17. Importance of kidney
• Main waste excreter
• Maintain AB Balance
• Maintain body fluid
• Makes erythropoietin, renin
• Biotransforms Vitamin D (calciferol)
• Excretes some drugs
19. At the end of this session we will learnAt the end of this session we will learn
• UTI can be aUTI can be a silentsilent killerkiller
• More common inMore common in femalesfemales
• Dx usually needs lab. testsDx usually needs lab. tests
• Upper UTI can be fatalUpper UTI can be fatal
• An important c/of CKD,An important c/of CKD, HTN,HTN, FTTFTT
• May have underlyingMay have underlying cong. anomaliescong. anomalies
• Follow-Up is very importantFollow-Up is very important
20. Facts of UTIFacts of UTI
•UTI is common in children: 1% of boys & 3-8% of girls.UTI is common in children: 1% of boys & 3-8% of girls. 2-8%2-8%
have an attack by 10yoa. 3have an attack by 10yoa. 3rdrd
bacterial inf.bacterial inf.
•Highest in <1yoa.Highest in <1yoa. Boys more if <6moBoys more if <6mo (2.7%/0.7%)(2.7%/0.7%) then girls ..then girls ..
•School children: UTI is x5 in girlsSchool children: UTI is x5 in girls
•Febrile UTI is more common in <1y. 7.5% of F. in <3mo ofFebrile UTI is more common in <1y. 7.5% of F. in <3mo of
age have UTI & 10% of them have bacteremiaage have UTI & 10% of them have bacteremia
Meningitis seen in 3-5% of NB with bacteraemic UTIMeningitis seen in 3-5% of NB with bacteraemic UTI
•30% UTI in <1y have recurrence: 85% within 6mo of 1y30% UTI in <1y have recurrence: 85% within 6mo of 1y
•Cystitis mostly occurs in older childrenCystitis mostly occurs in older children
•Asymptomatic bacteriuria in children is not a risk
1y: primary
21. TerminologiesTerminologies
• Urinary tract:Urinary tract: kidneys, ureters, UB, urethrakidneys, ureters, UB, urethra
• Pyuria:Pyuria: ≥10 pus cells/mm≥10 pus cells/mm33
in MSSUin MSSU
• Bacteriuria:Bacteriuria: urine contains bacteriaurine contains bacteria
• NocturiaNocturia:: one or more voiding during sleepone or more voiding during sleep
• EnuresisEnuresis:: involuntary voiding (bedwetting)involuntary voiding (bedwetting)
• UrgencyUrgency:: unstoppable urge to voidunstoppable urge to void
• HesitancyHesitancy:: difficult initiating voidingdifficult initiating voiding
• IncontinenceIncontinence:: involuntary leakage:involuntary leakage: Stress ,,Stress ,, :: leakage onleakage on
exertion, sneezing or coughing;exertion, sneezing or coughing; Urge ,,:Urge ,,:
leakage with urgencyleakage with urgency
22. Urinalysis:Urinalysis: macroscopic & microscopicmacroscopic & microscopic
• Done for:Done for: UTIs, kidney stones, screening/evaluating kidneyUTIs, kidney stones, screening/evaluating kidney
ds., monitoring DM & HTNds., monitoring DM & HTN
• Color, appearance: High color:Color, appearance: High color: dehydration, liver ds.,dehydration, liver ds.,
muscle damage. Some drugs change colormuscle damage. Some drugs change color
Gross hematuria:Gross hematuria: kidney stone or Cakidney stone or Ca
Foamy urine: proteinFoamy urine: protein
• Glucose, ketone, Hb, leukocyte esteraseGlucose, ketone, Hb, leukocyte esterase
(wbc), nitrites (bacteria), bilirubin,(wbc), nitrites (bacteria), bilirubin,
urobilinogen (liver ds. orurobilinogen (liver ds. or hemolysis)hemolysis)
23. Epidemiology: UTIEpidemiology: UTI
• In US:In US: 4 million OPD visits/y (1%)4 million OPD visits/y (1%)
• Urosepsis can be fatalUrosepsis can be fatal
• Sexually active women have the most UTIsSexually active women have the most UTIs
• 40% females have 1 symptomatic UTI in life40% females have 1 symptomatic UTI in life
• Elderly: 10% of M & 20% FElderly: 10% of M & 20% F
• x10-12 risk of UTI in uncircumcised boys
24. Peculiarities of UTIPeculiarities of UTI
• May beMay be asymptomaticasymptomatic (silent killer)(silent killer)
• UsuallyUsually no Fever but more symptomsno Fever but more symptoms in Lower UTIin Lower UTI
• May have nonspecific symptomsMay have nonspecific symptoms
• Fewer physical signsFewer physical signs
• Important c/of FTT, persistent V, RAPImportant c/of FTT, persistent V, RAP
• Often has cong. anomaliesOften has cong. anomalies
• May causeMay cause jaundicejaundice in young infantsin young infants
• May causeMay cause psychosispsychosis in elderlyin elderly
• Long tract predisposes to obstructionLong tract predisposes to obstruction
25. Defence Against UTIDefence Against UTI
• UBUB isis usuallyusually resistant to colonization viaresistant to colonization via
– voidingvoiding
– mucosal secretionmucosal secretion
– low PH, high osmolality, urealow PH, high osmolality, urea
– uroepithelial defenses (cytokines, PMNs)uroepithelial defenses (cytokines, PMNs)
– Tamm-Horsfall proteinTamm-Horsfall protein: from ascending limb of LoH &: from ascending limb of LoH &
DCT with antimicrobial actionDCT with antimicrobial action
27. • Catheterization:Catheterization:
• Menopause:Menopause: estrogen drops (Px against UTIs)estrogen drops (Px against UTIs)
• Elderly:Elderly: common in both M & F.common in both M & F. Often have agitation, delirium,Often have agitation, delirium,
confusion & /or behavioral changes. More risk of APN, urosepsisconfusion & /or behavioral changes. More risk of APN, urosepsis
• Infants: cInfants: changing diaper is imp. Wiping from front to backhanging diaper is imp. Wiping from front to back
also reduces risk of UTIs. F, smelly urine, anorexia, V,also reduces risk of UTIs. F, smelly urine, anorexia, V,
AP, FTT, & fussiness are commonAP, FTT, & fussiness are common
• Children:Children: 1% of boys & 3% of girls have UTIs before1% of boys & 3% of girls have UTIs before
puberty. Some have VUR; may delay voiding or voidpuberty. Some have VUR; may delay voiding or void
incompletely. They need more fluid & more voidingincompletely. They need more fluid & more voiding
Risk factors:Risk factors: Both sexes …Both sexes …
28. Catheter U.T.I.Catheter U.T.I.
• Bacteriuria inBacteriuria in 15%15% of cath. pts.of cath. pts.
• AllAll chr. cath. pts.: bacteriuriachr. cath. pts.: bacteriuria
• MO:MO: E. coli,E. coli, Proteus, Klebsiella, Serratia, Pseud., Enterococci,Proteus, Klebsiella, Serratia, Pseud., Enterococci,
CandidaCandida
• AB Resistance is commonAB Resistance is common
• Symptoms are often absent or minimalSymptoms are often absent or minimal
• Intermittent cathing reduces inf.Intermittent cathing reduces inf.
