UPPER URINARY TRACT INFECTION

Upper urinary tract infection
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

Definition
• UTI is an inflammatory response of the urothelium to
bacterial invasion that is usually associated with
bacteriuria and pyuria.
• Bacteriuria is the presence of bacteria in the urine.
• Pyuria, the presence of white blood cells (WBCs) in the
urine, is generally indicative of infection and/or an
inflammatory response of the urothelium to bacteria,
stones, an indwelling foreign body, or other conditions
that can contribute to pyuria.
3
Dept of Urology, GRH and KMC, Chennai.

• Bacteriuria without pyuria is generally indicative
of bacterial colonization without overt infection
of the urinary tract.
• Pyuria without bacteriuria, or sterile pyuria,
warrants further evaluation.
– Eg . Recent UTI treated with antibiotics
– Steroid therapy
– Pregnancy
– GU TB
– Diabetes
4

• Uncomplicated UTI describes an infection in a healthy
patient with a structurally and functionally normal
urinary tract;
• A complicated infection is associated with factors that
increase the chance of acquiring bacteria and decrease
the efficacy of therapy.
• The urinary tract is structurally or functionally
abnormal, the host is compromised, and/or the
bacteria have increased virulence or antimicrobial
resistance.
5

Factors for complicated UTI
• Functional or anatomical abnormality of urinary tract
• Male gender
• Pregnancy
• Elderly patient
• Diabetes
• Immunosuppression
• Childhood urinary tract infection
• Recent microbial agent use
• Indwelling urinary catheter
• Instrumentation
• Hospital acquired infection
• Symptoms for more than 7 days at presentation
6

• Asymptomatic bacteriuria - a person has no signs or
symptoms of a UTI, yet bacteria are identified in a
noncontaminated urine sample.
• In women, identified in quantitative counts of greater than or
equal to 100,000 CFUs in two consecutive voided samples
that are obtained in a fashion that minimizes contamination.
• In men, only one clean catch voided sample that identifies
one bacterial species in quantitative counts greater than or
equal to 100,000 CFUs is enough for asymptomatic
bacteriuria.
7

• A first or isolated infection is one that occurs
in an individual who has never had a UTI or
has one remote infection from a previous UTI.
• An unresolved infection is one that has not
responded to antimicrobial therapy and is
documented to be the same organism with a
similar resistance profile.
8

• A recurrent infection is one that occurs after
documented, successful resolution of an
antecedent infection. Two types of recurrent
infection:
1. Reinfection describes a new event associated
with reintroduction of bacteria into the urinary
tract.
2. Bacterial persistence refers to a recurrent UTI
caused by the same bacteria reemerging from a
focus within the urinary tract, such as an
infectious stone or the prostate.
9

• Domiciliary or outpatient UTIs occur in patients
who are not hospitalized or institutionalized at
the time they become infected.
• Nosocomial or health care–associated UTIs
occur in patients who are hospitalized or
institutionalized.
• Catheter-associated UTIs (CAUTIs) occur within
that population of patients with indwelling
bladder drainage catheters.
10

• Antimicrobial prophylaxis (AP) is the
attempted prevention of reinfections of the
urinary tract by the administration of
antimicrobial drugs.
• Antimicrobial suppression is the attempted
prevention of growth of a focus of bacterial
persistence that cannot be eradicated.
11

INCIDENCE & EPIDEMIOLOGY
• UTIs are the most common bacterial infection and, as
such, make a significant impact on health care costs.
• The incidence of bacteriuria increases with
institutionalization/hospitalization,
pregnancy ,
certain comorbidities ,
immunosuppression.
• No clear association between recurrent uncomplicated UTIs
and renal sequelae such as scarring,hypertension, or
progressive renal insufficiency.
12

PATHOGENESIS
• UTIs occur as a result of interactions between
the uropathogen and the host.
• Successful infection of the urinary tract is
determined in part by the virulence factors of
the bacteria, the inoculum size, and the
inadequacy of host defense mechanisms.
13

