Your SlideShare is downloading. ×
0
Urinary Tract InfectionsUrinary Tract Infections
DR.TARIK ELDARATDR.TARIK ELDARAT
MD UROLOGISTMD UROLOGIST
Friday, Septemb...
Today’s GoalsToday’s Goals
 Be able to define the various types of UTIsBe able to define the various types of UTIs
 Desc...
DefinitionsDefinitions
 UTI—inflammatory response of the urothelium toUTI—inflammatory response of the urothelium to
bact...
Bacteriuria: the presence of bacteria in the urine
Significant bacteriuria: 105
organism or more per milliliter
Pyuria: th...
 Pyuria alone=inflammationPyuria alone=inflammation
 Bacteriuria without pyuria=colonizationBacteriuria without pyuria=c...
The normal urinary tract is sterile
for many reasons:
Eradication of bacteria by urinary and mucous
flow:
secretory peptid...
DefensesDefenses
 Primary DefensePrimary Defense
– Flow of UrineFlow of Urine
– VoidingVoiding
 Secondary DefenseSeconda...
ClassificationClassification
 Isolated—first infections or those isolated by 6 months(30-Isolated—first infections or tho...
Friday, September 27, 2013
Friday, September 27, 2013
EpidemiologyEpidemiology
 7 million office visits annually(1.2% female, 0.6% male)7 million office visits annually(1.2% f...
PathogenesisPathogenesis
 Ascending—predominant routeAscending—predominant route
– Impairment of peristalsis enhancesImpa...
PathogensPathogens
 NosocomialNosocomial
– E. Coli—50%E. Coli—50%
– KlebsiellaKlebsiella
– EnterobacterEnterobacter
– Cit...
Community-Acquired UTICommunity-Acquired UTI
E.coli
K.pneumoniae
Proteus
S.saprophyticus
S.epi &
gm - enterics
Enterococcu...
Nosocomial UTINosocomial UTI
catheter associatedcatheter associated
Short Term Long Term
E.coli
E.coli
Pseudomonas
Pseudom...
Friday, September 27, 2013
Causative organismsCausative organisms
 Gram +ve: Enterococci, StaphylococcusGram +ve: Enterococci, Staphylococcus
saprop...
Escherichia coliEscherichia coli
 E. coli (serotypes: 02, O4, O6) which areE. coli (serotypes: 02, O4, O6) which are
fimb...
Gram negative bacilliGram negative bacilli
 Pseudomonas, Proteus, and KlebsiellaPseudomonas, Proteus, and Klebsiella
infe...
S. saprophyticusS. saprophyticus
 Infection more common in young women.Infection more common in young women.
Friday, Sept...
What parts of the urinary
tract can get infected?
Urethra - Urethritis
Urinary bladder – Cystitis
Ureters – Ureteritis
Kid...
Cystitis
IncidenceIncidence
 1-3% of all GP consultations1-3% of all GP consultations
 5% of women each year with symptoms. Up5% ...
What are the signs and symptoms
of UTI?
Cystitis
Frequency
Urgency
Dysuria – painful voiding
Pain or discomfort in
suprapu...
CausesCauses
 The most common cause is bacterial infectionThe most common cause is bacterial infection
– Eschericia coli ...
PreventionPrevention
 Drinking plenty of fluids helps preventDrinking plenty of fluids helps prevent
cystitis in the firs...
Beware!Beware!
 PregnantPregnant
 Under age 12Under age 12
 MalesMales
 Systemically ill (fever, sickness, backache)Sy...
InvestigationInvestigation
 Urine dipstickUrine dipstick
– can be done in the surgery and will be positive for nitrates a...
Differential DiagnosisDifferential Diagnosis
 Urethral syndromeUrethral syndrome
 Bladder lesion e.g. calculi, tumour.Bl...
Complications and PrognosisComplications and Prognosis
 Ascending infection can occur, leading to development ofAscending...
Management Issues - GeneralManagement Issues - General
 50% will resolve in 3 days without50% will resolve in 3 days with...
Management Issues - GeneralManagement Issues - General
 Culture is always indicated inCulture is always indicated in
– Me...
Self careSelf care
 Drink slightly acid drinks such as cranberryDrink slightly acid drinks such as cranberry
juice, lemon...
AntibioticsAntibiotics
 Trimethoprim is an effective first line treatment.Trimethoprim is an effective first line treatme...
AntibioticsAntibiotics
 3 days of antibiotic is as effective as 5 or 7 days3 days of antibiotic is as effective as 5 or 7...
Urinary Tract InfectionsUrinary Tract Infections
T r e a t m e n t o f R e c u r r e n t C y s t i t i s
T r e a t l o n g...
Antibiotics for UTI in PregnancyAntibiotics for UTI in Pregnancy
 Cephalosporins and penicillins are recommendedCephalosp...
Fever
Nausea and vomiting
More pronounced malaise
Pain in the back
(+) CVA tenderness
Acute
pyelonephritis
Friday, Septemb...
Acute PyelonephritisAcute Pyelonephritis
Clinical ManifestationsClinical Manifestations
 Classic signs of cystitisClassic signs of cystitis
– EnuresisEnuresis
– F...
But… In InfantsBut… In Infants
 Fever! Fever!!Fever! Fever!!
Fever!!!Fever!!!
 Lack classic signsLack classic signs
 Ir...
Risk factorsRisk factors
 Female (30%:10%)Female (30%:10%)
– Shorter urethral lengthShorter urethral length
– Urethral op...
Risk Factors: continuedRisk Factors: continued
 Factors that prohibitFactors that prohibit
complete emptying ofcomplete e...
DiagnosisDiagnosis
 Urine CollectionUrine Collection
– SuprapubicSuprapubic
AspirationAspiration
– CatheterizedCatheteriz...
Specimen collectionSpecimen collection
 Samples should be collected before the startSamples should be collected before th...
The Positive CultureThe Positive Culture
 SuprapubicSuprapubic
– Any number of pathogensAny number of pathogens
– Should ...
Know the Adequacy of YourKnow the Adequacy of Your
TestsTests
 ““standard urinalysis”standard urinalysis”
– Urine dipstic...
UTI - Who should be studied?UTI - Who should be studied?
 Acute pyelonephritisAcute pyelonephritis AllAll febrile UTIsfeb...
Urinary Tract InfectionsUrinary Tract Infections
Clinical ManifestationsClinical Manifestations
Feature Cystitis Pyeloneph...
Imaging TechniquesImaging Techniques
 IndicationsIndications
– Evaluation ofEvaluation of
obstructionobstruction
– Persis...
Pyelonephritis by MRIPyelonephritis by MRI
Intrarenal abscess by CTIntrarenal abscess by CT
Perinephric abscess by CTPerinephric abscess by CT
A 3y/o boy has fever, shaking chills, and flank painA 3y/o boy has fever, shaking chills, and flank pain
consistent with a...
