This document defines and describes urinary tract infections (UTIs). It discusses the definitions of UTI, bacteriuria, and pyuria. It also covers the pathogenesis, diagnosis, and treatment of various types of UTIs including cystitis, pyelonephritis, renal abscess, prostatitis, orchitis, and epididymitis. The document provides details on the causative organisms, clinical presentations, laboratory diagnostics, and antimicrobial management of these urinary infections.

1. URINARY TRACT
INFECTION

2. Definitions
UTI : Inflammatory response of urothelium to
bacterial invasion associated with bacteriuria
&
Pyuria.
Bacteriuria: Presence of bacteria in urine
which is normally free of bacteria.It may be
due to contamination.
Pyuria: Presence of WBCs in urine.
Bacteriuria without pyuria: Colonization with no
infection.
Pyuria without bacteriuria: T.B, stones, cancer.

3. Uncomplicated UTI: Inf. in normal U.T both
structurally & functionally.
Complicated UTI: U.T is functionally or
structurally
abnormal, host is compromised, increased
virule-
nce of bacteria (pregnancy, elderly, DM,
instrume-
ntation).
First or isolated: Never had inf. before or since
a
long time.
Unresolved inf.: not responded to

4. Incidence & Epidemiology
-UTIs are the most common bacterial inf.
-1.2% of office visits by females & 0.6% by
males.
-50% of females will experience UTI during life.
-Once a pt. has inf., is likely to develop
subseque-
nt infections.

5. Pathogenesis:
Routes of infection:
1-Ascending route:
-Bowel reservoir----urethra----bladder
e.g: perineum soiled with faeces.
indwelling catheter
-Cystitis may ascend to kidney by VUR.
2-Haematogenous route:
-Renal infection with staph. From a septic focus.
3-Lymphatic route:
-Not common.
-From adjacent organs (severe bowel inf. – RP
abscess).

6. Urinary Pathogens:
E. Coli : 85% of community acquired
50% of hospital acquired
Proteus, klebsiella, gm +ve (E. faecalis):
remain.
Bacterial adherence:
Bacterial adhesins:
-UP expresses a number of adhesins that allow
it
to attach to U.T tissues.

8. Natural defenses of U.T:
1- Periurethral & urethral region:
- Normal flora of introitus & urethra contain orga-
- nisms as lactobacilli & streptococci forming a
- barrier against UP.
- - Flow of urine.
2- Urine:
- Organisms normally colonizing the urethra do
not multiply in urine.
- Bacterial growth is inh. by dilute urine or high or
high osmolality assoc. with low Ph.
- Tamm-Horsfall ptn. (1000ng/ml) block bacterial
binding to urothelial receptors.
3- bladder emptying.
4- General immunity.

9. Diagnosis
- -Urine & U.T are normally free of bacteria &
infl.
Urine collection:
-Mid stream.
-How to collect ?
voided or catheterized
Suprapubic aspiration: highly accurate,
useful in newborn
pts who can not void
-Non circumcised: prepuce retracted, glans
washed
-In females: spread labia, wash introitus, mid

10. Urine analysis:
5-10 ml centrifuged for 5 min. at 2000 rpm.
Bacteriuria found in 90% of infs. with counts
>100000 CFU/ml.
2 WBCs/HPF in centrifuged specimen= 10 in an
unspined specimen & both correlates with bacte-
ruria.
Imaging techniques:
-Not required in most cases.
-Indications: fever- failure to respond to treatment
recurrent infs.- D.M- history of stones or surgery.
-Plain, IVU, VCUG, U/S, CT.

11. Principles of antimicrobial treatment:
-Efficacy is dependent on drug level in urine &
duration this level remains above MIC of inf.
organism.
-Concentration in blood is not important as in
urine, except in septicemia or bacterimia.
-Patients with renal failure:
Dose modification are necessary for drug
cleared only by kidneys.
Conc. power is impaired ---difficult eradication
of
infection.

12. Bladder infections
Uncomplicated cystitis:
-Most caes in females.
-25% between 20-40 yrs.
Risk factors:
-Weak urine flow.
-Promote colonization: sexual activity.
-Facilitate ascent: catheter, fecal incontinence.
Clinical presentation:
-Dysuria, frequency, urgency, S.P pain.
-Haematuria, foul smelling urine.
-Fever & chills usually absent (superficial mucosal
infection).
Causative organism: E. coli 80-90%

13. Lab diagnosis:
-urine analysis: pyuria, bacteriuria, hematuria.
-urine culture: often not necessary.
Treatment:
-TMP-SMX, quinolones, floroquinolones
-Duration: 3 days.
Complicated cystitis:
-Occur in compromised U.T or by resistant org.
-mild cystitis----life threatening renal inf. &
urosepsis.
-Urine culture is mandatory.
-treatment of cause.