29. Additional Risk factors in ..Additional Risk factors in ..
femalesfemales
– small straight urethra (4cm), near to anus, preg. (4%),small straight urethra (4cm), near to anus, preg. (4%),
coitus, diaphragm, spermicide,coitus, diaphragm, spermicide, menopause, RV Fistula,menopause, RV Fistula,
back to front wiping of perineum, holding voidingback to front wiping of perineum, holding voiding
malesmales
– uncircumcised (x10)uncircumcised (x10)
– BHP, condom catheter, PUVBHP, condom catheter, PUV
30. More UTI in pregnancy (4%)More UTI in pregnancy (4%)
hhormonal (progesterone) & structural changes: MO goormonal (progesterone) & structural changes: MO go
up easily. Physiological HDN: calycealup easily. Physiological HDN: calyceal & ureteral& ureteral
dilatation from 10w; 86% on R. (compression of uretersdilatation from 10w; 86% on R. (compression of ureters byby
enlargingenlarging uterus & ovarian veins): VUR & stasisuterus & ovarian veins): VUR & stasis
alkaline urine, glycosuriaalkaline urine, glycosuria & aminoaciduria: excellentaminoaciduria: excellent
culture medium, incomplete voidingculture medium, incomplete voiding
immunosuppressionimmunosuppression
AAsymptomatic bacteriuria (4-8%). 25% develop APNsymptomatic bacteriuria (4-8%). 25% develop APN
Complications:Complications: APN, preterm, unexplained perinatalAPN, preterm, unexplained perinatal
death, IUGR, NNS.death, IUGR, NNS. After anemia, UTI is the 2After anemia, UTI is the 2ndnd
commonest medical complication in preg.commonest medical complication in preg.
31. Obstructive UropathyObstructive Uropathy
FFlow is blocked:low is blocked:
• Common:Common: stone in UB, ureter, kidney;stone in UB, ureter, kidney; BHPBHP
• Ca.: UB, ureter, colon, cervical, uterus, metastasisCa.: UB, ureter, colon, cervical, uterus, metastasis
• Scar inside or outside of uretersScar inside or outside of ureters
• Uncommon: PUJO, neurogenic UB, PUVUncommon: PUJO, neurogenic UB, PUV
• Rare: idiopathic HDN of preg.Rare: idiopathic HDN of preg.
Site of obs.:Site of obs.:
– Ureter:Ureter: HDNHDN. It can be ac., or chr. It can be ac., or chr
– UB:UB: enlarged & trabeculated, hydroureters, HDNenlarged & trabeculated, hydroureters, HDN
– Urethra:Urethra: megacystis megaureter, HDNmegacystis megaureter, HDN
HDN: hydronephrosisHDN: hydronephrosis
35. VUR ..VUR ..
• Urine CSUrine CS
• Standard treatment:Standard treatment:
– AntibioticsAntibiotics
– SurgerySurgery
– Antibiotics + surgeryAntibiotics + surgery
• Prophylaxis is an optionProphylaxis is an option
42. UB diverticula:UB diverticula: pouches in UB: cong./acquired; oftenpouches in UB: cong./acquired; often
asymptomatic, may cause UTI, difficulty voiding, hematuria or abdo.asymptomatic, may cause UTI, difficulty voiding, hematuria or abdo.
fullness (voiding incompletely)fullness (voiding incompletely)
43. U.T.Is & D.M.U.T.Is & D.M.
• Higher risk for UTIsHigher risk for UTIs
– glycosuriaglycosuria: good medium: good medium
– immune sys. does not respond wellimmune sys. does not respond well
– neuropathyneuropathy
• incomplete voiding: bacterial survival; retrograde inf.incomplete voiding: bacterial survival; retrograde inf.
44. Common Organisms of U.T.I.Common Organisms of U.T.I.
Mainly G-veMainly G-ve
• Commonest:Commonest: E. coliE. coli (80%),(80%), Staph. saprophyticusStaph. saprophyticus
P. mirabilisP. mirabilis (more in male)(more in male)
• Klebsiella, Ps. aeruginosa,Klebsiella, Ps. aeruginosa, Gardnerella vaginalisGardnerella vaginalis
G+veG+ve
• E. fecalis, GBS, Staph. epidermidisE. fecalis, GBS, Staph. epidermidis
CandidaCandida
Chlamydia trachomatisChlamydia trachomatis
45. PathogenesisPathogenesis
• Common:Common: urethra is colonized & then MOurethra is colonized & then MO ascendsascends UB &UB &
adheres & colonizesadheres & colonizes
• CytokinesCytokines PMNsPMNs inflam.inflam.
• Ascends ureter & kidneyAscends ureter & kidney PNPN
• Invasion may be blood borneInvasion may be blood borne
• Septicemia may occurSepticemia may occur (urosepsis)(urosepsis)
MO: microorganism PN: pyelonephritisMO: microorganism PN: pyelonephritis
49. C.F. in Young ChildrenC.F. in Young Children
• nocturnal enuresisnocturnal enuresis
• day time wettingday time wetting
• F./temp. instabilityF./temp. instability
• febrile fitfebrile fit
• Irritability/lethargyIrritability/lethargy
• jaundicejaundice
• FTT, vomiting
• poor appetite
• dysuria, frequency
• urgency
Potential sequelae:
renal scarring, CRF, HTN
50. Ac. Upper U.T.I. (A.P.N.)Ac. Upper U.T.I. (A.P.N.)
• HGF:HGF: chills rigors, AP, ANV, dysuria, frequency, flank/loinchills rigors, AP, ANV, dysuria, frequency, flank/loin
to groin pain.to groin pain. May have LUTSMay have LUTS
• Renal angle tendernessRenal angle tenderness
• Elderly: oftenElderly: often psychosispsychosis may occurmay occur
• Bacteremia is commonBacteremia is common
Chr. PNChr. PN:: may not be due to inf.may not be due to inf.
Lower UTILower UTI:: usually ac.usually ac.
• Dysuria, frequency, urgencyDysuria, frequency, urgency (LUTS),(LUTS), nocturia. LB painnocturia. LB pain
• Urine is turbid, smelly, gross hematuria (30%), suprapubicUrine is turbid, smelly, gross hematuria (30%), suprapubic
discomfort +/- tendernessdiscomfort +/- tenderness
• F. often absentF. often absent
51. Complications of A.P.N.Complications of A.P.N.
• Urosepsis,Urosepsis, renal damage, perinephric abscessrenal damage, perinephric abscess
• In preg:In preg: abortion, LBW, pre-term, IUGR,abortion, LBW, pre-term, IUGR, anemia (BManemia (BM
suppression, hemolysis), HTN/PE,suppression, hemolysis), HTN/PE, ARDSARDS
Rec. of A.P.N. in preg.:10-18%Rec. of A.P.N. in preg.:10-18%
DD of A.P.N.DD of A.P.N.
• Appendicitis, ac. CholecystitisAppendicitis, ac. Cholecystitis
• UrolithiasisUrolithiasis
• Abruptio placenta, PID, ectopic pregnancyAbruptio placenta, PID, ectopic pregnancy
• Ruptured ovarian cystRuptured ovarian cyst
52. ComComplicated U.T.I.plicated U.T.I.
Risk of persistent/rec. UTI or Rx failure:Risk of persistent/rec. UTI or Rx failure: both lower
& upper UT
– feverfever
– cong. anomaliescong. anomalies
– BHPBHP
– instrumentationinstrumentation
– blockages, surgery, indwelling catheterblockages, surgery, indwelling catheter
– Neuropathic UBNeuropathic UB
– multi-drug resistant bacteriamulti-drug resistant bacteria
53. Asymptomatic bacteriuriaAsymptomatic bacteriuria (AB)(AB)
Bacteria in urine w/out SSBacteria in urine w/out SS.. CS shows a uropathogen.
Most need no Rx as no harmMost need no Rx as no harm.. 25% clear, 25%25% clear, 25%
symptomatic, reinfection is commonsymptomatic, reinfection is common
Rx ifRx if:: DM, preg. stones/transplant, elderly, VUR,DM, preg. stones/transplant, elderly, VUR,
young children. ABT for long-term cathetersyoung children. ABT for long-term catheters
may be harder to Rx as yeast inf.may be harder to Rx as yeast inf.
maymay develop.develop. Rx it before a UTRx it before a UT
procedureprocedure
• Causes:Causes: in some healthy people: women more (more inin some healthy people: women more (more in
preg.: 40% have kid. inf.). Catheters often will have itpreg.: 40% have kid. inf.). Catheters often will have it
54. Sterile PyuriaSterile Pyuria
• Microscopy or a urinary dipstick positive for leukocyteMicroscopy or a urinary dipstick positive for leukocyte
esterase but CS is negative (absence of bacteria)esterase but CS is negative (absence of bacteria)
• SP is highly prevalent: F:M 14: 2.7%. It is 23% amongSP is highly prevalent: F:M 14: 2.7%. It is 23% among
inpatients (excluding UTI)inpatients (excluding UTI)
• Causes: systemic illness, ABT, diuresis, TB, Chlamydia,Causes: systemic illness, ABT, diuresis, TB, Chlamydia,
appendicitis, etc.appendicitis, etc. (see table)(see table)
57. Clean catch urine sampleClean catch urine sample
• It prevents contaminationIt prevents contamination
• Collected when urine has been in UB for 2-3 hCollected when urine has been in UB for 2-3 h
• Can use a special kit to collect: it has a cup with a lid &Can use a special kit to collect: it has a cup with a lid &
wipes. Do not touch the inside of cup or lidwipes. Do not touch the inside of cup or lid
• Wash hands with soap & warm waterWash hands with soap & warm water
58. GIRLS:GIRLS: Wash inter-labia; use sterile wipes. Legs are spread.Wash inter-labia; use sterile wipes. Legs are spread.
