urinary tract infection for B.sC STUDENTS

1. URINARY TRACT INFECTION
DEFINITION
An urinary tract infection is an infection in any part of the urinary tract involving
the kidneys, ureters, bladder or urethra. These are the structures that urine passes
through before being eliminated from the body.
INCIDENCE
 UTI is 50 times more common in women
 5%per year developing symptoms
 2019- > 404.6 million individuals had
- UTIs globally
- 2,36,786 people died of UTIs
- UTI is uncommon in men below 60 years of age.

2. ETIOLOGICAL FACTORS
COMMON MICROORGANISMS CAUSING UTIs
Escherichia coli
Enterococcus
Klebsiella
Enterobacter
Proteus
Pseudomous
Staphylococcus
Serratia
Candida albicans

3. PREDISPOSING FACTORS
FACTORS INCREASING URINARY STASIS
 Intrinsic obstruction
 Extrinsic obstruction
 Urinary retention
 Renal impairment
FOREIGN BODIES
 Urinary tract calculi
 Catheters
 Urinary tract instrumentation.

4. ANATOMIC FACTORS
Congenital defects leading to obstruction
Fistula exposing urinary stream to skin, vagina, or fecal
stream
Shorter female urethra
Obesity
FACTORS COMPROMISING IMMUNE RESPONSE
 Aging
 HIV infection
 Diabetes mellitus
FUNCTIONAL DISORDER
 Constipation
 Voiding dysfunction

5. OTHER FACTORS
 Pregnancy
 Hypo oestrogenic state
 Multiple sex partners
 Use of spermicidal agents or contraceptive diaphragm
 Poor personal hygiene
CAUSES OF UTI
 Lack of water intake
 Holding your pee
 Improper hygiene
 Feminine products
 Diabetes
 Kidney stones
 Frequent sex
 Use of birth control 1 methods

7. CLASSIFICATION OF UTI
BASED ON LOCATION
UPPER UTI
Acute pyelonephritis
Chronic pyelonephritis
Interstitial pyelonephritis
Renal abscess
Perirenal abscess
LOWER UTI
Cystitis
Prostatitis
urethritis

8. BASED ON PATIENT CHARACTERISTICS
UNCOMPLICATED UTI
This refers to UTIs occurring in healthy individual with
structurally and functionally normal urinary tracts uncomplicated UTIs
usually respond well to treatment and do not have complicating factors.
COMPLICATED UTI
This UTI occur in individual with underlying health conditions
that increase the risk of infection or more treatment more challenges.
E.g UTI in pregnant women, individual with UTI having diabetes
RECURRENT UTI
Recurrent UTI are defined as multiple UTIs occurring within a
specific time period(2 or more infections in 6 months or 3 or more in 1
year). It requires further evaluation to identify underlying risk factors.

9. BACTERIAURIA ASYMPTOMATIC
Asymptomatic bacteriuria refers to the presence of bacteria in
the urine without causing any symptoms common in pregnant
women and elderly individuals.
HOSPITALACQUIRED UTI ( HAUTI)
HAUTI are UTI that develop in patients during their hospital
stay and can be associated with the use of urinary catheters or
other health care associated factors.

10. PATHOPHYSIOLOGY
COLONISATION
Colonization of microbes at peripheral area and ascends through the urethra
upwards to the bladder.
UROEPITHELIUM PENETRATION
Microbial epithelial cell attachment and penetration with the help of fimbriae
ASCENSION
Ascending of microbes towards kidney after colonization
PYELONEPHRITIS
Infection of renal parenchyma and inflammatory responses
ACUTE KIDNEY INJURY
If the inflammatory cascade continues leads to tubular obstruction,
interstitial edema and acute injury.