Emphysematous PyelonephritisEmphysematous Pyelonephritis
 1898 in JAMA: pneumaturia1898 in JAMA: pneumaturia
 An acute n...
Emphysematous PyelonephritisEmphysematous Pyelonephritis
/ Pathogenesis/ Pathogenesis
 Acute bacterial and fungal infecti...
Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
pathogenesispathogenesis
 Gas extension: renal and hepatic v...
Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
clinical findingsclinical findings
 Unilateral: 90%Unilatera...
Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
clinical findingsclinical findings
 Huang et al:Huang et al:...
Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
Radiological findingsRadiological findings
 CT: modality of ...
Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
ManagementManagement
 Traditionally: requiring emergent neph...
XanthogranulomatousXanthogranulomatous
pyelonephritispyelonephritis
 XGP: chronic suppurative atypical renalXGP: chronic ...
XGP / IncidenceXGP / Incidence
 0.6% of all surgically proven renal infection0.6% of all surgically proven renal infectio...
XGP / PathogenesisXGP / Pathogenesis
 Not been elucidatedNot been elucidated
 Play a role:Play a role:
-- urinary tract ...
XGP / Clinical findingsXGP / Clinical findings
 Quite nonspecific:Quite nonspecific:
-- anemia, malaise, leukocytosis, py...
XGP / Radiological findingsXGP / Radiological findings
 Renal ultrasound: hypoechoic massRenal ultrasound: hypoechoic mas...
XGP / ManagementXGP / Management
 Absolutely no medical therapyAbsolutely no medical therapy
 Open surgical nephrectomy:...
Urinary Tract InfectionsUrinary Tract Infections
Acute Uncomplicated Pyelonephritis in WomenAcute Uncomplicated Pyelonephr...
UTI ImagingUTI Imaging
 Renal ultrasoundRenal ultrasound
 IVUIVU
 Voiding cystourethrogramVoiding cystourethrogram
 DM...
VCUG - fluoro
B/L Reflux
R – grade IV
L – grade III
DMSA
L upper pole perfusion defect
At site of inflammation or scar
Fri...
 What determines a positive urine culture?What determines a positive urine culture?
 Suprapubic?Suprapubic?
 Transureth...
Principles of Antimicrobial TherapyPrinciples of Antimicrobial Therapy
 Treatment of UTI should result in sterileTreatmen...
Anbitiotic FormularyAnbitiotic Formulary
 TMP-SMX—inhibits dihydrofolic acid reductaseTMP-SMX—inhibits dihydrofolic acid ...
TreatmentTreatment
 Cystitis—3 DaysCystitis—3 Days
– 7 Days if duration of7 Days if duration of
symptoms, Diabetes, agesy...
Friday, September 27, 2013
Urinary Tract InfectionsUrinary Tract Infections
Candidates for ProphylaxisCandidates for Prophylaxis
 Women with ≥ 3 sym...
Friday, September 27, 2013
Prostatitis
Prostatitis: classificationProstatitis: classification
 Acute vs. chronic vs. prostatodyniaAcute vs. chronic vs. prostato...
Prostatitis: classificationProstatitis: classification
Bacteriuria Localized
prostate
infection
Inflammatory
response
Abno...
Prostatic massageProstatic massage
 AVOID IN ACUTE PROSTATITISAVOID IN ACUTE PROSTATITIS
 4 tube approach4 tube approach...
Acute bacterial prostatitisAcute bacterial prostatitis
 HistoryHistory
– Lower urinary tract obstruction, perineal pain,L...
Acute bacterial prostatitisAcute bacterial prostatitis
 ManagementManagement
– Outpatient therapyOutpatient therapy
» Bac...
Chronic bacterial prostatitisChronic bacterial prostatitis
 HistoryHistory
– Bladder outflow obstructionBladder outflow o...
Chronic bacterial prostatitisChronic bacterial prostatitis
 ManagementManagement
– Difficult to eradicate given poor pene...
Prostatitis: complicationsProstatitis: complications
 Renal parenchymal infectionRenal parenchymal infection
 Bacteremia...
ProstatodyniaProstatodynia
 HistoryHistory
– Persistent pelvic, suprapubic, infrapubic, scrotal,Persistent pelvic, suprap...
Upcoming SlideShare
Loading in...5
×

Urinary tract infections د طارق الضراط جامعة بنغازى

739

Published on

Published in: Technology, Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
739
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
54
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Prostatis will affect 50% of men at some time in their life; 2 million visits a year Fungal infections (ie Aspergillus) seen more often in immunocompromised patients
  • Most pts with dx of prostatitis are adults with perineal, lower back pn, lower abd pain, or ejaculatory complaints . Most don’t have bacteriuria and thus there is little bacterial evidence of infection Inflammatory response: in expressed prostatic secretions, semen, post massage urine, or prostate tissue
  • First 2 tubes should be sterile or have a colony count smaller by an order of magnitude The diagnosis of prostatitis requires VB3 to have 10 fold increase in colonies over VB1 3 tube approach gives us sample of urethra (1), bladder (2), and prostate 2 tube approach: obtain urine before and after massage– if WBC appear, prostatitis can be inferred
  • NOT A SUBTLE DIAGNOSIS Systemic symptoms include malaise, myalgias, or occasional toxic appearance Prostate massage may cause bacteremia or vas infection . Urine culture will generally reveal the pathogen .