Use 2 fingers to spread labia. Use 1 wipe to clean insideUse 2 fingers to spread labia. Use 1 wipe to clean inside
from front to back; 2from front to back; 2ndnd
to clean urethrato clean urethra
• Urinate a small amount into toilet, then holdUrinate a small amount into toilet, then hold
• Hold container a few in. from urethra& fill at halfHold container a few in. from urethra& fill at half
BOYS:BOYS: Clean glans with a sterile wipe after retractingClean glans with a sterile wipe after retracting
foreskin. Urinate a little into toilet, & stop; void again …foreskin. Urinate a little into toilet, & stop; void again …
59. INFANTSINFANTS
• Use special sticky bag; mayUse special sticky bag; may
need 2need 2
• Wash the area with soapWash the area with soap
and dry; then place the bagand dry; then place the bag
• In boys:In boys: put the entire penisput the entire penis in the bagin the bag
• In girls:In girls: place the bag over the labiaplace the bag over the labia
bagged urine for ME only!bagged urine for ME only!
60. • Both sexes:Both sexes: 2 mo-2y with first UTI2 mo-2y with first UTI
• In girlsIn girls 3-7y with febrile UTI3-7y with febrile UTI
• AAll children withll children with PN, rec. UTI:PN, rec. UTI:
USG: KUBUSG: KUB
DPTA, DMSADPTA, DMSA
MCUGMCUG
CT, MRICT, MRI
Imaging:Imaging: wwho to image?ho to image?
61. Urine CSUrine CS
• Proper collection is v. imp. Colony count:Proper collection is v. imp. Colony count:
– suprapubic aspirate >1,000 cfu/mlsuprapubic aspirate >1,000 cfu/ml
– catheter specimen >10,000 cfu/mlcatheter specimen >10,000 cfu/ml
– MSSUMSSU >100,000 cfu/ml>100,000 cfu/ml
• Urinalysis: pyuriaUrinalysis: pyuria 10 pus cells/HPF10 pus cells/HPF
positive nitrite/leukocyte esterase onpositive nitrite/leukocyte esterase on dipstickdipstick
62. False Negative CultureFalse Negative Culture
• AntibioticsAntibiotics
• AntisepticsAntiseptics
• Urethral syndromeUrethral syndrome
• TB of UTTB of UT
• DiuresisDiuresis
64. DD of UTIDD of UTI
• Gonorrhea (+/- syphilis)Gonorrhea (+/- syphilis)
• EnteroviasisEnteroviasis
• Chemical irritationChemical irritation
• In females:In females: trichomoniasis, bacterial vulvo-vaginitis,trichomoniasis, bacterial vulvo-vaginitis, ac.ac.
urethral syn.urethral syn., candidosis, other STD. Pus/fluid from, candidosis, other STD. Pus/fluid from
penis/vagina is common in STDs but not usually in UTIspenis/vagina is common in STDs but not usually in UTIs
Ac. urethral syn:Ac. urethral syn: symptoms of UTI without positivesymptoms of UTI without positive
culture (a/withculture (a/with C trachomatisC trachomatis). Mainly in females). Mainly in females
65. Management: gManagement: goalsoals
• Identify the invader, predisposing factorIdentify the invader, predisposing factor
• ABTABT
• Remove predisposing factors if possibleRemove predisposing factors if possible
66. • Dx of UTI:Dx of UTI: pyuria as well as significant CS of a singlepyuria as well as significant CS of a single
uropathogenuropathogen
• Rec. UTIs:Rec. UTIs: close FU should be done after 7-14d of ABTclose FU should be done after 7-14d of ABT
• For anatomic anomaliesFor anatomic anomalies: USG: USG
• No AB Px in rec. UTI in infants without VURNo AB Px in rec. UTI in infants without VUR
• VCUG/MCUGVCUG/MCUG: not routinely done after 1: not routinely done after 1stst
UTIUTI
– Do if HDN, scarring, high-grade VUR, obs. uropathy,Do if HDN, scarring, high-grade VUR, obs. uropathy,
atypical/complex clinical circumstances, rec. febrile UTIatypical/complex clinical circumstances, rec. febrile UTI
FU: follow up. Px.: prophylaxis
A.A.P.: Guidelines for UTI in Children
67. Antibiotics for UTIAntibiotics for UTI
– co-trimoxazole, cepalosporins, amoxicillin,co-trimoxazole, cepalosporins, amoxicillin,
co-amoxiclav, amino glycosidesco-amoxiclav, amino glycosides
– nitrofurantoin, fluoroquinolone, etc.nitrofurantoin, fluoroquinolone, etc.
Management ..Management ..
68. Principles of ABT in UTIPrinciples of ABT in UTI
• ShorterShorter course for lower UTIcourse for lower UTI
• Longer:Longer: uupper & complicated UTI, prostatitis,pper & complicated UTI, prostatitis,
EpididymoorchitisEpididymoorchitis
• Combination ABTCombination ABT for complicated UTIfor complicated UTI
• Parenteral ABParenteral AB in upper/complicated UTIin upper/complicated UTI
• Less frequent & low nocturnal dose in preventionLess frequent & low nocturnal dose in prevention
• Long term Px is in: VUR, obstructive uropathyLong term Px is in: VUR, obstructive uropathy
69. • Neonates:Neonates: ampicillin+gentamicin I.Vampicillin+gentamicin I.V
• APN:APN: 2 ABT, IV & hydration2 ABT, IV & hydration
•Duration of Rx:Duration of Rx:
– Cystitis – 3- 7dCystitis – 3- 7d
– PN –PN – 14d14d
•Prophylaxis: cotrim., cephaclor, cefuroxime, nitrofurantoinProphylaxis: cotrim., cephaclor, cefuroxime, nitrofurantoin
Risk of renal scarring is greatest in infants; low doseRisk of renal scarring is greatest in infants; low dose
prophylactic AB is recommendedprophylactic AB is recommended
Principles of ABT in U.T.I. …Principles of ABT in U.T.I. …
70. • Infrequent:Infrequent: treat attackstreat attacks
• Rx for 2wRx for 2w
• Look forLook for underlyingunderlying causecause
• In females think of sexual activity:In females think of sexual activity:
– avoiding spermicidalavoiding spermicidal
– complete voiding after intercoursecomplete voiding after intercourse
– post coital single dose ABTpost coital single dose ABT
ManagementManagement:: Recurrent U.T.I.Recurrent U.T.I.