13. CLINICAL MANIFESTATION
LOWER UTI
 Increased frequency of urination
 Dysuria
 Urgency
 Hematuria
UPPER UTI
 Increased frequency of urination
 Dysuria
 Urgency
 Hematuria
 Fever
 Malaise
 Loin pain
 Rigor

14. ELDERS
Increased frequency of urination
Dysuria
Incontinence
Hesitance
OTHERS
Cloudy and foul smelling urine
Suprapubic pain

15. COMPLICATIONS
Recurrent UTIs
Pyelonephritis
Kidney abscess
Prostatic abscess
Sepsis
Cystitis
Chromic kidney disease
Pregnancy complications
Renal papillary necrosis
Abscess formation

16. DIAGNOSTIC EVALUATION
History collection-voiding pattern, history of fever
Physical examination – clinical manifestation
Urine routine examination
Urine culture and sensitivity – to find out the type of organism
Imaging studies of the urinary tract are indicated in selected cases
- cystoscopy
- CT/ MRI
- ultrasonography

18. LABORATORY FINDINGS
NORMAL FINDINGS ABNORMAL FINDINGS
PH – 4.6 - 8.0 PH- Alkaline
Appearance - clear cloudy
Color – pale to amber yellow Deep amber
Odor - aromatic Foul smelling
Leukocyte esterase - none present
WBC - Absent present
Bacteria - absent present

19. URINALYSIS
Presence of Pus, white blood cell, red blood cells.
Bacterial count > 10 power of 5 /ml - significant bacteriuria
Leukocyte esterase- Dispsick test – WBC in urine
Nitrite dipstick test - pink
MANGEMENT
UTI – MANGEMENT
SYMPTOMATIC UTI – Anti biotic therapy
Asymptomatic UTI – no treatment required except in special
situations

21. DRUGS USED IN TREATMENT OF UTI
Inj. Amoxicillin
Inj. Co- amoxiclav
Inj. cefalexin
Inj. cefuroxime
Inj. trimethoprim
Inj. Nitrofurantoin
Inj. gentamycin
Inj. ciprofloxacin
Inj. meropenem
Inj. Pipercillin+tazobactum

22. NONPHARMACOLOGICALTREATMENT
Drink plenty of water
Clean external genitalia after urination
Change catheter for every 2 weeks
Empty the bladder when it is filled and do not stop to urinate
when it is filled.

23. DOES
 Go to the toilet as soon as possible the feel of urge
 Always empty your bladder fully
 Stay well hydrated
 Wipe your bottom from front to back when you go to the toilet
 Void urine as soon as possible after having sex
 Wear underwear made from cotton rather than synthetic material such
as nylon
 Avoid tight jeans and trousers.
DON'T
• Do not use perfumed bubble bath soap or talcum powder around your
genitals
• Do not use a diaphragm or condoms with spermicidal lubricant on them
– try another type of contraception.

24. ACUTE PYELO NEPHRITIS
DEFINITION
Pyelonephritis is an inflammation of the renal parenchyma
and collecting system( including the renal pelvis). The most
common cause is bacterial infection but fungi, protozoa or
viruses sometimes infect the kidney .
Pyelonephritis may be acute or chronic. Acute pyelonephritis
is usually manifested by enlarged kidneys with interstitial
infiltration of inflammatory cells.

26. INCIDENCE
Annual incidence- 4,59,000to 11,38,000cases in US
10.5 million to 25.9 million cases globally
India
Male-2-3 cases/10,000 population
Female3-4 cases /10,000 population.

27. Etiological factors
Backward flow of infected urine from the bladder to the upper
urinary tract.
Kidney stones.
Urinary tract catheterization.
Pregnancy.
Neurogenic bladder .
Benign prostatic hyperplasia .
Diabetes mellitus.

28. RISK FACTORS
Female -shorter urethra.
Male- uncircumcised infant.
Catheterization -bacteria carried directly into the bladder
during insertion.
Urine out flow obstruction.
Loss of neurological control.
Diabetes mellitus.