  • These antibiotics will penetrate the prostate well under circumstances of inflammation
  • Bladder outflow obstruction: frequency, dribbling, diminished stream, hesitancy, and urgency Usually seen in older men Dysuria etc more often seen in younger men Prostate may be enlarged, asymmetrical, boggy, or tender
  • Prostate fluid has high pH and makes it difficult for antibiotics to penetrate Bactrim is the main choice as it diffuses into and concentrates into prostatic fluid May sometimes take up to 8 –12 weeks Alpha blockers may be of benefit in acute prostatitis as well Suppressive therapy includes daily Bactrim, prostate reduction procedures **** 1/3 have symptomatic and bacteriologic cure; 1/3 have symptomatic cure; 1/3 have no improvement ****
  • Prostate abscess: immunocompromised, diabetes, indaquate initial therapy, foreign bodies, gu obstruction . Imaging may be necessary to document the abscess (might be felt on physical examination )
  • 1 . Empiric course of abx in case of occult infection though there is no data to support this
  • Transcript of "Urinary tract infections د طارق الضراط جامعة بنغازى"

    1. 1. Urinary Tract InfectionsUrinary Tract Infections DR.TARIK ELDARATDR.TARIK ELDARAT MD UROLOGISTMD UROLOGIST Friday, September 27, 2013
    2. 2. Today’s GoalsToday’s Goals  Be able to define the various types of UTIsBe able to define the various types of UTIs  Describe the classic signs of pyelonephritisDescribe the classic signs of pyelonephritis  Be able to determine if a urine culture is positiveBe able to determine if a urine culture is positive  Know the types of imaging needed and who needsKnow the types of imaging needed and who needs imagingimaging  Explain why we care so much about early diagnosis andExplain why we care so much about early diagnosis and prompt treatmentprompt treatment Friday, September 27, 2013
    3. 3. DefinitionsDefinitions  UTI—inflammatory response of the urothelium toUTI—inflammatory response of the urothelium to bacterial invasion.bacterial invasion.  Uncomplicated—Healthy patient with normal urinaryUncomplicated—Healthy patient with normal urinary tract.tract.  Complicated—compromised patient or one with aComplicated—compromised patient or one with a functional or structural abnormality.functional or structural abnormality.  RecurrentRecurrent – Reinfection—infection from different bacteria outside the urinaryReinfection—infection from different bacteria outside the urinary tract.tract. – Persistent—focus from within the urinary tract that is neverPersistent—focus from within the urinary tract that is never eradicated.eradicated. Friday, September 27, 2013
    4. 4. Bacteriuria: the presence of bacteria in the urine Significant bacteriuria: 105 organism or more per milliliter Pyuria: the presence of white blood cells in urine Pyuria with 5 or more cells per microscopic high-power field: reliable indicator of UTI The absence of such pyuria does not reliably exclude UTI Friday, September 27, 2013
    5. 5.  Pyuria alone=inflammationPyuria alone=inflammation  Bacteriuria without pyuria=colonizationBacteriuria without pyuria=colonization  Epithelial cells=contaminationEpithelial cells=contamination
    6. 6. The normal urinary tract is sterile for many reasons: Eradication of bacteria by urinary and mucous flow: secretory peptides target cytoplasm of bacteria Urothelial bactericidal activity Urinary secretory IgA Blood group antigens in secretion alter bacterial adhesion Friday, September 27, 2013
    7. 7. DefensesDefenses  Primary DefensePrimary Defense – Flow of UrineFlow of Urine – VoidingVoiding  Secondary DefenseSecondary Defense – LactoferrinLactoferrin – pHpH – IgAIgA – IL-6IL-6 – IL-8IL-8 – Tamm-HorsfallTamm-Horsfall Friday, September 27, 2013
    8. 8. ClassificationClassification  Isolated—first infections or those isolated by 6 months(30-Isolated—first infections or those isolated by 6 months(30- 40% of women).40% of women).  Unresolved—insufficient treatmentUnresolved—insufficient treatment – ResistanceResistance – Development of resistanceDevelopment of resistance – Two species one is resistantTwo species one is resistant – Rapid reinfection before completion of therapy onRapid reinfection before completion of therapy on initial organisminitial organism – Azotemia(poor concentration of drug)Azotemia(poor concentration of drug) – Papillary necrosis + azotemiaPapillary necrosis + azotemia – Staghorn Calculi(mass and concentration of bacteriaStaghorn Calculi(mass and concentration of bacteria too great)too great)Friday, September 27, 2013
    9. 9. Friday, September 27, 2013
    10. 10. Friday, September 27, 2013
    11. 11. EpidemiologyEpidemiology  7 million office visits annually(1.2% female, 0.6% male)7 million office visits annually(1.2% female, 0.6% male)  Prevalence increases with hospitalization, disease, numberPrevalence increases with hospitalization, disease, number of infections,of infections,  Susceptible females—2 infections in 6 months = 66%Susceptible females—2 infections in 6 months = 66% chance of developing infection in the next 6 months.chance of developing infection in the next 6 months.  Prophylaxis changes the time to recurrence not the chanceProphylaxis changes the time to recurrence not the chance of recurrence.of recurrence.  Pregnancy increases the clinical acuity of infections.Pregnancy increases the clinical acuity of infections. Friday, September 27, 2013
    12. 12. PathogenesisPathogenesis  Ascending—predominant routeAscending—predominant route – Impairment of peristalsis enhancesImpairment of peristalsis enhances infection(endotoxin from G- Bacteria,infection(endotoxin from G- Bacteria, pregnancy, obstruction)pregnancy, obstruction) – Pelvic Pressure enhancesPelvic Pressure enhances infection(obstruction, VUR)infection(obstruction, VUR)  Hematogenous—rareHematogenous—rare  Lymphatic—very rare(RP abscess)Lymphatic—very rare(RP abscess)Friday, September 27, 2013
    13. 13. PathogensPathogens  NosocomialNosocomial – E. Coli—50%E. Coli—50% – KlebsiellaKlebsiella – EnterobacterEnterobacter – CitrobacterCitrobacter – SerratiaSerratia – PseudomonasPseudomonas – S. epidermitisS. epidermitis  Community-AcquiredCommunity-Acquired – E. Coli—85%E. Coli—85% – ProteusProteus – KlebsiellaKlebsiella – E. faecalisE. faecalis – Staph.Staph. Saprophyticus(10%Saprophyticus(10% of young sexuallyof young sexually active females)active females) Friday, September 27, 2013
    14. 14. Community-Acquired UTICommunity-Acquired UTI E.coli K.pneumoniae Proteus S.saprophyticus S.epi & gm - enterics Enterococcus Friday, September 27, 2013
    15. 15. Nosocomial UTINosocomial UTI catheter associatedcatheter associated Short Term Long Term E.coli E.coli Pseudomonas Pseudomonas Proteus Proteus Enterobacter Candida Providencia Morganella S.aureus Enterococcus Friday, September 27, 2013
    16. 16. Friday, September 27, 2013
