2_2020_10_24!09_23_09_AM.ppt

1. Lower Urinary tract
infection
Dr. AMMAR FADIL

2. UTI
• Urinary tract infection (UTI) is a term that
is applied to a variety of clinical conditions
ranging from cystitis to severe infection of
the kidney with resultant sepsis.
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3. Lower UTI
cystitis
UTI
Upper UTI
Pyelonephritis
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4. UTI
May also be classified as
1. Isolated UTI
a single episode of lower tract infection occurs
frequently in females and is rarely complicated.
2. Recurrent UTI
is >2 infections in 6 months, or 3 within 12
months.
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5. Predisposing causes of urinary tract
infection
• Incomplete emptying of the bladder,
bladder outflow obstruction,
bladder diverticulum,
neurogenic bladder
• A calculus, foreign body or neoplasm.
• Incomplete emptying of the upper tract,
dilatation of the ureters associated with
pregnancy, or vesicoureteric reflux VUR.
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6. • Oestrogen deficiency, which may give rise
to lowered local resistance.
• Colonisation of the perineal skin by strains of
Escherichia coli expressing molecules that
facilitate adherence to mucosa
• Diabetes.
• Immunosuppression
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7. Acute cystitis
• urinary infection of the lower urinary tract,
principally the bladder.
• Acute cystitis ♀ > ♂.
• The primary mode of infection is
ascending from the periurethral / vaginal
and fecal flora.
• The diagnosis is made clinically.
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8. PRESENTATION
• There is frequent voiding of small volumes,
dysuria, urgency, suprapubic pain, hematuria.
• 50% of women will have an episode of cystitis
in their lifetime
– Fever and systemic symptoms are rare.
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9. INVESTIGATIONS
• Urinalysis WBCs in the urine & hematuria
may be present.
• Urine culture is required to confirm the
diagnosis & identify the causative organism.
• However, when the clinical picture &
urinalysis are suggestive of the Dx of
acute cystitis, urine culture may not be
needed.
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10. RADIOGRAPHIC IMAGING
• In uncomplicated infection of the bladder,
radiologic evaluation is often not
necessary
• recurrent UTI, Fever, UTI in children
• US
• VCUG
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11. Treatment
• Management for acute cystitis consists of a
short course of oral antibiotics.
–TMP SMX
–Nitrofurantoin
–Quinolones
Short oral course 3-5 d ♀
Days for ♂ & child 7 d
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12. Honeymoon Cystitis
• Is the term for a UTI that often occurs after
sexual activity. Sexual activity can push
infecting bacteria into the urethra resulting
in an infection.
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13. 13
• Recurrent UTI may be due to
– Reinfection (i.e., infection by a different
bacteria) or
– Bacterial persistence (infection by the same
organism).
Bacterial persistence is caused by
– the presence of bacteria within calculi
(e.g., struvite calculi)
– antimicrobial resistance,
– patient noncompliance with therapy

14. Recurrent UTI
1. Bacterial persistence
presence of bacteria within a site in the
urinary tract, leads to repeat episodes of
infection.
• Such sites include
 urolithiasis anywhere in the urinary tract,
 chronic bacterial prostatitis,
 obstructed or atrophic kidney
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15. 15
The recurrent UTIs will not resolve until
this underlying problem has been
addressed and corrected.
e.g. surgical removal of the infected source
(such as urinary calculi)

16. Recurrent UTI
2. Reinfections
usually occur after a prolonged interval
(months) from the previous infection and are
often caused by a different organism than
the previous infecting bacterium
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17. MANAGEMENT
• renal ultrasound, CT scan, cystoscopy) to
evaluate for a potential source of bacterial
persistence.
• In the absence of finding an underlying
functional or anatomic abnormality,
they can be managed in one of the
following ways.
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18. 18
• Low-dose antibiotic prophylaxis
trimethoprim, nitrofurantoin, low-dose
cephalexin, and the fluoroquinolones
appear to have minimal adverse effects on
the fecal and vaginal flora.
• Prophylactic therapy requires only a small
dose of an antimicrobial agent, generally
given at bedtime for 3 to 6 months