29. PATHOPHYSIOLOGY
Bacterial entry ascension
Adherence and invasion
Inflammatory response
Renal tissue inflammation
Cytokine release
Functional impairment
Vasodilation and increased blood flow
Abscess formation

30. CLINICAL MANIFESTATIONS
 Fever with chills
 leukocytosis
 Bacteriuria
 Pyuria
 Low back pain
 Flank pain
 Nausea and vomiting
 Headache
 Malaise
 Dysuria
 Pain and tenderness over Costo -vertebral angle

32. DIAGNOSTIC EVALUATION
 History collection
 physical examination -costal vertebral pain and tenderness
 Laboratory
 Urine analysis
 Urine for culture and sensitivity
 Radiological
 Ultrasound to detect hydronephrosis
 IV pyelogram is rarely indicated
 Radio nucleotide imaging with gallium citrate and Indium 111

33. MANAGEMENT
Medical management.
 Broad-spectrumantibiotic[ampicillin, vancomycin]
combined witan aminoglycosides[tobramycin]
 Switch to sensitivity-guided therapy.
 2 week course of antibiotics, recommended.
Adequate fluid intake
Non-steroidal anti inflammatory drugs
Analgesics
Follow up care.
Severe Symptoms
-Hospitalization along with above said measures.

34. CHRONIC PYELO NEPHRITIS
DEFINITION
Chronic pyelonephritis is a term used to describe a kidney
that has become small, atrophic, shrunken and has lost
function owing to scaring or fibrosis.
Repeated bouts of acute pyelonephritis leads to chronic
pyelonephritis.
Alternative terms:
Interstitial nephritis
Chronic atrophic pyelonephritis
Reflux nephropathy.

35. DISORDERS OF THE URETER
URETERAL ATRESIA
The ureter may be absent entirely, or it may end blindly after
extending only part of the way to the flank.
These anomalies are caused during embryologic development by
failure of the ureteral bud to form the mesonephric dust or by an
arrest in its development before it comes in contact with the
metanephric blastema
The genetic determinants of ureteral bud development and the
causes of bud abnormalities' are being eluminated and it is known
that GDNF signaling via the RET receptor is generally required
The end result of an atretic ureteral blood is an absent or
multicystic dysplastic kidney.

37. ECTOPIC URETER
An ectopic ureter is one that opens in some location
other than the bladder
80% associated with duplicate system
20% associated with single system
Most common sites – ureter, vestibule and vagina
In female present as urinary incontinence
Most common sites(in male) : posterior urethra and
seminal vesicles

39. DUPLEX URETER
Duplication of the ureter and the renal pelvis is a common
anomaly with an incidence of about 1 in 150 births
Unilateral duplication is 6 times more frequent than bilateral
It is more common in girls if duplicated has been detected in a
patient the likelihood of another sibling with duplication rises to 1
in 8

41. MEGA URETER
Isolated dilation of the ureter does not necessarily imply obstruction
There are three broad groups of conditions with widely dilated
ureters, as follows
1. Obstruction of the ureter itself this may be intrinsic (e.g stone) or
extrinsic (e.g retroperitoneal fibrosis) it is not associated with reflux
2. Bladder outflow obstruction with secondary ureteral obstruction.
E.g includes a neuropathic bladder, and posterior urethral values
this may or may not be associated with reflux.
3. A dilated but non obstructed ureter this often occurs without reflux
and there can be normal renal function this may be caused by an
adynamic segment of the lower ureter.

43. CANCER OF BLADDER
DEFINITION
CA bladder typically refers to "Carcinoma of the
Bladder," which is a medical term used to describe cancer that
develops in the tissues of the bladder. The bladder is a hollow
organ in the pelvis that stores urine before it is eliminated from
the body. Carcinoma is a type of cancer that originates in the
epithelial cells, which are the cells that line the internal and
external surfaces of the body.

44. INCIDENCE
According to global cancer statistics from the International Agency
for Research on Cancer (IARC) for the year 2020:
 Bladder cancer was the 10th most common cancer worldwide,
accounting for approximately 3.3% of all new cancer cases.
The age-standardized incidence rate of bladder cancer was
estimated to be around 9.4 cases per 100,000 population.
The incidence rates tend to be higher in more developed regions
compared to less developed regions.
More common in 50-70years of age
Males are affected more than females.