    17. 17. Causative organismsCausative organisms  Gram +ve: Enterococci, StaphylococcusGram +ve: Enterococci, Staphylococcus saprophyticus.saprophyticus.  Gram –ve:Gram –ve: Escherichia coliEscherichia coli,, ProteusProteus species,species, Pseudomonas aeruginosaPseudomonas aeruginosa,, KlebsiellaKlebsiella strains.strains.  Also: Mycobacterium tuberculosisAlso: Mycobacterium tuberculosis Friday, September 27, 2013
    18. 18. Escherichia coliEscherichia coli  E. coli (serotypes: 02, O4, O6) which areE. coli (serotypes: 02, O4, O6) which are fimbrinated strains adhering to uro-fimbrinated strains adhering to uro- epithelial cells, leading to colonization andepithelial cells, leading to colonization and infection is the commonest cause of urinaryinfection is the commonest cause of urinary tract infections.tract infections. Friday, September 27, 2013
    19. 19. Gram negative bacilliGram negative bacilli  Pseudomonas, Proteus, and KlebsiellaPseudomonas, Proteus, and Klebsiella infections often follow catheterization andinfections often follow catheterization and gynecological surgery (nosocomialgynecological surgery (nosocomial pathogen).pathogen).  Infection with proteus may be complicatedInfection with proteus may be complicated by phosphate stone formation as it is ureaby phosphate stone formation as it is urea leads to alkaline pH.leads to alkaline pH. Friday, September 27, 2013
    20. 20. S. saprophyticusS. saprophyticus  Infection more common in young women.Infection more common in young women. Friday, September 27, 2013
    21. 21. What parts of the urinary tract can get infected? Urethra - Urethritis Urinary bladder – Cystitis Ureters – Ureteritis Kidneys - Pyelonephritis Friday, September 27, 2013
    22. 22. Cystitis
    23. 23. IncidenceIncidence  1-3% of all GP consultations1-3% of all GP consultations  5% of women each year with symptoms. Up5% of women each year with symptoms. Up to 50% of women will suffer from ato 50% of women will suffer from a symptomatic UTI during their lifetime.symptomatic UTI during their lifetime.  UTI in men is much rarerUTI in men is much rarer  A proportion of patients may beA proportion of patients may be symptomatic in the absence of infection -symptomatic in the absence of infection - called 'urethral syndrome'called 'urethral syndrome'
    24. 24. What are the signs and symptoms of UTI? Cystitis Frequency Urgency Dysuria – painful voiding Pain or discomfort in suprapubic or perineal area or lower back Cloudy or foul-smelling urine Friday, September 27, 2013
    25. 25. CausesCauses  The most common cause is bacterial infectionThe most common cause is bacterial infection – Eschericia coli is the pathogen in 70% ofEschericia coli is the pathogen in 70% of uncomplicated case of lower urinary tract infections.uncomplicated case of lower urinary tract infections. – Other organisms include Proteus mirabilis, KlebsiellaOther organisms include Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus saprophyticus,pneumoniae, Staphylococcus saprophyticus, Staphylococcus aureus and Pseudomonas species.Staphylococcus aureus and Pseudomonas species.  Urethral Syndrome -not associated with anyUrethral Syndrome -not associated with any infectioninfection  Rarely kidney or bladder stones, prostatism,Rarely kidney or bladder stones, prostatism, diabetesdiabetes
    26. 26. PreventionPrevention  Drinking plenty of fluids helps preventDrinking plenty of fluids helps prevent cystitis in the first place.cystitis in the first place.  If cystitis follows sexual intercourse, someIf cystitis follows sexual intercourse, some advise passing urine soon after to try andadvise passing urine soon after to try and prevent it.prevent it.  There is no evidence to suggest a linkThere is no evidence to suggest a link between lower urinary tract infection andbetween lower urinary tract infection and use of bath preparationsuse of bath preparations
    27. 27. Beware!Beware!  PregnantPregnant  Under age 12Under age 12  MalesMales  Systemically ill (fever, sickness, backache)Systemically ill (fever, sickness, backache)  Catheterised patientsCatheterised patients  Kidney or bladder stonesKidney or bladder stones
    28. 28. InvestigationInvestigation  Urine dipstickUrine dipstick – can be done in the surgery and will be positive for nitrates andcan be done in the surgery and will be positive for nitrates and leucocytes (leukocyte esterase test). This helps to differentiateleucocytes (leukocyte esterase test). This helps to differentiate those with UTI from the 50% with urethral syndrome.those with UTI from the 50% with urethral syndrome.  Urine microscopy and culture reveals significant bacteruriaUrine microscopy and culture reveals significant bacteruria (usually >105 /ml).(usually >105 /ml).  Asymptomatic bacteruriaAsymptomatic bacteruria – is present in 12-20% of women aged 65-70 years and does notis present in 12-20% of women aged 65-70 years and does not impair renal function or shorten life so no treatmentimpair renal function or shorten life so no treatment – in 4-7% of pregnant women and associated with prematurein 4-7% of pregnant women and associated with premature delivery and low birth weight and always requires treatment.delivery and low birth weight and always requires treatment.
    29. 29. Differential DiagnosisDifferential Diagnosis  Urethral syndromeUrethral syndrome  Bladder lesion e.g. calculi, tumour.Bladder lesion e.g. calculi, tumour.  Candidal infectionCandidal infection  Chlamydia or other sexually transmitted disease.Chlamydia or other sexually transmitted disease.  UrethritisUrethritis  Drug induced cystitis (e.g. withDrug induced cystitis (e.g. with cyclophosphamide, allopurinol, danazol,cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other NSAIDs)tiaprofenic acid and possibly other NSAIDs)
    30. 30. Complications and PrognosisComplications and Prognosis  Ascending infection can occur, leading to development ofAscending infection can occur, leading to development of pyelonephritis, renal failure and sepsis.pyelonephritis, renal failure and sepsis.  In children, the combination of vesicoureteric reflux andIn children, the combination of vesicoureteric reflux and urinary tract infection can lead to permanent renalurinary tract infection can lead to permanent renal scarring, which may ultimately lead to the development ofscarring, which may ultimately lead to the development of hypertension or renal failure. 12-20% of children alreadyhypertension or renal failure. 12-20% of children already have radiological evidence of scarring on their firsthave radiological evidence of scarring on their first investigation for UTI.investigation for UTI.  Urinary tract infection during pregnancy is associated withUrinary tract infection during pregnancy is associated with prematurity, low birth weight of the baby and a highprematurity, low birth weight of the baby and a high incidence of pyelonephritis in women.incidence of pyelonephritis in women.  Recurrent infection occurs in up to 20% of young womenRecurrent infection occurs in up to 20% of young women with acute cystitis.with acute cystitis.