72. • RecurrenceRecurrence may be due to:may be due to:
- renal involvement, immunosuppression- renal involvement, immunosuppression
- structural abnormalities- structural abnormalities
- chr. bacterial prostatitis- chr. bacterial prostatitis
• Obs. should be corrected, If uncorrectable: Rx for 4-6w orObs. should be corrected, If uncorrectable: Rx for 4-6w or
as requiredas required
– FU monthly by CS & annual assessment of RFFU monthly by CS & annual assessment of RF
• Long term prophylaxisLong term prophylaxis:: freq. inf., VUR, obs. uropathyfreq. inf., VUR, obs. uropathy
73. What is the prognosis ?What is the prognosis ?
74. Prognosis …Prognosis …
• Uncomplicated UTI recovers completelyUncomplicated UTI recovers completely
• Recurrences (15-30%): within 2-3moRecurrences (15-30%): within 2-3mo
• Frequent UTI usually occurs in clusters f/by long remissionsFrequent UTI usually occurs in clusters f/by long remissions
• Rec. uncomplicated UTI: no CKDRec. uncomplicated UTI: no CKD
• Rec. complicated UTI: may lead to CKDRec. complicated UTI: may lead to CKD
• UTI may deteriorate underlying renal diseaseUTI may deteriorate underlying renal disease
• ……. usually occur in clusters followed by long remissions. usually occur in clusters followed by long remissions
75. Follow UpFollow Up
• Regular monthly urine RE & CS for 1yRegular monthly urine RE & CS for 1y
• Advise about voiding & cleanlinessAdvise about voiding & cleanliness
• Recurrence:Recurrence: 20% women with UTI will recur; 30% if 2
attacks; 80% if 3
• Recurrence in childrenRecurrence in children
– 12% of children U-512% of children U-5
– 18% of infants <6mo18% of infants <6mo
76. PreventionPrevention
• Plenty of liquidsPlenty of liquids, esp. water:, esp. water: dilutes urine; more & fulldilutes urine; more & full
voidingvoiding
• Wipe fromWipe from front to backfront to back
• Void: when you feel. Void soonVoid soon after coitus; aafter coitus; also, drink also, drink a
glass of waterglass of water
• Avoid potentiallyAvoid potentially irritating feminine products:irritating feminine products: sprays,sprays,
douches or powders, etc. in the genital areadouches or powders, etc. in the genital area
• Circumcision forCircumcision for boysboys
• Cranberry juiceCranberry juice
77.
78. CircumcisionCircumcision
• is a life-long significant protection againstis a life-long significant protection against HIVHIV (70%)(70%)
• decreases risk ofdecreases risk of UTIUTI
• STISTI
• protects Ca of penisprotects Ca of penis
• prevents inflam. of glands & foreskinprevents inflam. of glands & foreskin
• benefits women: improving hygiene, reducing STI’s, &benefits women: improving hygiene, reducing STI’s, &
reducing risk of CaCxreducing risk of CaCx
• Men’s health is as much about women’s health when itMen’s health is as much about women’s health when it
comes to STIcomes to STI
80. UTI ComplicationsUTI Complications
Major complications: APN (~ARF, CRF); sepsis (death)Major complications: APN (~ARF, CRF); sepsis (death)
More in the young, elderly, immunosuppressedMore in the young, elderly, immunosuppressed
Kidney damage or scarringKidney damage or scarring
UTI in preg,: IUGR, LBW, preterm, HTN, neonatal sepsisUTI in preg,: IUGR, LBW, preterm, HTN, neonatal sepsis
81. MCQMCQ
• Kidney disease is a silent killerKidney disease is a silent killer
• Ac. PN is a medical emergencyAc. PN is a medical emergency
• Lower UTI is more symptomatic than upper UTILower UTI is more symptomatic than upper UTI
• Proteus is the commonest MO in male UTIProteus is the commonest MO in male UTI
• Invading MO reaches the UT by ascendingInvading MO reaches the UT by ascending
• Circumcision significantly reduces risk of UTICircumcision significantly reduces risk of UTI
82. MCQMCQ
• The commonest bacteria in UTI is E coli
• Proteus is more common in female
• DMSA is for scarring
• DPTA for splitting
• Enteroviasis can mimic UTI
• Circumcision is very beneficial for femalesCircumcision is very beneficial for females
83. MCQMCQ
• UTI may cause jaundice in infants
• UTI is more common in females of all ages
• Cranberry juice may be useful for Px UTI
• UTI can cause psychosis in the elderly
• Pyuria invariably means UTI
• Urosepsis is a recognized complication of UTI
84. So I learned something,So I learned something, how about you ?how about you ?
UTI are a common c/of F in young children. UTI are not included in IMCI. UTI are 1 of the most common bacterial inf in children. Gram-ve MO are those most commonly isolated in uncomplicated UTI with E coli 70-90%
Pyuria is urine containing wbc or pus
Sterile pyuria, is urine which contains pus cells but is sterile on CS. It is often c/by STI, like gonorrhea, or viruses which will not grow in bacterial cultures. It is listed as a SE of some medications like paracetamol. Its is also a/with certain d, like Kawasaki d and GUTB. There are many known causes: systemic or inf, structural and physiological reasons, intrinsic kidney pathology, or drugs. It is not an uncommon finding. But, it may be misleading: standard lab CS may not be optimal for atypical MO. Lab may not report significant growth either because it was not a single MO or a uropathogen. CS &lt;100,000 cfu/mL may due to dilute urine was or an organism may be slow-growing. 50% women presenting with SS& 100-10,000 cfu/mL have genuine UB inf. Pyuria increases significance of a low CS count. Cell count PHF is inaccurate& use of a counting chamber or similar gives more accurate results
Aetiology: A recently (past 2w) treated UTI or inadequately ….
Fastidious MO (grows only in special media under specific conditions): N gonorrhoeae
Renal tract TB, Chlamydial urethritis
Contamination with antiseptic or vaginal leukocytes
Interstitial nephritis: sarcoidosis (lymphocytes not neutrophils), UT stones
Renal papillary necrosis: DM, SCD, analgesic nephropathy
UT neoplasm (renal& UB Ca), Polycystic kidneys, Interstitial cystitis, Prostatitis.
Kawasaki d. Other reported associations: appendicitis& SLE
A urinalysis is used to detect & manage UTI, kidney d & Dm. Checking appearance, conc. & content of urine. Abnormal urinalysis results may point to a d. UTI can make urine look cloudy. More protein in urine can be a s/kidney d.
Red/Pink Urine: Host of causes. Blood is 1 cause. Dipstick & urinalysis should be undertaken to DD. Strenuous exercise causes marcher’s hematuria. Dehydration causes HC urine. Rhubarb Beets Blackberries Red or pink additives cause this. Laxatives with senna, rifampicin, metronidazole, chlorpromazine & thioridazine propofol warfarin lead & Hg may cause this. Some may also cause hematuria
Tamm-Horsfall protein (THP) is a high MW glycoprotein. Most abundant protein in urine of healthy individuals
Enterococcus is a large genus of lactic a. bacteria; are G+ve cocci that often occur in pairs (diplococci) or short chains, & are difficult to DD from strep. on physical characters alone. 2 spp. are common commensal in gut: E. fecalis (90–95%) & E. faecium (5–10%). Rare clusters of inf occur with other spp.: E. casseliflavus, E. gallinarum, and E. raffinosus. They are facultative anaerobic (capable of cellular respiration in both O2-rich & O2-poor environments). Not spore-forming, they are tolerant of a wide range of env. conditions: extreme temp (10–45°C), pH (4.5–10.0), & high NaCl conc. They typically exhibit gamma-hemolysis on sheep&apos;s blood agar
Symptoms: slowly or suddenly,& if one or both kidneys are involved. Mild to severe flank pain. The pain may be felt on one or both sides. Fever NV edema Frequency poor stream Dribbling Not feeling as if the bladder is emptied Need to urinate more often at night Decreased amount of urine Blood in urine
Exams& Tests: USG CT IVP
VCUG Renal nuclear scan MRI
RX: Stents or drains placed in the ureter or in the renal pelvis may provide short-term relief.
Nephrostomy tubes. Foley catheter. Short-term relief from the blockage is possible without surgery. However, the cause of the blockage must be removed& the urinary system repaired. Surgery may be needed for long-term relief from the problem.
Outlook (Prognosis)
If the blockage comes on suddenly, kidney damage is less likely if the problem is detected& repaired promptly. Often, the damage to the kidneys goes away. Long-term damage to the kidneys may occur if the blockage has been present for a long time.
If only one kidney is damaged, chronic kidney problems are less likely.
You may need dialysis or a kidney transplant if there is damage to both kidneys& they do not function, even after the obstruction is repaired.