14.  Kidney Infections
Acute Pyelonephritis:
-Inflammation of both renal parenchyma &
pelvis.
Causative organism:
-E. coli (80%), proteus, klebsiella,
pseudomonas
-Rarely, gm +ve.
Pathology:
-Renal enlargement, capsule strips easily,
small
yellowish white cortical abscesses with
parench-

15. Clinical picture:
-Chills, fever (100F or >), flank pain.
-LUTS (dysuria, urgency, frequency).
-GIT symptoms.
Lab diagnosis:
-CBC: leucocytosis with predominance of
neutrophils, inc.ESR & C- reactive ptn.
U.A: WBCs in clumps, bacterial rods.
WBC casts
Specific casts (bacteria in ptn matrix).
U.C:
Blood culture:

16. Radiology:
IVU: renal enlargement (1.5 cm greater in
length).
focal ― (focal bacterial nephritis)
disappear with treatment.
calyceal & ureteral dilatation (endotoxins)
U/S & CT: to diagnose complicated PN
to reevaluate pts not responding
after
72 hours treatment.
Treatment: Antibiotics for 7 days.
Bed rest – antipyretics.

18. Emphysematous PN:
-Acute necrotising parenchymal & perirenal infn.
caused by gas forming UP.
-Organism cause fermentation of glucose ----CO2.
-However, not common in diabetics.
Should be considered compl. of severe PN.
-Mortality rate 20-40%
Causative organism:
-E. coli (commonest), klebsiella, proteus.
Clinical picture:
-Triad of fever, vomiting, flank pain.
-Pneumaturia, when infn. involves collecting
system.

19. Imaging:
-Plain KUB: crescentic gas shaddow (in renal
space) & loculated ― ― (in
parench.)
-IVU: rare of value (NF or poorly functioning K.)
U/S: gas.
CT: procedure of choice.
Treatment: surgical emergency
-Fluid resuscitation & broad spectrum
antibiotics.
-Nephrectomy if no improvement after few
days.

22. Renal Abscess:
-Collection of purulent material confined to renal
parenchyma.
-Usually due to VUR in an obstructed kidney.
-Causative organism: g +Ve or –Ve.
Clinical picture:
-Triad------cystitis
-History of g +Ve source of inf.(1-8 weeks) before
onset of symptoms. e.g: skin carbuncle.
Lab diagnosis:
-Leucocytosis, pyuria, bacteriuria (if communicat).
-Urine culture: no or different organism (bld
borne).

23. Radiology:
-Renal enlargement & distortion of renal contour.
-Renal fixation on insp. & exp. films.
-Obliteration of psoas shadow & scoliosis.
-CT is the procedure of choice
Renal enlargement & area of low attenuation.
Thickening of perinephric fascia.
Treatment:
-PC or open drainage (DD. Renal tumor).
-I.V antibiotics & observation, if <3cm.-----good
response.
-Follow up with U/S or CT till complete resolution.

25. Infected Hydronephrosis & Pyonephrosis:
Infected HN: bacterial inf. in a hydronephrotic k.
Pyonephrosis:inf. HN associated with suppuration
of renal parenchyma----partial or total loss of
renal function.
Differentiation not always easy.
Clinical picture:
-Triad.
-Bacteria may not be present if ureter completely
obstructed.
Radiology: internal ecchoes in dilated P.C
system.
Treatment: drainage &antibiotics.