Pathogenesis
14

Routes of Infection
Ascending Route
• Most bacteria enter the urinary tract from the bowel and skin
reservoir via ascent through the urethra into the bladder.
• Adherence of pathogens to the introital and urothelial mucosa plays a
significant role in ascending infections.
• Most episodes of pyelonephritis are caused by retrograde
ascent of bacteria from the bladder through the ureter to the renal
pelvis and parenchyma.
• Although reflux of urine is probably not required for ascending
infections, edema associated with cystitis may cause sufficient changes
in the ureterovesical junction to permit reflux. 15

Hematogenous Route
• Uncommon route
• Occassionally secondarily infected in patients with
Staphylococcus aureus bacteremia originating from oral sites
or with Candida fungemia.
Lymphatic Route
• Direct extension of bacteria from the adjacent organs via
lymphatics may occur in unusual circumstances, such as a
severe bowel infection or retroperitoneal abscesses.
16

Urinary Pathogens
• Most UTIs are caused by facultative anaerobes usually originating
from the bowel flora.
• Uropathogens such as Staphylococcus epidermidis and Candida
albicans originate from the flora of the vagina or perineal skin.
• E. coli is by far the most common cause of UTIs, accounting for
85% of community-acquired and 50% of hospital-acquired
infections.
• Gram-negative Enterobacteriaceae, eg. Proteus and Klebsiella,
• Gram-positive Enterococcus faecalis and Staphylococcus
saprophyticus are responsible for the remainder of most
community-acquired infections.
17

• E. coli sequence type ST131 (serotype O25b:H4)
merits special attention as a rapidly emerging
cause of multidrug-resistant infections, including
UTI.
• The prevalence of infecting organisms is
influenced by the patient’s age.
18

Upper urinary tract infection
Pyelonephritis
Renal abscess
Perinephritic abscess
Emphasematous pyelonephritis
Pyonephrosis
Xanthogranulomatous pyelonephritis
TB
Renal Malakoplakia
Other Infection
19

Acute pyelonephritis
Clinically presentation:
• classical triad:
Abrupt onset fever
Chills
Flank pain / costovertebral angle pain and/or tenderness
• sometimes accompanied by dysuria, increased
urinary frequency and urgency
20

Laboratory Diagnosis.
• Leukocytosis with a predominance of neutrophils.
• Urinalysis usually reveals numerous WBCs, often in clumps,
and bacterial rods or chains of cocci.
• The presence of large amounts of granular or leukocyte
casts in the urinary sediment is suggestive of acute
pyelonephritis.
Bacteriology
• Urine cultures are positive, but about 20% of patients
have urine cultures with fewer than 105 CFU/mL and
therefore negative results on Gram staining of the urine.
21

Imaging
Usuallynot necessary (if uncomplicated PN)
Reasons to image
Uncertain diagnosis
Severe symptoms
Atypical clinical situation
eg male gender , unresolving infecrtion, children, diabetics
Ruled out obstruction
Evaluate source in recurrent pyelonephritis
Maysee incidentally
22

USG:
• Ultrasound may show
focal parenchymal
swelling and regions
of increased or
decreased
echogenicity
Ultrasound of acute pyelonephritis.
Arrows show abnormally
echogenic and swollen upper pole
23

• CT and MRI also
may show focal
swelling and
diminished and in
homogeneous
parenchymal
contrast
enhancement.
Computed tomography of focal pyelonephritis.
Arrows show patchy regions of diminished
heterogeneousenhancement and swelling.
24

• Management.
Acute pyelonephritis subdivided into
(1) uncomplicated infection that does not warrant
hospitalization,
(2) uncomplicated infection in patients with normal urinary
tracts who are ill enough to warrant hospitalization for
parenteral therapy, and
(3) complicated infection associated with hospitalization,
catheterization, urologic surgery, or urinary tract
abnormalities
25