Possible Complications: OU can cause permanent& severe damage to the kidneys, resulting in kidney failure.
If the problem was c/by a blockage in the bladder, the bladder may have long-term damage. This may lead to problems emptying the bladder or leakage of urine
VUR: Gr. I: into distal U; GII: up to P& C; no dilatation, normal C fornicies. GIII: same as II but mild dilatation of PC. GIV: same as III but U& P are 2+dilated,& C are moderately blunted. GV: gross dilatation& tortuosity of UPC with significant blunting of the majority of C. Less common in African Americans
PUV. Oblique VCUG: filling defect in urethra with a marked change in urethral caliber at the level of the defect, a finding that indicates obstruction. Although the catheter is in place during voiding, the 2y changes crucial for Dx: trabeculated UB, prominent UB neck, dilated elongated posterior urethra are clear
G vaginalis is a facultative anaerobe Gram-variable rod; causes with many other bacteria mostly anerobic bacterial vaginosis due to a disruption in the normal flora. The resident Lactobacillus in the vagina are responsible for the acidity. Once they have supplanted the flora, AB with anerobic coverage may have to be given to re-establish the equilibrium. G. vaginalis is not the c/of the bacterial vaginosis, but a signal MO of the altered flora. While typically isolated in genital CS, it may also be detected in other samples from blood, urine, & pharynx. Although it is a major sp. present in bacterial vaginosis, it can also be isolated from women without any SS. It has a G+ve cell wall, but because the CW is so thin it can appear either G+ve/-ve under MC. It is associated microscopically with clue cells, which are epithelial cells covered in bacteria. It makes a pore-forming toxin, vaginolysin, which affects only human cells. Protease & sialidase enzyme activities frequently accompany it
Rx: metro- & clindamycin in both oral & vaginal gel/cream forms.
CF: may be asymptomatic. Vaginal discharge, irritation, fishy odor. In the &quot;amine whiff test&quot; 10% KOH is added to the discharge, a positive result is indicated if a fishy smell is produced. This& other tests can be used to distinguish between vaginal symptoms related to G. vaginalis from other MO (Trichomonas & Candida albicans) which are similar & may require different Rx. T vaginalis & G vaginalis have similar clinical presentations& can cause a frothy gray or yellow-green vaginal discharge, pruritus, & produce a positive &quot;whiff-test.&quot; The two can be DD using a wet mount slide, where a swab of the vaginal epithelium is diluted& then placed onto a slide for observation under a microscope. Gardnerella reveals a classic &quot;clue cell&quot; under the microscope, showing bacteria adhering to the surface of sq. epithelial cells. Both conditions are treated with metro- or clindamycin
Fungal infections are more likely to affect the bladder& kidney& often reach the kidney through the bloodstream. It does sometimes start in the lower urinary tract (urethra& bladder) as a result of the insertion of a catheter when treating other urinary tract conditions.
Commonest fungus of a UTI is Candida species although other species (Cryptococcus spp, Aspergillus spp) may be. Fungal UTI like renal candidiasis is rare& mostly seen in immunocompromised (HIV/AIDS, uncontrolled DM, Ca, chemo-)
Enterococcus faecalis and Enterococcus faecium: Nonhemolytic streptococci, gamma haemolytic streptococci, enterococcus, group D streptococci, vancomycin-resistant enterococcus (VRE). Formerly known as Streptococcus faecalis and Streptococcus faecium.
Urosepsis is the ac. systemic inf. 2y to a UTI
Seminal vesiculitis commonly occurs 2y to prostatitis; but, can occur independently. Prompt Rx of prostatitis should be done in order to prevent the progression of prostatitis into seminal vesiculitis
LUTS: group of clinical symptoms involving UB, urinary sphincter, urethra, &, in men, prostate. LUTS is a preferred term for prostatism, & applied to men. LUTS also affect F. 1 can have 1 or more LUTS at a time, % recurrence is not uncommon. It affect 40% of older men
Chr. PN is characterized by renal inflam & fibrosis induced by rec./persistent renal inf, VUR, or other c/of UT obs. Dx is based on US/CT. It occurs almost exclusively in major anatomic anomalies, most commonly in young children with VUR (cong. incompetence of UV valve due to a short intramural segment). VUR is seen in 40% young children with symptomatic UTIs & in almost all children with renal scars. It may also be acquired by pts. with a flaccid UB. Dx of VUR is frequently estbd. on the basis of radiologic evidence obtained during an evaluation for RUTI in young children
ChrPN is characterized by renal inflam & fibrosis by rec or persistent renal inf, VUR, or other c/of UT obs. Dx is based USG or CT. It occurs almost exclusively in young children with VUR (incompetent ureterovesical valve due to a short intramural segment). VUR is present in 30-40% of young children with symptomatic UTIs & in almost all children with renal scars. It may also be acquired in a flaccid bladder due to SC injury. Dx of VUR is frequently established on the basis of radiologic evidence (MCUG)
Complicated UTI significantly increases the rate of Rx failures. Causes:
1. Structural abnor.: calculi, infected cysts, renal/UB abscesses, certain forms of PN, SC injury, cath.
2. Metabolic/hormonal: DM & preg
3. Impaired host responses, like transplant (esp. renal transplants) & AIDS
4. Unusual pathogens, like yeast
A growing number of CUTIs are healthcare associated. The most common pathogens include E. coli, enterococci, P aeruginosa, candid, K pneumoniae.
PN is almost always the result of bacteria migrating from UB to kidneys, which is enhanced by VUR. In uncomplicated PN, the bacterial invasion & renal damage are limited to the pyelocalyceal-medullary region; in complicated PN, all regions of the kidney may be affected. If the inf progresses, bacteria may invade the blood
AB: 100k cfu/ml in 2 successive samples with no symptoms
2-11% in preg
x2 in preg with sickle cell trait.
x3 with DM
Associated with UT abnormality
If untreated chances of developing acute cystitis (40%), pyelonephritis (22-
27%)& increased chances of chronic renal failure.
Pyelonephritis in pregnancy leads to septicaemia in 10-20% case& ARDS in
2% cases.
Other complications are IUGR, preterm labour (two times risk), LBW (50%), hypertension& PE (risk is doubled), anaemia (due to marrow suppression, increased RBC destruction& decreased RBC production), chorioamnionitis& amnionitis.
Screening for ASB is recommended for pregnant women at first prenatal visit.
Or between 12 to 16 wks of pregnancy.
Urine culture is an appropriate screening tool
Rapid, accurate Dx of UTI in childhood is imp, & pyuria is often considered critical in DX in addition to the presence of large numbers of bacteria. Clinically imp pyuria has been defined as &gt;lOX 106 leucocytes/l of urine. Only 1-5% of healthy schoolchildren exceed this. Pyuria might occur often in febrile children without a UTI, perhaps as a non-specific response to F has recently been described as untenablePyuria is common in F without a UTI & is due to an increase in urinary leucocyte excretion but not a direct reflection of neutrophilia. Pyuria may be a non-sp feature of F & may reflect a generalised increase in wbc migration, perhaps mediated by changes in membrane permeability or wbc. Almost 9% of F without a UTI have obvious pyuria.