27. Perinephric abscess:
Etiology:
-Rupture of a cortical abscess into perinephric
sp.
-Infected perirenal hematoma or urinoma.
-Spread of osteomyelitis from T.B lumbar
spine.
When it rupture through renal fascia ---
paraneph.
abscess.
Clinical picture: insidious onset, 1/3 afebrile.
Local signs of infl. (hotness, redness, oedema,
loin mass may be pointing)

28. Radiology:
-Absent psoas shaddow, elevated or immobile
diaphram.
-U/S & CT: ecchogenic collection.
Treatment:
-Surgical drainage (if large)
-PC ― (if small)

29. PROSTATITIS
Etiology:
1- G –Ve: E. coli (80%), kleb.,
pseudomonas,….
2- G +Ve: staph aureus (5-10%)
3- Chlamydia & U. urealyticum: minor role.
Risk factors:
1- Intra-prostatic ductal reflux.
2- Immunologic alteration inside prostate.
3- Acute epididymitis, indwelling catheter,
TURP

30. Pathology:
-Increase no. of infl. cells within parenchyma.
-Lymphocytic infil. in stroma adjacent to acini
(most common pattern).
-Corpora amylacea (deposition of pr. secretion
around a sloughed epithelial cell) may obstruct
pr. gland.
Classification: “Traditional classification
system”
Type s. of UTI bacteria infl.
cells
1-ABP: severe + +
2-CBP: mild + +
3-NBP: ----- - +
4-Prostatodynia: ----- - -

31. Clinical picture:
1- ABP: fever, severe irritative & obstructive
C/O.
5%------- CBP
2- CBP: asymptomatic
irritative & obstructive C/O
3- NBP: pain (predominant C/O) in
perineum,S.P,
penis, testis, low back.
4- Prostatodynia: painful ejaculation (50%)
symptoms tend to wane & wax over

32. Diagnosis:
1- Physical examination:
-Important but not helpful for diagnosis or
classificat
ABP: prostate is hot, boggy, very tender
Other types: prostate is normal.
2- Cytology & culture:
- Stamey 4 glass urine collection
Treatment:
1- Antibiotics: for ABP & CBP.
2- Alpha adr. blockers: for NBP & prostatodynia
with poor relaxation of B.N -----increase ur. flow
&
decrease IPR.

34. 3- Anti-inflammatory:
NSAIDs- cortisone.
4- Ms. relaxants:
NBP & prostatodynia may be due to smooth &
skeletal ms dysregulation of pelvis
& perineum.
5- Phytotherapy:
Some plant extracts show 5 alpha- reductase
activity, alpha blocker, anti- inflammatory.
6- Allopurinol:
IPR---inc. metabolites containing purine &
pyrimidine in pr. ducts-----inflammation.

35. Orchitis:
Definition:
-Inflammation of testis, & also describe testicular
pain without evidence of infl.
Etiology:
-Isolated orchitis is relatively rare & usually viral
due to blood spread.
-Orchitis of bacterial origin usually occur due to
local spread from ipsi. epididymis (E. coli, pseud.,
Staph, strept.,N. gonorrhea).
Presentation:
-Pain- fever- nausea & vomiting- tenderness-
secondary hydrocele.

36. Diagnosis:
Urine analysis- urethral swab
U/S: to rule out malignancy & torsion
Treatment:
- Rest- scrotal support- hydration- antipyretics-
AI
- Antibiotics.
Chronic orchitis:
-Inflammation & pain in testis, without swelling
for >6 weeks.
-Self limited & may take years to resolve.

37. Epididymitis:
-Acute : sudden pain, infl., swelling.
-Chronic: pain & infl. with no swelling >6 weeks.
may be due to inadequate treatment.
-Spread from bladder, urethra & prostate.
-Starts in tail-----body-----head.
-Testis is involved in most cases-----epididymo-
orchitis.
Treatment:
-antibiotics for 4-6 weeks.
-Chronic: self-limiting taking long duration.
-Epididymectomy: with treatment failure & to cure
pain.

38. Tuberculosis (T.B)
-Always considered in a pt. with vague long
standing urinary C/O with no obvious cause.
-Age: 20-40 yrs, uncommon in children.
When to suspect?
-Following presentation without obvious
etiology.
Frequency—recurrent cystitis not responding
to
treatment---gross or microscopic hematuria---
sterile pyuria.

39. T.B of kidney:
-Organism settle in blood v. close to glomeruli.
-Caseating granulomas develop & consist of giant
cells (Langhans) surrounded by lymphocytes &
fibroblasts.
-Caseous material open through calyces---cavities
of moth-eaten appearance.
-Course depends on virulence & resistance.
-If pathology progress + obst.---autonephrectomy.
-If healing occur---fibrosis & calcification---stricture
in calyces or PUJ.
-Mycobacterium may remain viable in calcific
lesions.