26

Pyelonephritis
• Complications:
Acute PN:
Renal abscess
Perinephritic abscess
Emphysematous pyelonephritis
Pyonephrosis
Chronic PN
• Scarring/ atrophy
• XGP
• Malakoplakia
• Papillay necrosis
27

Renal abscess
• Renal abscess or carbuncle is a collection of purulent
material confined to the renal parenchyma.
• Before the antimicrobial era, 80% of renal abscesses were
attributed to hematogenous seeding by Staphylococci.
• Since about 1970, gram-negative organisms have been
implicated in the majority of adults with renal abscesses.
• The most common organisms include E. coli, Klebsiella,
Proteus, and Pseudomonas spp.
28

Renal abscess
Clinical presentation:
• fever,
• chills,
• abdominal or flank pain, and
• occasionally weight loss and malaise
29

Renal abscess
Laboratory finding.
• The patient typically has marked leukocytosis.
• Because gram-positive organisms are most
commonly blood-borne, urine cultures in
these cases typically show no growth or a
microorganism different from that isolated
from the abscess.
30

Renal abscess
Imaging:
• USG is the quickest and least
expensive.
• Rounded, thick wall cystic
mass with debris
• An echo-free or low-
echodensity space-
occupying lesion with
increased transmission
is found.
Transverse ultrasound image of the right
kidney demonstratesa poorly marginated
rounded focal hypoechoic mass (arrows) in
the anteriorportion of the kidney. 31

Renal abscess
• CT -diagnostic procedure of choice
because it provides excellent
delineation of the tissue.
• On CT, abscesses are
characteristically well defined
before and after contrast agent
enhancement. The findings
depend in part on the age and
severity of the abscess.
NCCT scan- mid pole of the right
kidney demonstratesright renal
enlargement and an area of decreased
attenuation(arrows). 32

Chronic renal abscess
computed tomography scan shows an irregular septated
low-density mass (M) extensively involving the left kidney.
Note thickening of perinephric fascia and extensive
compression of the renal collecting system. Findings are
typical of renal abscess. 33

Renal abscess
Management
• IV antibiotic therapy
• Percutaneous or open incision and drainage
• Nephrectomy (rare)
34

Renal abscess
35

Perinephric Abscess
• It extends beyond the renal capsule but is contained by
Gerota fascia.
• When a perinephric infection ruptures through the Gerota
fascia into the pararenal space, the abscess becomes
paranephric.
• Diabetes mellitus is present in approximately one-third of
patients.
• E. coli, Proteus, and S. aureus account for most infections
36

Perinephric Abscess
• Cause:
– rupture of an acute cortical abscess into the perinephric
space,
– Extravasated infected urine from obstruction,
– hematogenous seeding from sites of infection
(mostly by skin infection)
- Adjacent organ infection (IBD, thoracolumber spine
Osteomyelitis, bowel perforation)
37

Perinephric Abscess
• Clinically presentation like pyelonephritis only.
• Sometimes palpable mass present.
• After giving 4-5 days antibiotics- symptoms
not subsiding then think about abscess.
38

Perinephric Abscess
CT is particularly valuable for
demonstrating the primary
abscess.
NCCT- the lower pole of the right kidney (previous
left nephrectomy)shows extensive perinephric
abscess. Extensiveabscess distortsand enlarges the
renal contour, infiltratesperinephric fat and extends
into the psoas muscle (asterisk) and the soft tissues
of the flank. 39

Perinephric abscess
Management:
• IV antibiotics
• Percutaneous/ open drainage
if size - > 3cms
• Nephrectomy (rare)- if kidney severely
infected or non functioning.
40

Pyonephrosis
• Infected hydronephrosis is bacterial infection in a
hydronephrotic kidney.
• The term pyonephrosis refers to infected hydronephrosis
associated with suppurative destruction of the parenchyma of
the kidney, in which there is total or nearly total loss of renal
function.
• very ill
• High fever,
• chills
• flank pain
• tenderness 41