CAUSES OF SP
STI: HSV-2 & HPV, gonorrhea, chlamydia, syphilis, mycoplasma, & trichomoniasis
In men, majority of STI are symptomatic urethritis &, less commonly, epididymitis or disseminated gonococcal inf. Many women are asymptomatic initially, & PID may develop without symptoms
Gonorrhea & Chlamydia
In an Australian study, 1295 symptomatic men with nongonococcal urethritis& pyuria were evaluated for sexually transmitted diseases. C. trachomatis was detected in 401 men (31%), & Mycoplasma genitalium was diagnosed in 134 men (10%).12 A Japanese study involving 51 men showed that the 16S ribosomal RNA gene of Ureaplasma urealyticum (quantified by means of a real-time polymerase-chain-reaction [PCR] assay) was associated with the presence of symptoms of urethritis& higher leukocyte counts in first voided urine.13
Genital Herpes& Herpes Zoster
Genital vesicular eruption, which is characteristic of HSV-2 infection, extrudes wbc into urine. Pyuria may be associated with HSV-2–associated urethritis& cervicitis.14 The diagnosis of genital herpes is determined by means of HSV PCR, an antigen-detection immunofluorescence test, or an enzyme immunoassay.15
In a 12-year study involving 423 patients with herpes zoster, 17 patients (4%) manifested changes in lumbosacral dermatomes& voiding dysfunction. Twelve patients with cystitis-associated symptoms (3% of all the patients with herpes zoster) had pyuria.16
HPV& Human Immunodeficiency Virus Infections
In one study, among 114 patients with biopsy-proven HPV infection, 14 patients (12.3%) had an intraurethral lesion.17 A British survey tested 3123 urine samples obtained from male& female respondents who were 18 to 44 years of age. HPV DNA was detected in 29.0% of samples obtained from women& in 17.4% of samples obtained from men.18 The respondents were not screened by means of measurement of leukocytes. However, one study showed that male patients with HPV infection can have urethral discharge containing inflammatory cells.19
Pyuria is associated with advanced human immunodeficiency virus (HIV) infection. In one study, among 104 patients with untreated HIV infection, 13% had pyuria.20
Other Viral Infections
Viral infections such as adenovirus,21 BK polyomavirus,22& cytomegalovirus23 may cause hemorrhagic cystitis in immunocompromised children. However, these infections are typically not associated with pyuria.
Genitourinary Tuberculosis
Nearly 10,000 tuberculosis infections are reported in the United States each year.24 Genitourinary tuberculosis, the most common form of nonpulmonary tuberculosis after lymphadenopathy, accounts for 27% of cases (range, 14 to 41). Hematuria& pyuria are typical findings in genitourinary tuberculosis. This condition can infect the kidneys, ureters, bladder, prostate,& genitalia.25 Genitourinary tuberculosis can cause renal calyceal destruction, calyceal obstruction, or hydronephrosis, or all of these conditions.
Since the incidence of tubercular infection is 13 to 26 times as high among foreign-born persons& recent immigrantsas among non-Hispanic whites, clinical suspicion of tuberculosis infection should be higher in these patients when they present with SP. In the United States, the incidence of tubercular infection is also higher among Asians, Hispanics,& blacks than among whites.24 In addition, nonpulmonary tuberculosis is more common in ethnic minority groups.24,26
The tuberculin skin test is helpful in determining whether a person has been exposed to tuberculosis, but false positive results often occur in patients who have received the Mycobacterium bovis bacilli Calmette–Guérin (BCG) vaccine,& a false negative skin test may occur in patients with impaired T-cell function. Interferon-γ–release assays are whole-blood tests that are not affected by BCG immunization.27
M. tuberculosis may also be identified on urine culture. However, in a study involving 42 patients in whom there was suspicion of genitourinary tuberculosis on the basis of radiologic abnormalities, mycobacteria were isolated in the urine acid-fast bacilli culture in only 13 of 35 patients (37%)& bladder biopsy was positive in 11 of 24 patients (46%), whereas urinary PCR for M. tuberculosiswas positive in 33 of 35 patients (94%).28
Fungal Infections
Candida infections are a common source of urosepsis in hospitalized patients, especially those who are immunocompromised.29,30 Candida albicans is the most prevalent species; however, C. glabrata, C. tropicalis, C. krusei,& other candida species can also cause infection.
Speciation is important because of differences in antifungal susceptibility.30 Notably, patients with diabetes are prone to candida infections, patients who have received transplants are vulnerable to aspergillosis,& patients with HIV infection may be susceptible to cryptococcuria. Blastomycosis, coccidioidomycosis,& histoplasmosis are associated with intense environmental exposures (e.g., disruption of the environment by construction, sandstorms, or tornadoes or exposure to a high concentration of bird excrement). All these fungal infections may cause genitourinary infection with associated pyuria.31
Urine microscopy may show budding yeast forms or hyphae, but identification of fungus requires special culture medium& from 3 days to 3 weeks for speciation.32 In patients with candida or aspergillus infections, imaging studies may reveal filling defects in the collecting system or bladder caused by fungal materials that are referred to as “fungal balls.”
Parasitic Infections
Trichomonas vaginalis is one of the most common human parasitic infections in the United States& the most prevalent nonviral sexually transmitted infection. Infection can be diagnosed by identification of the motile parasite during microscopic examination of a wet-mount preparation of cervicovaginal secretions in women& urethral discharge in men, but PCR is more sensitive. In one study, 46 of 205 male partners of women with confirmed trichomonas infection (22%) had culture-detected infection, whereas 201 of 205 male partners (98%) had infection detected by means of PCR.33
An estimated 119 million people in the world are infected with Schistosoma haematobium.34Transmission requires the contamination of water by egg-containing feces or urine, a specific freshwater snail as intermediate host,& human contact with water inhabited by the intermediate host snails.35 The urogenital system is affected in 75% of infected persons. Radiographic studies may show calcification of the bladder wall or ureter. Diagnosis has been based on microscopic examination of urine, but this method is dependent on the skill of the observer& is known for low sensitivity. A recent study showed that real-time PCR has 100% sensitivity as an indicator of infection intensity.34
In a 10-year study involving more than 25,000 ill travelers from endemic areas, 410 cases of schistosomiasis were identified; 83% of the infections were acquired in Africa. A total of 63% of the patients with schistosomiasis presented within 6 months after travel.36
Inflammatory& Autoimmune Conditions
The cause of the combination of interstitial cystitis& the painful bladder syndrome, which occurs primarily in women, is unclear. In an evaluation of 122 patients in whom this condition was suspected, 22 (18%) had detectable leukocyte esterase with a negative nitrite indicative of SP& prodromal inflammatory changes in the bladder.37
Kawasaki’s disease often manifests with SP, microscopic hematuria,& proteinuria associated with renal involvement. In one study, SP, which is typically associated with more severe systemic inflammation, was identified in 40 of 133 patients (30%).38 In another study, SP was identified in 215 of 946 patients with systemic lupus erythematosus (23%).39 In addition, analgesic nephropathy can cause SP in association with chronic interstitial nephritis& renal papillary necrosis.40
Inflammation outside the Urinary Tract& Other Urologic Conditions
One study involving 210 patients who were hospitalized for infections outside the urinary tract (e.g., pneumonia, bacterial septicemia, intraabdominal infection, enteritis,& female genital tract infections) identified 31 patients (15%) with SP.3 In addition, pyuria may be associated with radiation cystitis, urinary stones, foreign bodies, stents, transvaginal mesh, urinary fistulae, polycystic kidney disease, renal-transplant rejection,& intrinsic renal disease.41
EVALUATION OF PATIENTS WITH SP
As noted above, the differential diagnosis of SP is broad (Figure 1FIGURE 1Clinical, Epidemiologic,& Laboratory Assessment of a Patient with SP.). A complete history& physical examination with consideration of the factors listed in Table 1TABLE 1Causes of SP. are required to identify the potential causes of genitourinary inflammation. Specific evaluation for sexually transmitted infections is warranted. Evaluation to detect bacterial, fungal,& parasitic infections is indicated in patients with a clinical history that suggests specific infections.
Abdominal, renal,& bladder imaging should be considered for evaluation of febrile or otherwise symptomatic patients. Inflammatory conditions near the urinary tract as well as systemic diseases should be included in the differential diagnosis (Table 2TABLE 2Diagnosis& Management of Causes of SP.). SP has historically been considered to be suggestive of genitourinary tuberculosis, but a wide variety of other causes must be considered.
Criteria for successful treatment of conditions that cause SP include curtailment or resolution of symptoms, a negative culture, or a negative PCR assay. Pyuria may persist because of underlying
What is a nuclear medicine renal scan?
Renal scan: can be done with 2 substances:
DTPA or MAG3 are similar, but MAG3 gives significantly better images in some pts., particularly v young children & those pts. with poor kidney function. Both are used to look at the blood supply, function & excretion of urine from kidneys. It can find out what % each kidney contributes to the total kidney function. A DTPA Scan may also be undertaken to evaluate:
renal tubular function and perfusion (how the body fluids circulate through the kidneys); renovascular HTN (high BP in the arteries of the kidneys); RA stenosis; renal tubular obs. & trauma or damage (blockage or interruption of the ureters); renal transplant perfusion and function.
