dyssynergia frequency – dysuria syndrome </li></ul><ul><li>Atrophic urethritis (senile) </li></ul><ul><li>Distal urethral syndrome </li></ul><ul><li>Abacterial cystitis /urethritis ( mycoplasma, herpes, chemical) </li></ul><ul><li>TB, schistosomiasis </li></ul><ul><li>Intersitial cystitis </li></ul><ul><li>Cystitis cystca and Alkaline encrustin cystitis </li></ul><ul><li>Pregnancy, diabetes, LVF, CCF, diuretics, polyuria </li></ul><ul><li>Causes of Frequency – Dysuria </li></ul>
  26. 26. Acute Cystitis <ul><li>More common in women than under 50 men </li></ul><ul><ul><ul><ul><ul><li>Short urethra </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sexual intercourse </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>child birth trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mentruation </li></ul></ul></ul></ul></ul><ul><li>Asymtomatic bacteriurea 5-10 % ( without any demonstrable cause) </li></ul><ul><li>Men are protected due to prostatic secretions </li></ul>
  27. 27. URINARY PATHOGENS/ ROUTES <ul><li>Ascending route – faecal – perineal –Urethral </li></ul><ul><li>Descending route- TB </li></ul><ul><li>Adjoining organs – fallopian tubes, vagina, Gut </li></ul><ul><li>E. Coli – 80% </li></ul><ul><ul><li>Proteus </li></ul></ul><ul><ul><li>Staph Epidermidis </li></ul></ul><ul><ul><li>Strept fecalis </li></ul></ul><ul><ul><ul><li>long standing cath / neurogenic bladder </li></ul></ul></ul><ul><ul><ul><ul><li>Klebsiella </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pseudomonas </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Staph. Aureus </li></ul></ul></ul></ul>
  28. 28. Predisposing factors <ul><ul><li>Incomplete emptying </li></ul></ul><ul><ul><ul><li>(BOO </li></ul></ul></ul><ul><ul><ul><ul><li>bladder neck stenosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Enlarged prostate--------- benign / malignant / inflamatory </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Post urethral valve </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Urethral stricture </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stone / foreign body impaction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ext, meatal stenoaia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Phemosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Detrusor sphincter dyssynergia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Penile carcinoma </li></ul></ul></ul></ul><ul><ul><ul><li>, VUR, </li></ul></ul></ul><ul><ul><ul><li>vesical diverticulum, </li></ul></ul></ul><ul><ul><ul><li>neurogenic bladder/decompensation of bladder </li></ul></ul></ul><ul><ul><ul><li>Cystocele / UV prolapse </li></ul></ul></ul><ul><ul><li>calculus, </li></ul></ul><ul><ul><li>foreign body, </li></ul></ul><ul><ul><li>neoplasm </li></ul></ul><ul><ul><li>estrogen def. </li></ul></ul><ul><ul><li>, Perineal colonization with E. Coli </li></ul></ul><ul><ul><li>instrumentation </li></ul></ul>
  29. 29. <ul><li>Clinical Features </li></ul><ul><ul><li>Irritative voiding symptoms </li></ul></ul><ul><ul><li>Low back ache & Suprapubic, penile, labial, parineal pain </li></ul></ul><ul><ul><li>Cloudy foul smelling urine, haemeturia </li></ul></ul><ul><ul><li>Constitutional symptomic – rare </li></ul></ul><ul><ul><li>Tenderness Hypogastrium </li></ul></ul><ul><li>Diagnosis </li></ul><ul><li>Urine R/E </li></ul><ul><li>Urine C/S </li></ul><ul><li>Further investigations </li></ul><ul><ul><li>Cystoscopy </li></ul></ul><ul><ul><li>Uroflowmetery </li></ul></ul><ul><ul><li>US for PVRU </li></ul></ul><ul><ul><li>IVU </li></ul></ul><ul><ul><li>urodynamics </li></ul></ul>