Pyonephrosis
Radiologic Findings.
• USG- internal echoes, fluid debris within the
dependent portion of a dilated pyelocalyceal
system.
• CT is nonspecific but may show thickening of
the renal pelvis, stranding of the perirenal fat,
and a striated nephrogram.
42

Pyonephrosis
(A) Longitudinal ultrasound image of the right kidney demonstrates echogenic central
collectingcomplex with radiating echogenic septa (arrows)and thinned hypoechoic
parenchyma. Multiple dilated calyces (o) with diffuse low-levelechoes are seen.
(B) Antegrade pyelogram performed through a percutaneous nephrostomy catheter
correlateswell with the ultrasound image. Dilated pus-filledcalyces are demonstrated.
The renal pelvis is obliteratedby chronic scarring and stone disease.. 43

Pyonephrosis
Gross specimen. The kidney shows marked thinning of the renal
cortex and medulla, suppurative destruction of the parenchyma, and
distention of the pelvis and calyces. Previous incision released a large
quantity of purulent material. The ureter showed obstruction distal
to the point of section.
44

Pyonephrosis
Management.
• Appropriate antimicrobial drugs and
• Drainage of the infected pelvis.
45

• It is a urologic emergency characterized by an acute
necrotizing parenchymal and perirenal infection caused by
gas-forming uropathogens.
• First case reported by Kelly and Maccullum in 1898 .
• Since then terms such as ‘renal emphysema’,
‘pneumonephritis’ as well as ‘emphysematous
pyelonephritis’
• In 1962, Schultz and Klorfein suggested the use of
‘emphysematous pyelonephritis’ as the preferred term.
46

–EPN most often occurs in persons with
diabetes mellitus especially women.
–Presentation is similar to that of acute
pyelonephritis.
–But often has a fulminating course, and can
be fatal if not recognized and treated
promptly
47

Epidemiology:
• Mean age of patients with EPN is 55 years, with a range of 19-
81 years.
• 6 times more common in women.
• Ninety-five percent of patients have diabetes.
• In most patients, the diabetes is uncontrolled, with high levels
of glycosylated hemoglobin (72%) or of blood sugar.
• Renal stones are another predisposing condition and
therefore affect the frequency of EPN
• Left kidney is affected more commonly than the right.
Bilateral cases have also been reported.
48

Other reported factors associated with the
development of EPN are
– drug abuse,
– neurogenic bladder
– Alcoholism
– anatomic anomaly like polycystic kidney disease
49

Etiology :
• Enteric gram-negative facultative anaerobes.
• Escherichia coli- 66% of patients, and
Klebsiella species- 26% of patients.
• Proteus, pseudomonas, and streptococcus species are other
organisms found in patients with EPN.
• Mixed organisms are observed in 10% of patients.
• Rarely, fungi (eg, aspergillus fumigatus, candida species) and
protozoa (entamoeba histolytica) have been isolated in patients
with EPN.
50

Pathology:
• Various factors involved in the pathogenesis of
this condition have been suggested, including
– high levels of glucose within the tissues,
– the presence of gas-forming microorganisms,
– impaired vascular blood supply,
– reduced host immunity,
– the presence of obstruction within the urinary
tract
51

Pathophysiology:
• Urinary tract infections are common in persons with diabetes,
• Factors that predispose to EPN in persons with diabetes may
include uncontrolled diabetes, high levels of glycosylated
hemoglobin and impaired host immune mechanisms.
• High tissue glucose levels- provide the substrate for microorganisms
such as E. Coli, producing carbon dioxide by the fermentation of
sugar
• Diabetic microangiopathy may also contribute to the slow transport
of catabolic products and may lead to accumulation of gas.
52

Risk factors:
53

54

Clinical Presentation:
• Fever (79%)
• Abdominal or flank pain (71%)
• Nausea and vomiting(17%)
• Dyspnea (13%)
• Acute renal impairment (35%)
• Altered sensorium (19%)
• Shock (29%)
• Other possible findings include the following:
– Crepitus, Pneumaturia
– Subcutaneous emphysema and pneumomediastinum
55