How do I prepare for a renal scan?
It is imp., prior to having the scan, that you have plenty of fluid to drink and are well hydrated. If the study is being done to evaluate renal HTN or RA stenosis, some BP medications should be stopped x4-7 d. If you think you may be pregnant or are breast feeding you must inform your doctor or specialist who is referring you for the DTPA Scan and the radiology staff where you are having the DTPA Scan. They will discuss with you any need to stop breast feeding and minimise nonessential contact with your baby for a short time.
What happens during a renal scan?
On arrival, you will be measured for your height and weight and also given some water to drink prior to the scan to make certain you are well hydrated.
For the DTPA Scan, you will be lying down on the scanning bed, with the gamma camera under the bed. It is important to keep still during the test as any movement of the body will blur the images and give poor scan results. The imaging itself does not hurt.
A small injection in a vein will be given, usually in the arm. A cannula (thin plastic tube) will be inserted into your vein and will stay in the vein for the duration of the test. Apart from the initial prick this should not cause you any discomfort.
Through this cannula the radiopharmaceutical is injected. This can be detected by the gamma camera and will provide clear images of the kidneys. After about 15 minutes of scanning, you may be given a second injection through the same cannula of a diuretic called frusemide (Lasix). This causes the kidneys to make more urine by decreasing the amount of water that the kidneys resorb as part of the filtering process. There is also an increased flow of urine through the ureters which makes any obstruction of the ureters easier to see.
As with any drug there is a small chance of an allergic or adverse reaction. Please discuss this with your doctor or with the medical staff performing the examination if you have any queries or concerns. The frusemide will help your kidneys to work harder, so your bladder will fill faster. At the end of the scan you may be asked to go to the toilet and empty your bladder, then return for a further 2 minutes of imaging. The cannula is removed before you leave the department.
Are there any after effects of a renal scan?
There are no after effects of a DTPA Scan. You will not feel any different.
If a dose of a diuretic (frusemide) is given to cause an increased flow of urine, you may feel thirsty and need to drink plenty of fluids for the rest of the day so that your body does not dry out and you become dehydrated. You may also need to visit the toilet more often to empty your bladder.
How long does a renal scan take?
The test itself will take approximately 30 to 60 minutes. The time varies because the rate at which the kidneys function will differ for each individual.
What are the risks of a renal scan?
There are no known associated risks involved in the DTPA scan itself.
The test involves a small dose of ionising radiation which is relatively small and similar to many other routine medical imaging tests. For more detailed information (see radiation risk of medical imaging for adults and children).
If you are pregnant or breast feeding, please inform your doctor before booking the scan. Some of the medications that are used in nuclear medicine studies can pass into the mother’s milk and to the baby. You may be asked to discontinue breast feeding for a short time after the scan and will need to express from both breasts. Please discuss with the nuclear medicine physician or technologist when feeding can resume and if you need to limit contact with your baby for a short time.
What are the benefits of a renal scan?
This test provides information on the blood supply, function and excretion of urine from the kidneys.
A DTPA Scan can help your doctor assess how each of your kidneys is working and find out what percentage each kidney contributes to the total kidney function. It is important for your health that your kidneys are functioning properly.
Who does the renal scan?
A nuclear medicine technologist will give the injection, perform the scan and process the images. A nuclear medicine specialist will review the images along with your medical history, and provide a written report for your referring doctor. See Nuclear Medicine for more details about these health professionals.
Where is a renal scan done?
A DTPA scan is done in a nuclear medicine department of a hospital or a private radiology or nuclear medicine practice with nuclear medicine facilities.
When can I expect the results of my renal scan?
The time it takes your doctor to receive a written report on the test or procedure will vary depending on:
the urgency with which the results are required by your doctor;
the complexity of the test or procedure;
whether more information is needed from your doctor before the test or procedure can be interpreted by the radiologist;
whether you have had previous X-rays or other medical imaging that need to be compared with this test or procedure (this is commonly the case if you have a disease or condition that is being assessed as to its progress);
how the report is sent to your doctor (i.e. phone, email, fax or mail).
Please feel free to ask the private practice, clinic, or hospital when the written report will be provided to your doctor.
It is important that you discuss the results with your doctor, either in person or on the telephone, so that they can explain what the results mean for you.
Nuclear Medicine DMSA Scan
Health professional information
What is a DMSA scan?
DMSA, or dimercaptosuccinic acid, is a radioactive substance (called a tracer) that is injected into a vein and enters the kidneys. It is detected by gamma cameras and enables a scan to be taken of the inside of the kidneys. See nuclear medicine for more detailed information about the processes used.
The scan shows which areas of the kidneys are working normally and which areas have been damaged (usually following kidney infections).
How do I prepare for a DMSA scan?
There is no preparation for a DMSA Scan. You can eat and drink normally.
If you think you may be pregnant or are breast feeding you must inform your doctor or specialist who is referring you for the DMSA Scan and the radiology staff where you are having the DMSA Scan. They will discuss with you any need to stop breast feeding and minimise your contact with your baby for a short time.
What happens during a DMSA scan?
There are 2 parts to a DMSA scan – an injection of a radiopharmaceutical and then images taken with a gamma camera.
You will receive a small injection of a radiopharmaceutical into a vein, usually in your arm. Sometimes, the injection may be followed up immediately by pictures being taken with a gamma camera to show which areas of the kidneys are making urine normally and which areas have been damaged. Other radiopharmaceuticals perform this test better and the main purpose of a nuclear medicine DMSA scan is the delayed images.
Two to four hours after having the injection you return to have the scan. During this time you will feel no effect from the injection and can maintain normal activities. The radiopharmaceutical is detected by a gamma camera (that takes images or pictures showing the functioning of the kidneys. These can include one or several still “long exposure” images, and often the creation of a 3D image where the camera moves around your whole body taking pictures from many angles. These pictures are then used to create a 3D image of your kidneys. The reason for the delay between the injection and having pictures taken is to give the radiopharmaceutical a chance to be absorbed into the kidneys. You will not feel any different whilst you are being imaged and there is no noise or lights.
The radiopharmaceutical you receive is eliminated from your body through the urine. For that reason, you should drink plenty of fluids and urinate frequently following the injection. How much fluid will depend on each individual but you should be well hydrated, and for an adult this could be 3-4 glasses of water. Your urine will not change colour. However, as it contains the radioactive tracer it is recommended that you wash your hands well after going to the toilet.
In the case of babies and youngsters in nappies who are having a DMSA scan, there will be a small amount of radioactivity in the urine and therefore on the child’s nappy. The radiotracer will not affect the baby’s skin, but carers should wash the baby’s bottom as is normal practice and wash their hands thoroughly. Cloth nappies need to be washed thoroughly and disposable nappies put in a plastic bag and sealed before being disposed of.
Are there any after effects of a DMSA scan?
There are no after effects from a DMSA scan of the kidneys.
How long does a DMSA scan take?
A DMSA scan of the kidneys involves an injection of the DMSA tracer solution and then imaging 2-4 hours after the injection. You can usually leave the hospital, radiology or nuclear medicine practice between the two parts of the procedure and eat and drink normally during this time. The reason for the delay between the 2 parts is to give the solution a chance to be absorbed by the kidneys.
The imaging itself takes about half an hour. You will not feel any different whilst you are being imaged.
When small children are having a DMSA scan, it can be difficult giving them the DMSA tracer injection, so various techniques are used such as distracting their attention with DVDs/videos or toys. In some cases local anaesthetic may be used or, more rarely, sedation (see how can I make my child’s examination less stressful?).
What are the risks of a DMSA scan?
There are no risks involved in the DMSA scan procedure itself.
There is a small dose of ionising radiation that is similar to other routine medical imaging tests (see radiation risk of medical imaging for adults and children)
What are the benefits of a DMSA scan?