  30. 30. PYURIA WITHOUT BACTERIUTIA <ul><ul><ul><li>Tuberculosis, </li></ul></ul></ul><ul><ul><ul><li>Neisseria Gonorrhoeae </li></ul></ul></ul><ul><ul><ul><li>Abacterial cystitis </li></ul></ul></ul><ul><ul><ul><li>stones </li></ul></ul></ul><ul><ul><ul><li>carcinoma in situ </li></ul></ul></ul><ul><ul><ul><li>Renal papillary necrosis </li></ul></ul></ul><ul><ul><ul><li>Incomplete treatment of UTI </li></ul></ul></ul>
  31. 31. PRINCIPLES of MANAGEMENT <ul><li>INITIAL ELEMINATION </li></ul><ul><ul><li>Medical measures </li></ul></ul><ul><ul><ul><li>SERUM/URINARY LEVELS </li></ul></ul></ul><ul><ul><ul><li>BACTERIAL RESISTENCE </li></ul></ul></ul><ul><ul><li>Surgical measures </li></ul></ul><ul><li>Identification of underlying cause </li></ul><ul><li>Treatment of underlying abnormality </li></ul><ul><li>Prophylactic and suppressive treatment </li></ul>
  32. 32. FACTORS <ul><li>TOXINS </li></ul><ul><li>K antigens </li></ul><ul><li>ADHESINS-pili-MS </li></ul><ul><li>EPTHELIAL CELLS </li></ul><ul><li>HLA-A3antigen </li></ul><ul><li>LEWIS BLOOD GROUP </li></ul><ul><li>FLOW OF URINE,PH </li></ul><ul><li>ANTIBODIES IL6&8 </li></ul><ul><li>MUCO-P </li></ul>
  33. 33. MUTANTS <ul><li>5-10% </li></ul>
  34. 34. TRANSFERABLE RESISTANCE <ul><li>MORE COMMON </li></ul><ul><li>MULTIPLE STRAINS </li></ul><ul><li>FECAL FLORA </li></ul><ul><li>NITROFURANTOIN </li></ul><ul><li>Suppressive </li></ul><ul><li>Prophylactic </li></ul>
  35. 35. NATURAL RESISTANCE <ul><li>PROTEUS </li></ul><ul><li>Strepto-Faecalis-cephalexin </li></ul>
  36. 36. BACTERIAL RESISTANCE <ul><li>NATURAL </li></ul><ul><li>RESISTANT MUTANTS </li></ul><ul><li>R FACTOR TRANSFERABLE EXTRACHROMOSOMAL PLASMID MEDIATED </li></ul><ul><li>MIC </li></ul><ul><li>DRUGS </li></ul><ul><li>HYDRATION </li></ul><ul><li>COMLIANCE </li></ul>
  37. 37. Genito urinary tuberculosis <ul><li>        Always secondary </li></ul><ul><ul><ul><ul><ul><li> Haematogenous route </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Focus ?? </li></ul></ul></ul></ul></ul><ul><li>       involved </li></ul><ul><ul><ul><ul><li>Kidney & prostate </li></ul></ul></ul></ul><ul><li>       </li></ul>
  38. 38. Pathogenesis <ul><ul><ul><li>Usually one kidney, both in miliary TB </li></ul></ul></ul><ul><ul><ul><li>Edematous, friable, damage prone </li></ul></ul></ul><ul><li>Tubercle granuloma renal pyramids -> Ulcer </li></ul><ul><li>Pus & mycobacteria -> urine </li></ul><ul><li>Ulcer breaks into calyx -> Calyceal Stricture </li></ul><ul><li>Pyonephrosis, renal abscess, (localized) </li></ul><ul><li>Caseation (putty kidney) -> calcified ( cement kidney) </li></ul><ul><li>Perirenal   abscess      </li></ul><ul><li>Pseudo calculi. </li></ul><ul><li>Uretrel stricture & fibrosis </li></ul><ul><li>Tubercles & ulcer around ureteric orifice </li></ul><ul><li>Contracted bladder. </li></ul><ul><li>Epidedymo-orchitis </li></ul><ul><li>                     </li></ul>
  39. 39. Clinical Findings <ul><li>20-40 yrs. Men > women. R>L </li></ul><ul><li>Slow progression – 15 – 20 years </li></ul><ul><li>No symptoms initially </li></ul><ul><li>LUTS – (F) when lower tract involved </li></ul><ul><li>Cystitis not responding to antibiotic </li></ul><ul><li>Sterile pyuria </li></ul><ul><li>Haematuria, </li></ul><ul><li>Strargury </li></ul><ul><li>Pain </li></ul><ul><ul><ul><li>On bladder filling - suprapubic </li></ul></ul></ul><ul><ul><ul><li>On micturation – burning </li></ul></ul></ul><ul><ul><ul><li>Superadded infection – agonizing, penis tip, vulva </li></ul></ul></ul><ul><ul><ul><li>Renal , minimal, dull ache </li></ul></ul></ul><ul><li>Constitutional pain </li></ul><ul><ul><ul><ul><li>Weight loss, evening pyrexia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>High grade fever- superadded infection, milliary TB </li></ul></ul></ul></ul>