Gross examination of emphysematouspyelonephritis:
(a) specimen of enlargedkidney with loss of cortex and medulla with
adherent perirenal fatty tissue (highlighted by arrow),
(b) foci of abscess within parenchyma(highlighted by arrow),
(c) abscess extending towardcapsule (highlighted by arrow)
Gross specimen
56

Diagnosis:
• Laboratory findings include :
– Leukocytosis
– Pyuria
– Infected urine
– Thrombocytopenia
– An elevated creatinine level
– Positive blood culture results
57

• May show mottled gas
within renal fossa or
• Crescentic gas collection
within gerota's fascia.
• Linear gas shadows along
paraspinal region may also
be seen, representing
retroperitoneal air.
X-Ray
58

•May show an enlarged kidney
with coarse echoes within
renal parenchyma or collecting
system
•Dirty echogenic foci with ring-
down artifacts representing air
('dirty shadowing') may also be
seen
USG
59

60

• Acc to Wan et al classification
Type I (dry type) has a 65-70% mortality rate
Type II (wet type) has a 15-20% mortality rate
Although transformation from type I to type II
has been observed following conservative
treatment.
61

Type 1
•Greater than one-third renal
parenchymal destruction
•Streaky or mottled appearance
of gas
•Intra- or Extrarenal fluid
collections are characteristically
absent
•more aggressive and lead to
death shortly, if not intervened
early
•Mortality 70%
CT Image
62

Type 2
•Destruction of less than one-
third of the parenchyma
•Renal or extrarenal collections
associated with bubbly or
loculated gas, or gas within
pelvicalyceal system or ureter
•Mortality 20%
63

64

Risk factors:
• Thrombocytopenia,
• Elevated serum creatinine levels,
• Altered sensorium,
• Shock
65

Antibiotics selection:
• Class 1 – A third-generation cephalosporin, with or without
amikacin, plus percutaneous catheter drainage in patients
with obstructive uropathy
• Class 2, 3, and 4 without risk factors – A third-generation
cephalosporin, with or without amikacin, plus
percutaneous catheter drainage
• Class 2, 3, and 4 with risk factors – Carbapenem with or
without vancomycin plus percutaneous catheter drainage
66

• Indication of Nephrectomy:
– Treatment of choice for most patients
– No access to percutaneous drainage or internal stenting (after
patient is stabilized)
– Gas in the renal parenchyma or "dry-type" EPN
– Possibly bilateral nephrectomy in patients with bilateral EPN
– Class 3 and class 4 EPN: In the presence of more than 2 risk
factors
67

• Factors associated with a poor prognosis in
patients with
– Altered level of consciousness,
– multiple organ failure,
– hyperglycemia, and
– leukocytosis.
68

69

Chronic pyelonephritis
• In patients without underlying renal or urinary tract
disease, chronic pyelonephritis secondary to UTI is a
rare disease and an even more rare cause of chronic
renal failure.
Clinical Presentation.
– There are no symptoms of chronic pyelonephritis until it
produces renal insufficiency, and then the symptoms are
similar to those of any other form of chronic renal failure.
70

Imaging
• IVP
– asymmetry and
irregularity of the
kidney outlines,
– blunting and
dilation of one or
more calyces,
– cortical scars at the
corresponding site
cyst
71

CT scan : cortical scar
& bluted calyces
72

Pathology
• In chronic pyelonephritis, the gross kidney is
often diffusely contracted, scarred, and pitted.
• The scars are Y-shaped, flat, broad-based
depressions with red-brown granular bases.
73

Management :
• Preserved renal function
• Treat infection
74

• XGPN is a rare, severe, chronic renal infection typically
resulting in diffuse renal destruction.
• Most cases are unilateral and result in a nonfunctioning,
enlarged kidney associated with obstructive uropathy
secondary to nephrolithiasis.
• It begins within the pelvis and calyces and subsequently
extends into and destroys renal parenchymal and
adjacent tissues.
• It has been known to imitate almost every other
inflammatory disease of the kidney, as well as renal cell
carcinoma, on radiographic examination. 75