    31. 31. Management Issues - GeneralManagement Issues - General  50% will resolve in 3 days without50% will resolve in 3 days without treatmenttreatment  No evidence to support “drink plenty”No evidence to support “drink plenty”  It is reasonable to start treatment withoutIt is reasonable to start treatment without culture if the dipstick is positive for nitratesculture if the dipstick is positive for nitrates or leucocytes.or leucocytes.  MSU if dipstick negative but suspicionMSU if dipstick negative but suspicion
    32. 32. Management Issues - GeneralManagement Issues - General  Culture is always indicated inCulture is always indicated in – MenMen – Pregnant womenPregnant women – ChildrenChildren – Those with failure of empirical treatmentThose with failure of empirical treatment – Those with complicated infectionThose with complicated infection
    33. 33. Self careSelf care  Drink slightly acid drinks such as cranberryDrink slightly acid drinks such as cranberry juice, lemon squash or pure orange juicejuice, lemon squash or pure orange juice (poor trial evidence for this)(poor trial evidence for this)  Try a mixture of potassium citrate availableTry a mixture of potassium citrate available from your pharmacist (little evidence butfrom your pharmacist (little evidence but widely recommended)widely recommended)
    34. 34. AntibioticsAntibiotics  Trimethoprim is an effective first line treatment.Trimethoprim is an effective first line treatment.  Cephalosporins are as effective as trimethoprimCephalosporins are as effective as trimethoprim but more expensive and more likely to disrupt gutbut more expensive and more likely to disrupt gut flora.flora.  Nitrofurantoin is as effective as trimethoprim butNitrofurantoin is as effective as trimethoprim but more expensive and frequently causes nausea andmore expensive and frequently causes nausea and vomitingvomiting  The 4-quinolones (ciprofloxacin, norfloxacin,The 4-quinolones (ciprofloxacin, norfloxacin, ofloxacin) are effective in the treatment of cystitis.ofloxacin) are effective in the treatment of cystitis. To preserve their efficacy, they should not usuallyTo preserve their efficacy, they should not usually be used as first line therapybe used as first line therapy
    35. 35. AntibioticsAntibiotics  3 days of antibiotic is as effective as 5 or 7 days3 days of antibiotic is as effective as 5 or 7 days  Single dose antibiotic results in lower cure ratesSingle dose antibiotic results in lower cure rates and more recurrences overall than longer courses.and more recurrences overall than longer courses.  In relapse of infection (i.e. reinfection with theIn relapse of infection (i.e. reinfection with the same bacteria), treatment with antibiotic for up tosame bacteria), treatment with antibiotic for up to 6 weeks is recommended.6 weeks is recommended.
    36. 36. Urinary Tract InfectionsUrinary Tract Infections T r e a t m e n t o f R e c u r r e n t C y s t i t i s T r e a t l o n g e r ( 2 - 6 w e e k s ) R e l a p s e S e e k o c c u l t s o u r c e o f i n f e c t o n U r o l o g i c e v a l u a t i o n D a i l y o r t h r i c e w e e k l y p r o p h y l a x i s N o r e l a t i o n t o c o i t u s P o s t c o i t a l p r o p h y l a x i s T e m p o r a l l y r e l a t e d t o c o i t u s ³ 3 U T I / y r P a t i e n t i n i t i a t e d t h e r a p y ³ 2 U T I / y r U r o l o g i c e v a l u a t i o n n o t r o u t i n e l y i n d i c a t e d R e i n f e c t i o n D i a p h r a g m a n d s p e r m i c i d e C o n s i d e r c h a n g i n g c o n t r a c e p t i v e m e t h o d R e c u r r e n t C y s t i t i s
    37. 37. Antibiotics for UTI in PregnancyAntibiotics for UTI in Pregnancy  Cephalosporins and penicillins are recommendedCephalosporins and penicillins are recommended in pregnancy because of their long term safetyin pregnancy because of their long term safety recordrecord  Nitrofurantoin is also likely to be safe duringNitrofurantoin is also likely to be safe during pregnancypregnancy  Quinolones, Trimethoprim and Tetracyclines areQuinolones, Trimethoprim and Tetracyclines are not recommended for use during pregnancynot recommended for use during pregnancy  Seven days of treatment is required.Seven days of treatment is required.  Urine should be tested regularly throughoutUrine should be tested regularly throughout pregnancy following initial infection.pregnancy following initial infection.
    38. 38. Fever Nausea and vomiting More pronounced malaise Pain in the back (+) CVA tenderness Acute pyelonephritis Friday, September 27, 2013
    39. 39. Acute PyelonephritisAcute Pyelonephritis
    40. 40. Clinical ManifestationsClinical Manifestations  Classic signs of cystitisClassic signs of cystitis – EnuresisEnuresis – FrequencyFrequency – DysuriaDysuria – HesitancyHesitancy – Suprapubic discomfortSuprapubic discomfort  Classic signs of pyelonephritisClassic signs of pyelonephritis – +/- UTI signs+/- UTI signs – ChillsChills – NauseaNausea – Flank painFlank pain In older children and adults Friday, September 27, 2013
    41. 41. But… In InfantsBut… In Infants  Fever! Fever!!Fever! Fever!! Fever!!!Fever!!!  Lack classic signsLack classic signs  IrritabiltyIrritabilty  Poor feedingPoor feeding  VomitingVomiting  DiarrheaDiarrhea Present in <1/2 of infants with UTIs Friday, September 27, 2013
    42. 42. Risk factorsRisk factors  Female (30%:10%)Female (30%:10%) – Shorter urethral lengthShorter urethral length – Urethral opening close to the anusUrethral opening close to the anus – Exposure to spermicideExposure to spermicide » Has antimicrobial activity, disrupt the periurethralHas antimicrobial activity, disrupt the periurethral flora contentflora content Friday, September 27, 2013
    43. 43. Risk Factors: continuedRisk Factors: continued  Factors that prohibitFactors that prohibit complete emptying ofcomplete emptying of the bladderthe bladder – ConstipationConstipation – cystocele, rectocele,cystocele, rectocele, uterine prolapse,uterine prolapse, urinary calculi, BPHurinary calculi, BPH  Estrogen deficiencyEstrogen deficiency  Oral antimicrobialsOral antimicrobials  ImmobilityImmobility  Poor hygienePoor hygiene  Poor toileting habitsPoor toileting habits  Fecal incontinenceFecal incontinence  CatheterizationCatheterization  Diabetes mellitusDiabetes mellitus  DehydrationDehydration Friday, September 27, 2013