19. continuous prophylactic antibiotic
• Nitrofurantoin, 50 or 100 mg daily
• TMP-SMX, 40/200 mg daily
• Trimethoprim, 100 mg daily
• Cephalexin, 250 mg daily
• Ciprofloxacin, 250 mg daily
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20. Recurrent cystitis/ UTI
• ♀with reinfection do not usually have an
underlying functional or anatomical abnormality.
But have higher adherence of bacteria to their
mucosal cells compared to women who never had
UTI.
• ♂ with reinfection may have underlying bladder
outlet obstruction (due to prostate enlargement or
urethral stricture), which makes them more likely to
develop a repeated infection.
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21. Other Measures in women
–When the recurrent cystitis/UTI is
related to sexual activity frequent
emptying of the bladder after coitus.
–either CPA or post intercourse
prophylaxis can significantly reduce the
incidence of recurrent infection
• Yogurt applied to the vulva and vagina can
help restore normal vaginal flora,
• Cranberry taken orally
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22. Infection in pregnancy
• The incidence of asymptomatic bacteriuria in
pregnant women is twice as high as in non-
pregnant women.
• Simple uncomplicated infection can be treated
following urine culture with an antibiotic that is
not contraindicated in pregnancy, such as
cephalosporin or ampicillin.
• Pyelonephritis need I.V ABS and close
observation. 22

23. Antibiotics in urology
• TMP SMX:
– highly effective against many
uropathogenes except pseudomonas &
entreococcus.
– interfere with bacterial metabolism of folate.
SE: rash, GIT upset, leukopenia.
CI: G6PD, pregnant
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24. Quinolones
• Ciprofloxacin, levofloxacin
• broad spectrum, interfere with bacterial
DNA.
Adverse reactions include tendon damage,
arthropathy in children
CI: children & pregnant
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25. Nitrofurantoin
has good activity against most gram –ve
except Pseudomonas & proteus.
It inhibit bacterial enzymes & DNA
activity.
SE: polyneuropathy, hepatotoxicity.
• Aminoglycosides
used for complicated UTI.
When combined with ampicilline act
against enterococci
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26. Cephalosporine
Have good activity against most uropathogene.
1st generation gram positive & E.Coli.
2nd generation anaerobic & H.influenze.
3rd generation ceftriaxone , cefotaxim
boader coverage against G –ve less
against G+ve
4th generation cefepim
oral 3rd cefixime effective in febrile UTI in
children
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27. Penicillin
• Are ineffective against uropathogene.
• Ampicilline & amoxicilline have good activity against uropathogene but G-ve bacteria quickly develop resistance.
• Addition of B lactamase inhibitor such as clavulanic acid makes combination more active against G-ve
bacteria.
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28. Schistosomiasis (bilharziasis)
• Urinary schistosomiasis is caused by the
Schistoma haematobium. It is endemic in Iraq,
Egypt, and the Middle East.
• Fresh water bulinus snails release the infective
form of the parasite (cercariae), which can
penetrate skin, and migrate to the liver (as
schistosomules), where they mature.
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29. 29
• Adult flukes couple, migrate to vesical veins,
and lay eggs , which leave the body by
penetrating the bladder and entering the urine.
The disease has two stages:
• active (when adult worms are
actively laying eggs)
• inactive (when the adult has died, and there
is a reaction to the remaining eggs). The
development of squamous cell carcinoma of
the bladder is result of the chronic
inflammation.

30. Clinical features
Swimmer’s itch.
• Active inflammation results in hematuria,
frequency, and terminal dysuria.
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31. Investigations
Urinalysis
Early morning urine specimen, to see ova
with terminal spine.
• Serology tests (ELISA).
IVP
may show a calcified, contracted bladder,
and obstructive uropathy.
• Cystoscopy identifies eggs in the trigone
(“sandy patches”).
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32. KUB
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33. Contracted bladder
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34. Sandy patches: calcified dead
ova with degeneration of
overlying epithelium.
Carcinoma is common end
result in bilharziasis.
Squamous celled C.A (due
to metaplasia)
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35. Complication
Chronic infection can lead to obstructive uropathy,
ureteric stenosis, renal failure, and bladder
contraction.
The most significant and concerning
complication is the development of
squamous cell carcinoma of the bladder
that often presents at an advanced stage.
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36. Interstitial cystitis/ BPS
• Interstitial cystitis (IC). this is confined to women,
also known as painful bladder syndrome of
unknown etiology
• IC is characterized by
daytime & night time urinary frequency,
urgency, suprapubic pain,
no identifiable pathological cause.
urinary tract infection are absent.
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37. Interstitial cystitis/BPS
IC is a diagnosis of exclusion.
Urine culture
Cystoscopy: characteristic ulcer is
found in the fundus.
Bladder biopsy
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38. treatment
• Oral : Amitriptyline,
Pentosanpolysulphate, cimitidine
• Intravesical: onabotulinum toxin A plus
Hydrostatic dilatation under anaesthesia
may give relief for some months.
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39. 39
• Recurrent UTI due to reinfection treated by
low-dose continuous prophylactic antibiotic
has been shown to reduce the recurrences of
UTI by 95% compared to placebo.