Risk factors:
• Following nephrolithiasis (stag horn) 83%
• Increased risk in diabetics
• Following recurrent UTIs
• Urological instrumentation
• Common in 5th-7th decade
• Common in women
• No predilection for either kidney
76

Nephrolithiasis (stag horn)
I
obstruction
I
stasis
I
infection
I
tissue destruction
I
collection of lipid material by macrophages
I
lipid laden macrophages (xanthoma cell) are distributed in
sheets around parenchymal abscess and calyces and are
intermixed with lymphocytes ,giant cells &plasma cells.
Pathogenesis:
77

Gross specimen:
• (A) Gross specimen. Kidney is
massively enlarged, measuring 23 ×
12 cm; the normal architecture is
replaced by a shaggy yellow upper
pole mass corresponding to
xanthogranulomatous
inflammation and numerous
distorted and dilated calyces.
• (B) Microscopically, the shaggy
yellow tissue is composed primarily
of lipid-laden histiocytes mixed
with other inflammatory cells
78

On section: Macroscopically:
Kidney demonstrate:
• Nephrolithiasis
• Peripelvic fibrosis(comparatively less dilated/contracted
pelvis)
• Calyceal dilatation filled with pus
• Papillary necrosis
• Multiple parenchymal abscess (advanced disease) with
yellowish tissue & pus
• Cortex is thin often replace by Xantho granulomatous tissue
• Capsule is thickened
• Inflammatory extension into peripelvic & parapelvic space is
common
79

MICROSCOPIC EXAMINATION:
• Yellowish nodules line the calyces
and surrounds parenchymal
abscesses
• Contain dark sheets of lipid laden
macrophages (foamy histiocytes
with small dark nucleus & clear
cytoplasm)
• Intermixed lymphocytes, giant
cells and plasma cells
80

Two types
Diffuse : [80%] entire kidney is involved
Segmental :[20%] only the parenchyma
surrounding one or more calyces or one pole of
a duplicated collecting system
Staging
1- within kidney
2- within Gerota’s fascia
3- outside Gerota’s fascia
81

*Flank pain (69%)
*Fever & chills (69%)
*Persistent bacteriuria(46%)
*Flank mass(62%)
*calculi(35%)
Less commonly
*Hypertension
*Hematuria
*Hepatomegaly
*Vague symptoms like malaise
82

Bacteriology & Lab findings:
• Proteus (most common organism involved) association with stone
formation and subsequent c/c obstruction and irritation
• Ecoli(also common)
• Anaerobes
• 10%(mixed infections)
Only 1/3 patients have a positive urine culture
URINE ANALYSIS : Shows pus &protein
BLOOD TESTS: Anemia ,hepatic dysfunction(50%) ,
Azotemia or frank renal failure uncommon( XGN- almost always U/L)
83

CT SCAN :
most useful
Classic triad (50-80%)
-unilateral renal enlargement
-little or no function
-large calculus in renal pelvis
• “ bear claw “ sign
• Massive caliectasis
• stone
84

CT SCAN :
*large reniform mass with renal pelvis tightly surrounding a
central calcification without pelvic dilatation
*Renal parenchyma is replaced by multiple water density
masses representing dilated calyces &abscess cavity
*On enhancement the walls of the cavity demonstrate a
prominent blush owing to vascularity of granulation tissue
*CT is useful to know the extent of renal involvement & also
adjacent organ or abdominal wall.
85

RETROGRADE PYELOGRAPHY:
• point of obstruction
• dilatation of pelvis &calyces
• ulcerated pyelocalyceal system with multiple irregular filling
defect (if extensive parenchymal damage)
USG:
• demonstrate global enlargement of the kidney
• normal architecture is replaced by multiple hypoechoic fluid
filled masses correspond to debris filled ,
• dilated calyces or foci of parenchymal destruction
86