  40. 40. Examination <ul><li>Kidney not palpable except late </li></ul><ul><li>Enlarged non tender epididymus, vasa and seminal vesicals </li></ul><ul><li>Chronic draining scortal sinus </li></ul><ul><li>Induration or nodulation of prostate </li></ul>
  41. 41. <ul><li>Diagnosis </li></ul><ul><li>Urine R/E </li></ul><ul><li>Urine C/S </li></ul><ul><li>Urine AFB (3 morning- ZN) & culture ( LJ) </li></ul><ul><li>X-ray chest, abdomen </li></ul><ul><li>Not detected radiologically/culture till advanced </li></ul>
  42. 42. <ul><li>IVU </li></ul><ul><ul><ul><li>Normal, NFK (auto-nephrectomy) </li></ul></ul></ul><ul><ul><ul><li>Indistint papilla (ulcer), moth eaten </li></ul></ul></ul><ul><ul><ul><li>Calyceal stenosis </li></ul></ul></ul><ul><ul><ul><li>Hydronephrosis (stricture pelvis / ureter – lower, multiple) </li></ul></ul></ul><ul><ul><ul><li>Abscess (SOL) splaying calyces, communicating to calyces </li></ul></ul></ul><ul><ul><ul><li>Shrunken thick / irregular wall bladder </li></ul></ul></ul><ul><ul><ul><li>Obstructed ureter ( passing thru thick bladder wall) </li></ul></ul></ul><ul><li>RPUG </li></ul><ul><li>Cystoscopy / biopsy </li></ul><ul><ul><ul><li>Peri ureteral tubercles / ulcers </li></ul></ul></ul><ul><ul><ul><li>Small capacity </li></ul></ul></ul><ul><ul><ul><li>Golf hole orifeces </li></ul></ul></ul><ul><li>  </li></ul>
  43. 43. Treatment, medical ATT <ul><li>Radiological evidence </li></ul><ul><li>Demonstration of AFB / culture </li></ul><ul><li>Tissue diagnosis (Bx) </li></ul><ul><li>    D.O.T </li></ul><ul><ul><ul><li>       Isoniazid – 300mg </li></ul></ul></ul><ul><ul><ul><li>       Rifampicin – 600mg </li></ul></ul></ul><ul><ul><ul><li>       Ethambutol – 25mg / kg </li></ul></ul></ul><ul><ul><ul><li>       Pyrazinamide – 1.5 gm </li></ul></ul></ul><ul><ul><li>Surgeon : ensure review in first few weeks stricturing continues after treatment startd </li></ul></ul><ul><ul><li>Steroids </li></ul></ul>
  44. 44. Surgery <ul><ul><ul><li>conservative </li></ul></ul></ul><ul><ul><ul><li>Aim: remove infective foci </li></ul></ul></ul><ul><ul><ul><li>relieve obstruction </li></ul></ul></ul><ul><ul><ul><li>Time : 6-12 weeks ATT </li></ul></ul></ul><ul><ul><ul><li>Kidney –  ureter </li></ul></ul></ul><ul><ul><ul><ul><li>Salvage procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Uretero-calycostomy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pyeloplasty </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ureteric re-implant </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Boari flap, bowl interposition </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Nephro-ureterectomy </li></ul></ul></ul></ul><ul><ul><ul><li>Bladder – </li></ul></ul></ul><ul><ul><ul><ul><li>  Fulgration of ulcer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>  Ilio / Caeco cystoplasty, detubularised </li></ul></ul></ul></ul><ul><ul><ul><li>Testis </li></ul></ul></ul><ul><ul><ul><ul><li>Epididymectomy </li></ul></ul></ul></ul>
  45. 45. <ul><li>Prognosis good </li></ul><ul><li>Complications </li></ul><ul><ul><ul><li>Anemia </li></ul></ul></ul><ul><ul><ul><li>NFK / Renal failure </li></ul></ul></ul><ul><ul><ul><li>Fistulae formation </li></ul></ul></ul><ul><ul><ul><li>Peritonitis </li></ul></ul></ul><ul><ul><ul><li>Milliary TB </li></ul></ul></ul><ul><ul><ul><li>Infertility </li></ul></ul></ul>

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