    44. 44. DiagnosisDiagnosis  Urine CollectionUrine Collection – SuprapubicSuprapubic AspirationAspiration – CatheterizedCatheterized specimenspecimen – VoidedVoided specimenspecimen  UrinalysisUrinalysis – Sensitive toSensitive to colonies ofcolonies of 30K/ml or less30K/ml or less – Bacteria seenBacteria seen on microscopyon microscopy with no growthwith no growth may be vaginalmay be vaginal floraflora Friday, September 27, 2013
    45. 45. Specimen collectionSpecimen collection  Samples should be collected before the startSamples should be collected before the start of antibiotics.of antibiotics.  Transport within 2 h. if delay is suspectedTransport within 2 h. if delay is suspected then refrigeration at 4C or boric acid.then refrigeration at 4C or boric acid.  Mid stream urine.Mid stream urine.  Adhesive bags; in infants.Adhesive bags; in infants. Friday, September 27, 2013
    46. 46. The Positive CultureThe Positive Culture  SuprapubicSuprapubic – Any number of pathogensAny number of pathogens – Should be completely sterileShould be completely sterile  TransurethralTransurethral – 101033 colony forming unitscolony forming units  Clean catchClean catch – 101055 colony forming unitscolony forming units Friday, September 27, 2013
    47. 47. Know the Adequacy of YourKnow the Adequacy of Your TestsTests  ““standard urinalysis”standard urinalysis” – Urine dipstickUrine dipstick – MicroscopyMicroscopy  ““enhanced urinalysis”enhanced urinalysis” – MicroscopyMicroscopy – Gram stainGram stain – 84% sensitivity84% sensitivity  Neither is sensitive enough to rule out UTINeither is sensitive enough to rule out UTI Nitrites Leukocyte esterase 15% of UTIs missed if culture not done Friday, September 27, 2013
    48. 48. UTI - Who should be studied?UTI - Who should be studied?  Acute pyelonephritisAcute pyelonephritis AllAll febrile UTIsfebrile UTIs  Males of any age with first UTIMales of any age with first UTI  Girls younger than 3 years with first UTIGirls younger than 3 years with first UTI  Girls older than 3 years with second UTIGirls older than 3 years with second UTI  Girls older than 3 years with first UTI with:Girls older than 3 years with first UTI with: – Family history of UTIsFamily history of UTIs – Abnormal voiding patternAbnormal voiding pattern – Poor growthPoor growth – HypertensionHypertension – Abnormalities of urinary tractAbnormalities of urinary tract – Failure to respond promptly to therapyFailure to respond promptly to therapy Friday, September 27, 2013
    49. 49. Urinary Tract InfectionsUrinary Tract Infections Clinical ManifestationsClinical Manifestations Feature Cystitis Pyelonephritis Urosepsis Dysuria, frequency + + or - + or - Suprapubic pain + + or - + or Ğ Fever, tachycardia, hypotension etc. - + + CVA tenderness - + + or - Duration of symptoms (days) 1 Ğ 7 1 Ğ 2 <1 - 1
    50. 50. Imaging TechniquesImaging Techniques  IndicationsIndications – Evaluation ofEvaluation of obstructionobstruction – Persistence ofPersistence of fever after 5-6fever after 5-6 days of treatmentdays of treatment – DiabetesDiabetes MellitusMellitus – TB, fungus, ureaTB, fungus, urea splittingsplitting Friday, September 27, 2013
    51. 51. Pyelonephritis by MRIPyelonephritis by MRI
    52. 52. Intrarenal abscess by CTIntrarenal abscess by CT
    53. 53. Perinephric abscess by CTPerinephric abscess by CT
    54. 54. A 3y/o boy has fever, shaking chills, and flank painA 3y/o boy has fever, shaking chills, and flank pain consistent with a diagnosis of pyelonephritits.consistent with a diagnosis of pyelonephritits. Of the following, the BEST procedure to performOf the following, the BEST procedure to perform immediately to define the anatomy of the genitourinaryimmediately to define the anatomy of the genitourinary tract is:tract is: – A. cystoscopyA. cystoscopy – B. intravenous pyelographyB. intravenous pyelography – C. radioisotopic renographyC. radioisotopic renography – D. renal ultrasonographyD. renal ultrasonography – E. voiding cysourethrogramE. voiding cysourethrogram
    55. 55. Emphysematous PyelonephritisEmphysematous Pyelonephritis  1898 in JAMA: pneumaturia1898 in JAMA: pneumaturia  An acute necrotizing infection cause by gasAn acute necrotizing infection cause by gas formationformation  Incidence: middle-aged or elderlyIncidence: middle-aged or elderly  Diabetes (90%), or obstructive renal unitDiabetes (90%), or obstructive renal unit  Female-to-man = 6:1Female-to-man = 6:1  Left kidney: 60%Left kidney: 60%  Mortality: 20~80%Mortality: 20~80%
    56. 56. Emphysematous PyelonephritisEmphysematous Pyelonephritis / Pathogenesis/ Pathogenesis  Acute bacterial and fungal infection:Acute bacterial and fungal infection: -- E. Coli: 70~90%-- E. Coli: 70~90% -- Klebsiella, Proteus, Clostridium and-- Klebsiella, Proteus, Clostridium and CandidaCandida  Gas in upper urinary tract:Gas in upper urinary tract: -- iatrogenically via upper tract manipulation-- iatrogenically via upper tract manipulation -- fistula to bowel-- fistula to bowel -- ascending infection-- ascending infection
    57. 57. Emphysematous Pyelonephritis /Emphysematous Pyelonephritis / pathogenesispathogenesis  Gas extension: renal and hepatic veinGas extension: renal and hepatic vein  Diabetics predisposed to gas formation:Diabetics predisposed to gas formation: -- high glucose level throughout tissue-- high glucose level throughout tissue -- diabetic microangiopathic disease-- diabetic microangiopathic disease -- immunodeficient-like state-- immunodeficient-like state
    58. 58. Emphysematous Pyelonephritis /Emphysematous Pyelonephritis / clinical findingsclinical findings  Unilateral: 90%Unilateral: 90%  Clinical findings:Clinical findings: -- fever and pyuria: 80%-- fever and pyuria: 80% -- flank or abdominal pain: 70%-- flank or abdominal pain: 70%
    59. 59. Emphysematous Pyelonephritis /Emphysematous Pyelonephritis / clinical findingsclinical findings  Huang et al:Huang et al: -- 48 cases-- 48 cases -- 46 cases: diabetics-- 46 cases: diabetics -- mortality: initial presentation-- mortality: initial presentation 1). thrombocytopenia1). thrombocytopenia 2). acute renal insufficiency2). acute renal insufficiency 3). Proteinuria3). Proteinuria 4). Mental status change4). Mental status change 5). Shock5). Shock -- no affect: age, sex, site of infection and glucose-- no affect: age, sex, site of infection and glucose levellevel
    60. 60. Emphysematous Pyelonephritis /Emphysematous Pyelonephritis / Radiological findingsRadiological findings  CT: modality of choiceCT: modality of choice -- excellent sensitivity and precise-- excellent sensitivity and precise localization of gaslocalization of gas  Abdomen radiograph: poor sensitivityAbdomen radiograph: poor sensitivity (33%)(33%)