A DMSA scan enables the doctor to evaluate the functioning tissue of your kidneys because the radiopharmaceutical does not attach itself to areas of the kidneys that are damaged. Doctors can measure the relative function of each kidney to see if one kidney functions differently to the other, and by performing regular DMSA scans they can monitor any changes to inflammation of the kidneys.
Who does the DMSA scan?
The DMSA scan of the kidneys is performed by nuclear medicine technologists who are trained to perform this type of test. The technologists provide these images to a nuclear medicine specialist.
This specialist will direct the technologist on which images are required to give an accurate diagnosis. The specialist also writes a report and sends it back to the doctor who referred you for the DMSA Scan.
See nuclear medicine for more detailed information.
Where is a DMSA scan done?
Most large public and private hospitals and private radiology and nuclear medicine practices have nuclear medicine facilities where DMSA scans are performed.
When can I expect the results of my DMSA scan?
The time that it takes your doctor to receive a written report on the test or procedure you have had will vary, depending on:
the urgency with which the result is needed;
the complexity of the examination;
whether more information is needed from your doctor before the examination can be interpreted by the radiologist;
whether you have had previous X-rays or other medical imaging that needs to be compared with this new test or procedure (this is commonly the case if you
have a disease or condition that is being followed to assess your progress);
how the report is conveyed from the practice or hospital to your doctor (i.e. phone, email, fax or mail).
Please feel free to ask the private practice, clinic, or hospital where you are having your test or procedure when your doctor is likely to have the written report.
It is important that you discuss the results with the doctor who referred you, either in person or on the telephone, so that they can explain what the results mean for you.
Further information about DMSA scan:
This is a simple test to perform that allows the doctor to assess any damage to the kidneys – usually looking for scarring as a result of urinary reflux (backflow of urine from the bladder to the kidneys ) or damage following trauma or reduced blood supply, e.g. from blocked renal arteries.
Regular scans (for example one every year) are often performed to monitor any change in the function of the kidneys or their response to treatments you may be having.
DMSA: dimercaptosuccinic a. A DMSA scan uses radioactive chemicals to create special pictures of kidneys. These pictures can help assess how well the kidneys are working. DMSA builds up in kidneys. Pictures of the kidneys are then taken using a special camera
NITRITES: normally are not found in urine but result when bacteria reduce urinary nitrates to nitrites. Many G-ve & some G+ve MO are capable of this, & a positive dipstick nitrite test indicates that these MO are present in significant numbers (&gt;10k/mL). This test is specific but not highly sensitive. Thus, a +ve result is helpful. The nitrite dipstick reagent is sensitive to air, so containers is closed immediately after removing a strip. After 1w of exposure, 1/3rd of strips give false-positive results, and after 2, 3/4ths.
Non-nitrate–reducing MO also may cause false-negative results, & pts. who consume a low-nitrate diet may have false-negative results.
LEUKOCYTE ESTERASE: is produced by neutrophils & may signal pyuria a/with UTI. To detect significant pyuria accurately, 30sec-2min should be allowed for the dipstick reagent strip to change color, depending in the brand used. Leukocyte casts indicate inflam to the kidney. MO like Chlamydia & Ureaplasma urealyticum should be considered in pts. with pyuria & negative cultures. Other c/of SP: balanitis, urethritis, TB, UB tumors, viral inf, nephrolithiasis, FB, exercise, GN, & steroid & c.phosphamide
Honeymoon Cystitis: often occurs after sex. A few women get a UTI frequently after sex (honeymoon or not). Sex can push infecting bacteria into urethra. F with a diaphragm are at a higher risk.
Ac. urethral syn:(abacterial cystitis): LUTS (frequency, urgency, dysuria, suprapubic discomfort) but no pathogen or any urological abnormality. Dx is based on history, negative CS, dynamic cystourethroscopy & urodynamic studies. The term is now controversial as no Dx criteria & there is an overlap with other Dx (interstitial cystitis). It affects ¼ adult women particularly young
Risks: grand multiparity, delivery without episiotomy & 2 or more abortions.
More in F & in white.
Presentation: suprapubic discomfort, dysuria, frequency.
Do thorough abdominal & gynaecological exam
DD: Stress incontinence, Atrophic urethritis& vaginal atrophy in peri- or postmenopausal women, UTI, other c/of SP, Urethritis due to: C trachomatis , Lactobacilli, N gonorrhoeae, Ureoplasma urealyticum, Urethral stenosis& spasm.
Other structural abnormalities (diverticula), Allergy/irritation (nylon underwear), Trauma during intercourse, Vaginal infection, Generalised anxiety.
Investigations: dipstick, microscopy, CS
Urethral swab for chlamydia, chlamydial-antigens in first-pass urine sample.
If chlamydia-negative& persistent symptoms, obtain a sample by SP aspiration or urethral catheterisation& culture under special conditions for &apos;fastidious&apos; or slow-growing organisms. Any organisms detected in this way are clinically significant.
If no infection, consider cystoscopy to exclude non-infective causes. Further investigations may also include pelvic USG, MRI, IVU& urodynamic.
Management: psychological problems should be considered; often irrelevant. Behavioural therapy (including biofeedback, meditation,& hypnosis) has been used with some success. Highly acidic foods, including spicy foods, should be avoided.
Exercise& massage programmes can be very helpful.
Urethral massage may help by encouraging drainage of mucus from chronically infected periurethral glands.
Medication: Rx UTI& chlamydia as indicated.
Vaginal oestrogen cream may be curative in atrophic urethritis.
Surgery: Urethral dilatation assumes that symptoms are due to urethral spasm or stricture. However, there is very little clinical evidence of effectiveness& it may cause periurethral fibrosis leading to urethral strictures. Urethral dilatation is therefore only now performed if true urethral stenosis is found.
Complications: Chronic pain may have a severe psychological impact.
Prognosis: usually improve with age but may be lifelong
Stealth UTI
UTIs without symptoms are not unusual; urine tests can show that bacteria are present in the urine& the condition is termed asymptomatic bacteriuria. Usually this condition is not treated, but in some patients it is better to treat them with antibiotics (for example, pregnant women, some children,& kidney transplant patients)
Treating UTIs
Dx & Rx of children 2-24mo of age with UTI & unexplained F. Strategies depend on whether ABT immediately or can be delayed safely until CS & urinalysis. Dx is based on pyuria & 50k CFUs/mL of a single uropathogen in an well collected specimen; urinalysis alone does not confirm Dx. After 7-14d of ABT, close FU is done, with evaluation of the urine in febrile episodes. USG of KUB should be done to detect malformation. Routine VCUG after the first UTI is not recommended; VCUG is indicated if HDN, scarring, or other findings that would suggest either VUR/obstruction, as well as in other atypical or complex clinical circumstances. VCUG also should be performed if there is a recurrence of febrile UTI
Although severe kidney infections are often treated in the hospital with IV antibiotics, most UTIs (and many mild-to-moderate kidney infections) are treated with oral antibiotics. However, many clinicians are sending urine samples to identify the infecting organisms& determine their antimicrobial resistance. It is not unusual for a doctor to call a patient& switch antibiotics because of antibiotic resistance. In addition, the doctor will usually recommend that the patient take in plenty of fluids (water)& encourage frequent urination to flush bacteria out of the urinary tract.
Treating Recurrent UTIs
Recurrent UTIs are not unusual; you should ask your primary care physician (PCP) for a referral to a urologist if you have three or more UTIs per year to see if there may be an underlying urinary tract problem that may be the cause. Your PCP may also suggest taking long-term (months) low-dose antibiotics, recommend taking an oral antibiotic after sex, or taking an oral antibiotic as needed when UTI symptoms appear.
Cranberry juice: may have infection-fighting properties& drinking it daily may help prevent UTI. Greatest effect in women with rec. UTIs. There&apos;s little harm to drink it, but watch the calories. Mostly safe, but may upset stomach.
Don&apos;t drink it if you take the warfarin, because this may lead to bleeding
Balanitis is an inflam of glans, or head, of penis
Balanoposthitis: balanitis & posthitis (inflam of foreskin) usually occur together