46. ETIOLOGY
1. Tobacco Use: Smoking is one of the most significant risk factors for
bladder cancer. Chemicals in tobacco smoke are absorbed into the
bloodstream and excreted in the urine, which can lead to direct contact
with the bladder lining and increase the risk of cancer.
2. Exposure to Chemicals: Occupational exposure to certain chemicals
and substances, such as aromatic amines (found in certain dyes,
rubber, and chemical manufacturing), can increase the risk of bladder
cancer. Workers in industries like dye, rubber, leather, and chemical
manufacturing may be at higher risk.
3. Age and Gender: Bladder cancer is more common in older
individuals. Men are more likely to develop bladder cancer than
women.
4. Chronic Bladder Inflammation: Chronic urinary tract infections or
inflammation of the bladder, such as those resulting from long-term
use of urinary catheters or recurrent infections, may increase the risk
of bladder cancer.

47. CONT..
5.Genetic Factors: Family history of bladder cancer may increase
the risk, suggesting a genetic component. However, specific
genetic mutations associated with bladder cancer risk have not
been fully elucidated.
6.Previous Cancer Treatment: Certain cancer treatments, such as
radiation therapy and certain chemotherapy drugs, may increase
the risk of bladder cancer.
7.Personal or Family History: Individuals who have a personal
history of bladder cancer or a family history of the disease may be
at a higher risk.

48. CONT..
8.Diet: Some research suggests that a diet high in fried
foods, processed meats, and low in fruits and vegetables may
be associated with an increased risk of bladder cancer.
9.Arsenic Exposure: In regions where drinking water
contains high levels of arsenic, there may be an elevated risk
of bladder cancer.
10.Cyclophosphamide Use: Long-term use of the
medication cyclophosphamide, often used for treating certain
medical conditions, has been linked to an increased risk of
bladder cancer.

49. RISK FACTORS
Cigarette smoking
Exposure to environmental carcinogens(dye,rubber,leather
etc)
Recurrent UTI
Bladder stones
High urinary PH
High cholesterol intake
Pelvic radiation therapy
Cancers arising from prostate,colon,and rectum in males

50. TYPES
Bladder cancer can be categorized into several types based on the
specific type of cells where the cancer originates. The most common
types of bladder cancer are:
Transitional Cell Carcinoma (TCC):
Also known as urothelial carcinoma, this is the most prevalent
type of bladder cancer, accounting for the majority of cases. It
originates in the urothelial cells that line the inner surface of the
bladder. TCC can also occur in the renal pelvis (part of the kidney),
ureters, and urethra.
Squamous Cell Carcinoma:
This type of bladder cancer develops from the thin, flat
squamous cells that may form due to chronic irritation or infection of
the bladder. It is more common in regions where chronic infections
or schistosomiasis (a parasitic infection) are prevalent.

51. Adenocarcinoma: Adenocarcinoma of the bladder is a rarer form
of bladder cancer that originates in the glandular cells that produce
mucus and other fluids. It can develop from urachal remnants
(structures in fetal development) or from metaplasia (changes in
cell type) of urothelial cells.
Small Cell Carcinoma: This is a highly aggressive and rare type
of bladder cancer that originates from neuroendocrine cells. It
tends to grow quickly and may require aggressive treatment.
Sarcomatoid Carcinoma: Another aggressive variant, this type
of bladder cancer contains both malignant epithelial cells and
sarcoma-like components. It is also relatively rare.
Micropapillary Carcinoma: This is a less common but
aggressive subtype of urothelial carcinoma characterized by
distinct papillary structures.

52. STAGES OF CANCER
The TNM system is used for staging and stands for:
• Tumor (T): Describes the size and extent of the primary
tumor.
• Lymph Nodes (N): Indicates whether nearby lymph nodes
are involved and the extent of involvement.
• Metastasis (M): Specifies whether the cancer has spread to
distant parts of the body.