44. T.B of ureter:
-T.B ureteritis---fibrosis---str. usually at UVJ
-Whole ureter may be affected---multiple levels
ureteric str.
T.B of bladder:
-Starts around U.O---infl. & edema---T.B
granuloma
-T.B ulcers is rare, occasionally whole bladder
is
covered by infl. velvety granulation---bladder
fibr-

47. T.B of epididymis & testis:
-Painful & infl. scrotal swelling. D.D: ep.orchitis.
-Globus minor affected alone in 40%.
-Testicular affection without ep. is very rare.
-Scrotal sinus.
T.B of penis----superficial glanular ulcer.
D.D:Tr.
T.B of urethra ---urethral stricture.

48. Diagnosis:
1-Tuberculin test:
-M.T.B complex (M.T.B—M. bovis—M.
microti—M. africanum).
-Intradermal inj. of a PPD of tuberculin.
-Infl. condition reaching max.between 48-72
hrs.
-Central indurated zone surrounded by
erythema.
-+Ve reaction =inf., but not indication of active
T.B or C/O due to T.B.
2-Urine examination:

49. 3-Urine culture:
-Lowenstein-Jensen.
-Takes 6-8 weeks (slowly growing).
-3-5 consequetive early morning samples
(org. is intermittently excreted).
4-Imaging:
-Plain KUB:
-Calcification in kidney, ureter, bladder, seminal
vesicle.
-Plain chest & spine.
-IVU:
-Fibrosed & occluded calyx (lost calyx).
-Moth-eaten cavities, HUN, contracted bladder.

50. Treatment
First line drugs:
1-Isoniazid (INH): hepatotoxicity, peripheral
neuritis.
5 mg/kg maximum 300 mg
2-Rifampicin: hepatotoxicity
10 mg/kg max. 600 mg
3-Pyrazinamide: hepatotoxicity
20-25 mg/kg
4-Streptomycin: ototoxicity
5-Ethambutol: retrobulbar neuritis
15-25 mg/kg

51. Cornerstone is multidrug treatment to decrease
duration of treatment & drug resistant developm-
ent.
Second line drugs:
-kanamycin—amikacin—ciprofloxacin……
Guidelines:
-Short course 6 months regimen.
-All drugs given in a single dose.
-Followup with urine culture at 3, 6, 12 months
after treatment finished.
Surgery: delayed until medical treatment adminis-
tered for 4-6 weeks.

52. Parasitic diseases
Urinary schistosomiasis:
Caused by S. haematobium.
Pathology & pathogenesis:
-Worms in pelvic v. plexus----eggs in lower UT.
-Granulomas formed in response to egg Ag------
large,bulky, hyperemic polypoid masses. As egg
laying ceases, eggs are destroyed or calcified &
infl. wanes & replaced by f.t. (inactive form).
Acute
& chronic bladder ulcers
-Obstructive uropathy occur due to chronic dis.
Usually bilateral asymmetrical (JV & lower ureter)
-Bladder cancer is a sequalae:early, sq.c.c (60-

53. Presentation:
Acute:‖ Katayama fever‖
-fever, lymphadenopathy, splenomegaly, urticaria
-occur 3-9 weeks after inf.
-terminal hematuria & dysuria.
Chronic:
-HUN—contracted bladder
Diagnosis:
1-Presence of eggs with terminal spikes is diagn-
ostic of & only possible during active inf.
2-Serologic tests: do not diff. between acute & ch
inf.
3-Plain & IVU.

54. Treatment:
Medical:
Praziquentel: drug of choice
cure rate 80-100%
dose:2 oral doses of 40mg/kg in 24 hrs
No serious side effects.
Surgical: nephrectomy—ureteric implantation

55. Filariasis
Lymphatic filariasis:
-Causative organism: W. bancrofti
-Cycle proceeds from human---mosquito---human.
-Acute lymphatic infiltration----fever, lymphangitis
& lymphadenitis---chronic lymphatic obstruction
& dilation----hydrocele, elephantiasis of limbs &
chyluria.
-Diagnosis: C.p & Giemsa stain for blood.
-Treatment:
Diethylcarbamazine (DEC), ivermectin,
albendazole.

56. Nonlymphatic Filariasis:
-Transmitted by black flies (Simulum species).
-Adult worms inhibit S.C tissues----f. nodules in
which it is encapsulated.
-Microfilaria travel through dermis & eye ---------
-blindness.
-Diagnosis:
Microscopic exam. of skin snips under normal
saline or Giemsa stain.
Treatment:
-Ivermectin. DEC not used due to severe
allergic