RADIONUCLIDE RENAL SCANNING:
99mTC-DMSA is used
confirm differential function of the involved kidney
MRI :
not yet super seeded to CT
advantage is in delineating extrarenal extension of inflammation
T1 weighted image : appear as cystic foci of intermediate
intensity signal
T2 weighted image : hyperintensity signal
-- All radiological studies although distinctive often cannot
differentiate between XGPN & Renal cell ca
87

Management:
*Primary obstacle to correct treatment is incorrect diagnosis
*with CT scan preoperative diagnosis is 90%
Antimicrobial therapy
*To stabilise the patient preoperatively
*occasionally with initial stages long term antimicrobial therapy
will eradicate infection & restore renal function
Percutaneous drainage -not curative
88

NEPHRECTOMY
*If diagnosed preoperatively for diffuse type nephrectomy
is the treatment of choice
*For segmental involvement partial nephrectomy is
considered
LAPROSCOPIC NEPHRECTOMY
-reasonable , but high conversion rate
-recent approach
89

Renal Parenchymal Malakoplakia
• Greek word meaning “soft plaque,”
• Originally described to affect the bladder but has been found to
affect the genitourinary and gastrointestinal tracts, skin, lungs,
bones, and mesenteric lymph nodes.
• It is an inflammatory granulomatous lesion.
• described originally by Michaelis and Gutmann (1902)
• It was characterized by von Hansemann (1903) as soft, yellow-
brown plaques with lesions in which the histiocytes contain distinct
basophilic lysosomal inclusion bodies or Michaelis-Gutmann bodies.
90

• Malacoplakia probably results from abnormal macrophage
function in response to a bacterial infection, which is most
often due to E. coli.
• It is hypothesized that bacteria or bacterial fragments form
the nidus for the calcium phosphate crystals that laminate the
Michaelis-Gutmann bodies.
91

Pathology
• The diagnosis is made by biopsy.
• Large histiocytes, known as von
Hansemann cells
• small basophilic, extracytoplasmic,or
intracytoplasmic calculospherules
called Michaelis-Gutmann bodies,
which are pathognomonic.
• MG bodies can be absent in early
stage.
92

• Macrophages in malacoplakia contain large amounts of α1-
antitrypsin.
• Therefore immunohistochemical staining for α1- antitrypsin
may be a useful test for an early and accurate differential
diagnosis of malacoplakia.
93

Epidemiology:
• Most patients are older than 50 years.
• Female: male = 4:1
• Malakoplakia rarely presents in patients with HIV
infection and AIDS,which may be because of the preservation
of monocytic antimicrobial function in these patients.
• Increasingly described after solid organ transplantation,
particularly renal transplant recipients
94

Radiologic Findings
Excretory urography
– Enlarged kidneys with multiple filling defects.
– Renal calcification, lithiasis, and hydronephrosis are absent.
Ultrasound
– renal enlargement.
– Confluent masses with increased echogenicity.
Arteriography
– typically reveals a hypovascular mass without peripheral
neovascularity.
95

CT Findings:
• Bilateralor unilateral
• Focal, multifocalor diffuse
• Infiltratingmasses
• ± Renal pelvisinvolvement
• Uncommoncalcifications
• The foci of malacoplakia are less
dense and non enhancing than the
surrounding enhanced parenchyma .
96

Management
• Directed at control of the UTIs with antimicrobial agents
• Sulfonamides, rifampicin, doxycycline and TMP are useful
because of their intracellular bactericidal activity.
• Fluoroquinolones have also proven effective in the
management.
• Ascorbic acid and cholinergic agents such as bethanechol in
conjunction with antimicrobial therapy have reported good
results[cGMP] . 97

• If the disease progresses in spite of antimicrobial treatment-
then plan for Nephrectomy.
• When parenchymal renal malacoplakia is bilateral or occurs in
the transplanted kidney, death usually occurs within 6
months.
• Patients with unilateral disease usually have a long-term
survival after nephrectomy.
98

Thank you…
99

UPPER URINARY TRACT INFECTION

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UPPER URINARY TRACT INFECTION