53. Stages for bladder
CANCER
• Stage 0 (CIS): Carcinoma in situ, where cancerous cells are
present only in the innermost lining of the bladder.
• Stage I: Cancer has invaded the connective tissue layer beneath
the bladder lining.
• Stage II: Cancer has invaded the muscle layer of the bladder
wall.
• Stage III: Cancer has spread to nearby tissues, such as the
prostate, uterus, or vagina (locally advanced disease).
• Stage IV: Cancer has spread beyond the bladder to distant
organs or lymph nodes (metastatic disease).

54. TNM CLASSIFICATION
Tumor (T) Classification:
• Ta: Non-invasive papillary carcinoma
• Tis: Carcinoma in situ (CIS), involving only the innermost lining of the
bladder
• T1: Tumor invades the connective tissue beneath the bladder lining but
not the muscle layer
• T2:
• T2a: Tumor invades the superficial muscle layer (inner half)
• T2b: Tumor invades the deep muscle layer (outer half)
• T3:
• T3a: Tumor invades the fatty tissue surrounding the bladder
• T3b: Tumor invades the prostate (in males) or the uterus or vagina (in
females)
• T4: Tumor invades adjacent structures, such as the pelvic wall,
abdominal wall, or abdominal organs

55. Lymph Nodes (N) Classification:
• Nx: Regional lymph nodes cannot be assessed
• N0: No regional lymph node involvement
• N1: Cancer has spread to a single regional lymph node
• N2: Cancer has spread to two or more regional lymph
nodes
• N3: Cancer has spread to distant lymph nodes
Metastasis (M) Classification:
• M0: No distant metastasis
• M1: Distant metastasis is present

58. Stage Grouping
 Once the T, N, and M categories are determined, they are combined to
assign an overall stage group:
• Stage 0 (CIS): Tis, N0, M0
• Stage I: T1, N0, M0
• Stage II: T2a, T2b, N0, M0
• Stage III:
• IIIa: T3a, N0, M0
• IIIb: T3b, T4a, N0, M0
• Stage IV:
• IVa: T4b, N0, M0
• IVb: Any T, N1-N3, M0
• IVc: Any T, any N, M1

59. PATHOPHYSIOLOGY
Exposure of the bladder wall to a carcinogen
Bladder wall irritation
Pre malignant changes start from the transitional layer
These changes are called as cell dysplasia
Formation of warts like growth in the wall

60. CONT…
Formation of locally invasive carcinoma in situ penetrates
the submucosal and mucosal layer of the bladder forming
deep invasive cancer
Progress to adjacent structures
Distant metastasis to liver,bone,through lymphnodes and
blood

62. CLINICAL MANIFESTATIONS
Haematuria
Urinary symptoms
-Frequency of urine
-Urgency of urination
-Pain during urination
-burning sensation
Pain
Pelvic mass/ swelling

63. Advanced symptoms
 Weight loss
 Fatigue
 Bone pain
 Swelling in legs
 Anemia

64. DIAGNOSTIC EVALUATION
Medical History and Physical Examination:
1.Medical history- including any symptoms experiencing and
risk factors like smoking or chemical exposures.
2.A physical examination - to assess your overall health and
check for any signs of bladder or urinary tract issues.
Urinalysis and Urine Cytology:
1.A urinalysis - blood, abnormal cells, or other substances in the
urine.
2.Urine cytology involves examining urine samples under a
microscope to look for cancer cells.

66. Imaging studies
Ultrasound:
This non-invasive imaging method uses sound waves to create images
of the bladder and surrounding structures.
CT Scan (Computed Tomography):
A CT scan provides detailed cross-sectional images of the abdomen
and pelvis, helping visualize the extent of the cancer and potential spread.
MRI (Magnetic Resonance Imaging):
MRI can provide additional information about tumor size, location,
and involvement of nearby structures.
Cystoscopy:
A thin, flexible tube with a camera (cystoscope) is inserted through
the urethra to directly visualize the bladder lining. Biopsies can also be taken
during cystoscopy.