    61. 61. Emphysematous Pyelonephritis /Emphysematous Pyelonephritis / ManagementManagement  Traditionally: requiring emergent nephrectomyTraditionally: requiring emergent nephrectomy  Minimally invasive drainage: acceptableMinimally invasive drainage: acceptable -- equivalent success to surgery-- equivalent success to surgery  Release obstructionRelease obstruction  Quinolone therapyQuinolone therapy  Huang: thrombocytopenia, acute renalHuang: thrombocytopenia, acute renal insufficiency, mental status change and shockinsufficiency, mental status change and shock -- <2: percutaneous drainage + IV antibiotics-- <2: percutaneous drainage + IV antibiotics -- ≥2: emergency nephrectomy-- ≥2: emergency nephrectomy
    62. 62. XanthogranulomatousXanthogranulomatous pyelonephritispyelonephritis  XGP: chronic suppurative atypical renalXGP: chronic suppurative atypical renal parenchymal infectionparenchymal infection  Imitator: RCC, abscess and inflammatoryImitator: RCC, abscess and inflammatory diseasedisease  Associated: renal calculi and chronicAssociated: renal calculi and chronic urinary tract infectionurinary tract infection  Majority involve: non-functional kidneyMajority involve: non-functional kidney
    63. 63. XGP / IncidenceXGP / Incidence  0.6% of all surgically proven renal infection0.6% of all surgically proven renal infection  Women : men = 4:1Women : men = 4:1  More commonly in diabeticsMore commonly in diabetics  5th ~ 7th decades5th ~ 7th decades  Almost always unilateralAlmost always unilateral
    64. 64. XGP / PathogenesisXGP / Pathogenesis  Not been elucidatedNot been elucidated  Play a role:Play a role: -- urinary tract anomalies, obstruction, chronic-- urinary tract anomalies, obstruction, chronic infection, renal ischemia, immunodeficiency andinfection, renal ischemia, immunodeficiency and abnormal lipid metabolismabnormal lipid metabolism  Diagnosis: made by histological examination ofDiagnosis: made by histological examination of surgically removed kidneysurgically removed kidney  Characteristic: foamy macrophageCharacteristic: foamy macrophage  Culture: proteus mirabilus (50%), E. Coli (20%)Culture: proteus mirabilus (50%), E. Coli (20%)
    65. 65. XGP / Clinical findingsXGP / Clinical findings  Quite nonspecific:Quite nonspecific: -- anemia, malaise, leukocytosis, pyuria, flank-- anemia, malaise, leukocytosis, pyuria, flank pain or flank masspain or flank mass ……  Children: weight loss or failure to thriveChildren: weight loss or failure to thrive  Associated:Associated: -- renal calculi: 75%-- renal calculi: 75% -- CPN: 78%-- CPN: 78%
    66. 66. XGP / Radiological findingsXGP / Radiological findings  Renal ultrasound: hypoechoic massRenal ultrasound: hypoechoic mass  Advent CT: accurate with sensitivity (90%)Advent CT: accurate with sensitivity (90%) -- poor enhancing mass, thickened-- poor enhancing mass, thickened GerotaGerota’’s fascia and bears fascia and bear’’s paw signs paw sign
    67. 67. XGP / ManagementXGP / Management  Absolutely no medical therapyAbsolutely no medical therapy  Open surgical nephrectomy: standard careOpen surgical nephrectomy: standard care  XGP kidney: extension to hilium and contiguousXGP kidney: extension to hilium and contiguous organorgan -- laparoscopic surgery: not apply-- laparoscopic surgery: not apply  Bercowsky:Bercowsky: -- laparoscopic nephrectomy: 60%-- laparoscopic nephrectomy: 60% complications vs opencomplications vs open  Focal variety of XGP: nephron sparing surgeryFocal variety of XGP: nephron sparing surgery
    68. 68. Urinary Tract InfectionsUrinary Tract Infections Acute Uncomplicated Pyelonephritis in WomenAcute Uncomplicated Pyelonephritis in Women  Mild-to-moderate illnessMild-to-moderate illness – Outpatient therapyOutpatient therapy – Fluoroquinolone 7 - 14 daysFluoroquinolone 7 - 14 days  Severe illnessSevere illness – Hospitalization requiredHospitalization required – Parenteral cephalosporin, fluoroquinolone orParenteral cephalosporin, fluoroquinolone or aminoglycoside, after afebrile - oral therapy (10 - 14aminoglycoside, after afebrile - oral therapy (10 - 14 day total)day total)  Pregnancy - avoid fluoroquinolonesPregnancy - avoid fluoroquinolones
    69. 69. UTI ImagingUTI Imaging  Renal ultrasoundRenal ultrasound  IVUIVU  Voiding cystourethrogramVoiding cystourethrogram  DMSA or glucoheptonate scanDMSA or glucoheptonate scan  CT – rarely neededCT – rarely needed Friday, September 27, 2013
    70. 70. VCUG - fluoro B/L Reflux R – grade IV L – grade III DMSA L upper pole perfusion defect At site of inflammation or scar Friday, September 27, 2013
    71. 71.  What determines a positive urine culture?What determines a positive urine culture?  Suprapubic?Suprapubic?  Transurethral?Transurethral?  Clean-Catch?Clean-Catch?  Why do we care so much about prompt diagnosis andWhy do we care so much about prompt diagnosis and treatment?treatment? Suprapubic Any number of pathogens Transurethral 103 colony forming units Clean catch 105 colony forming units 27-64% of those with pyelonephritis develop renal scarring 13-15% of end stage renal disease Due to Undiagnosed/Untreated UTI in childhood Friday, September 27, 2013
    72. 72. Principles of Antimicrobial TherapyPrinciples of Antimicrobial Therapy  Treatment of UTI should result in sterileTreatment of UTI should result in sterile urine.urine.  Antimicrobial levels in urine.Antimicrobial levels in urine.  Resistant clones present 5-10% of casesResistant clones present 5-10% of cases with empiric treatment.with empiric treatment. Friday, September 27, 2013
    73. 73. Anbitiotic FormularyAnbitiotic Formulary  TMP-SMX—inhibits dihydrofolic acid reductaseTMP-SMX—inhibits dihydrofolic acid reductase – Enterococcus and Pseudomonas are resistantEnterococcus and Pseudomonas are resistant  Nitrofurantoin—mechanism unknownNitrofurantoin—mechanism unknown – Pseudomonas and Proteus resistant, not useful in upper tract infections,Pseudomonas and Proteus resistant, not useful in upper tract infections, development of resistance very lowdevelopment of resistance very low  Cephalosporins—1Cephalosporins—1stst to 3to 3rdrd generation increases Gram negative andgeneration increases Gram negative and anaerobic coverageanaerobic coverage  Aminopenicillins—effective enterococcus, 30% resistanceAminopenicillins—effective enterococcus, 30% resistance development in common uropathogen isolates.development in common uropathogen isolates.  Aminoglycoside—combined with ampicillin 1Aminoglycoside—combined with ampicillin 1stst line therapy forline therapy for urosepsis, nephrotoxicurosepsis, nephrotoxic  Flouroquinolone—DNA gyrase inhibitor, enterococcus resistant,Flouroquinolone—DNA gyrase inhibitor, enterococcus resistant, damages cartilage in animal studiesdamages cartilage in animal studies Friday, September 27, 2013
    74. 74. TreatmentTreatment  Cystitis—3 DaysCystitis—3 Days – 7 Days if duration of7 Days if duration of symptoms, Diabetes, agesymptoms, Diabetes, age greater than 65, orgreater than 65, or pregnancypregnancy  PyelonephritisPyelonephritis – WomenWomen » 7 days uncomplicated7 days uncomplicated without sepsiswithout sepsis » Inpatient 10-14 daysInpatient 10-14 days  Comlicated PyelonephritisComlicated Pyelonephritis – 14-21 day course14-21 day course  ProphylaxisProphylaxis – Endocarditis—Amp/GentEndocarditis—Amp/Gent or Vanc/Gentor Vanc/Gent – Indwelling catheter—2Indwelling catheter—2 Doses(prior susceptibility)Doses(prior susceptibility) – Catheter removal—preopCatheter removal—preop and 72 hours afterand 72 hours after – TURP—Pre and Post OpTURP—Pre and Post Op Friday, September 27, 2013
    75. 75. Friday, September 27, 2013
    76. 76. Urinary Tract InfectionsUrinary Tract Infections Candidates for ProphylaxisCandidates for Prophylaxis  Women with ≥ 3 symptomatic uncomplicatedWomen with ≥ 3 symptomatic uncomplicated infections per 12 monthsinfections per 12 months  Pregnant women with asymptomaticPregnant women with asymptomatic bacteriuria or previous symptomatic UTI isbacteriuria or previous symptomatic UTI is pregnancypregnancy  Men with recurrent UTIsMen with recurrent UTIs
    77. 77. Friday, September 27, 2013 Prostatitis
    78. 78. Prostatitis: classificationProstatitis: classification  Acute vs. chronic vs. prostatodyniaAcute vs. chronic vs. prostatodynia  Source of infectionSource of infection – Ascending urethral infection, urinary reflux, extensionAscending urethral infection, urinary reflux, extension of rectal infection, or hematogenous spreadof rectal infection, or hematogenous spread  BacterialBacterial – E. coli, Proteus, Klebsiella, Pseudomonas, enterococci,E. coli, Proteus, Klebsiella, Pseudomonas, enterococci, Chlamydia, UreaplasmaChlamydia, Ureaplasma  Other agentsOther agents – Viral, fungal, andViral, fungal, and TrichomonasTrichomonas
    79. 79. Prostatitis: classificationProstatitis: classification Bacteriuria Localized prostate infection Inflammatory response Abnormal prostate exam Systemic illness Acute bacterial prostatitis + + + + + Chronic bacterial prostatitis + + + - - Prostato- dynia - - +/- +/- -
    80. 80. Prostatic massageProstatic massage  AVOID IN ACUTE PROSTATITISAVOID IN ACUTE PROSTATITIS  4 tube approach4 tube approach – VB1: urethral urinary sampleVB1: urethral urinary sample – VB2: bladder urinary sampleVB2: bladder urinary sample – EPS: expressed prostate secretionsEPS: expressed prostate secretions – VB3: post-massage urinary sampleVB3: post-massage urinary sample » >10 WBC/hpf abnormal>10 WBC/hpf abnormal » >5,000 colonies/mm abnormal>5,000 colonies/mm abnormal  2 tube approach2 tube approach
    81. 81. Acute bacterial prostatitisAcute bacterial prostatitis  HistoryHistory – Lower urinary tract obstruction, perineal pain,Lower urinary tract obstruction, perineal pain, dysuria, and feverdysuria, and fever – Systemic symptomsSystemic symptoms  PhysicalPhysical – Tender, warm, boggy, swollen prostateTender, warm, boggy, swollen prostate – Massage isMassage is NOTNOT indicated in acute prostatitisindicated in acute prostatitis
    82. 82. Acute bacterial prostatitisAcute bacterial prostatitis  ManagementManagement – Outpatient therapyOutpatient therapy » Bactrim, ampicillin, or quinolone for 4 – 6 weeksBactrim, ampicillin, or quinolone for 4 – 6 weeks » Bedrest, analgesics, antipyretics, stool softenersBedrest, analgesics, antipyretics, stool softeners – Inpatient therapyInpatient therapy » Parental antibiotics: ampicillin and gentamycinParental antibiotics: ampicillin and gentamycin » Avoid urethral catheterization for retentionAvoid urethral catheterization for retention » Urology consultUrology consult
    83. 83. Chronic bacterial prostatitisChronic bacterial prostatitis  HistoryHistory – Bladder outflow obstructionBladder outflow obstruction – Dysuria; perineal, low back, or testicular painDysuria; perineal, low back, or testicular pain – Hematuria, hematospermia, painful ejaculationHematuria, hematospermia, painful ejaculation  Physical examinationPhysical examination – Variable prostate examVariable prostate exam  Relapsing UTI in men is the hallmark of chronicRelapsing UTI in men is the hallmark of chronic bacterial prostatitisbacterial prostatitis – GNR most common; alsoGNR most common; also Enterococcus and S. saprophyticusEnterococcus and S. saprophyticus
    84. 84. Chronic bacterial prostatitisChronic bacterial prostatitis  ManagementManagement – Difficult to eradicate given poor penetration ofDifficult to eradicate given poor penetration of antibiotic into the non-inflamed prostateantibiotic into the non-inflamed prostate – Bactrim and fluoroquinolonesBactrim and fluoroquinolones » Doxycycline and macrolides second-lineDoxycycline and macrolides second-line – Prolonged treatment requiredProlonged treatment required – Recheck prostatic fluid after treatmentRecheck prostatic fluid after treatment – Alpha-blockers to reduce symptomsAlpha-blockers to reduce symptoms – Suppressive therapySuppressive therapy
    85. 85. Prostatitis: complicationsProstatitis: complications  Renal parenchymal infectionRenal parenchymal infection  BacteremiaBacteremia  Prostate abscessProstate abscess – ImmunocompromisedImmunocompromised – FB; obstructionFB; obstruction  Prostatic stonesProstatic stones – Nidus for persistentNidus for persistent infectioninfection
    86. 86. ProstatodyniaProstatodynia  HistoryHistory – Persistent pelvic, suprapubic, infrapubic, scrotal,Persistent pelvic, suprapubic, infrapubic, scrotal, inguinal, or perineal paininguinal, or perineal pain – Lower tract obstruction and dysuriaLower tract obstruction and dysuria – Absence of systemic symptomsAbsence of systemic symptoms  Physical exam usually unremarkablePhysical exam usually unremarkable  No bacteria identified and no evidence ofNo bacteria identified and no evidence of inflammation presentinflammation present  Limited course of antibiotics, alpha blockadeLimited course of antibiotics, alpha blockade
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×