67. Biopsy and Pathology:
During cystoscopy, small tissue samples (biopsies) can
be taken from any suspicious areas for examination
under a microscope (pathology). This helps determine
the type and grade of the cancer.
Transurethral Resection of Bladder Tumor (TURBT):
In cases of suspected non-invasive bladder cancer, a
TURBT procedure may be performed during
cystoscopy. It involves removing the tumor and some
surrounding tissue for examination.

68. Additional Tests:
If invasive or advanced bladder cancer is suspected,
additional tests like bone scans or PET scans may be done
to assess if the cancer has spread to other parts of the body.

69. MEDICAL MANAGEMENT
Intravesical Therapy:
1.BCG (Bacillus Calmette-Guérin): BCG is a weakened
form of the tuberculosis bacteria. It is instilled directly into
the bladder after transurethral resection of bladder tumor
(TURBT) for non-muscle invasive bladder cancer
(NMIBC). BCG stimulates the immune system to attack
and destroy cancer cells.
2.Chemotherapy Agents: Intravesical chemotherapy drugs
(such as mitomycin C, epirubicin, or gemcitabine) are
placed directly into the bladder to kill or slow the growth
of cancer cells. They are often used after TURBT to reduce
the risk of cancer recurrence.

70. Systemic Chemotherapy:
Chemotherapy drugs can be given intravenously to target cancer
cells throughout the body. Systemic chemotherapy may be used
for muscle invasive bladder cancer (MIBC) that has spread
beyond the bladder or for advanced/metastatic bladder cancer.
Common chemotherapy regimens include cisplatin-based
combinations (such as MVAC: methotrexate, vinblastine,
doxorubicin, and cisplatin) or gemcitabine and cisplatin (GC).
Immunotherapy (Checkpoint Inhibitors):
1.Immune checkpoint inhibitors, such as pembrolizumab
(Keytruda) and atezolizumab (Tecentriq), help the immune
system recognize and attack cancer cells. They are used for
advanced or metastatic bladder cancer that has progressed after
chemotherapy.

71. Targeted Therapy:
Erdafitinib (Balversa): This targeted therapy is approved for
advanced bladder cancer with specific genetic alterations
(FGFR3 or FGFR2 mutations).
Enfortumab Vedotin (Padcev): A targeted drug for advanced
bladder cancer that targets Nectin-4 protein on cancer cells.
Palliative Care:
Palliative care focuses on managing symptoms and
improving the quality of life for patients with advanced or
metastatic bladder cancer. Medications may be used to alleviate
pain, manage side effects, and address other symptoms.

72. SURGICAL MANAGEMENT
Transurethral Resection of Bladder Tumor (TURBT):
TURBT is often the initial step in diagnosing and treating
non-muscle invasive bladder cancer (NMIBC).
Radical Cystectomy:
Radical cystectomy is the surgical removal of the entire
bladder and nearby lymph nodes. It is the standard treatment for
muscle-invasive bladder cancer (MIBC) or high-risk NMIBC that
doesn't respond to other therapies.

73. Partial Cystectomy:
In select cases, a portion of the bladder containing the tumor may
be removed while preserving the rest of the bladder. This approach is less
common and is usually reserved for tumors in specific locations.
Robotic or Laparoscopic Surgery:
Minimally invasive techniques, such as robotic-assisted or
laparoscopic surgery, may be used for some cystectomy procedures.
These methods involve smaller incisions, which can lead to shorter
hospital stays and quicker recovery times.
Lymph Node Dissection:
During radical cystectomy, nearby lymph nodes may be removed
and examined for cancer spread.

74. Urinary diversion procedures are performed to create new
ways for urine to exit the body. Common methods include:
Ileal Conduit: A piece of the small intestine is used to create
a conduit for urine to pass from the ureters to an opening
(stoma) on the abdomen. A bag is attached to collect urine.
Neobladder: A new bladder reservoir is created from a
segment of the intestine and connected to the urethra,
allowing for more natural urination.
Continent Urinary Diversion: A pouch is constructed
internally to collect urine. The patient catheterizes the
pouch to empty it.

75. RADIATION THERAPY
External Beam Radiation Therapy (EBRT):
In EBRT, a machine called a linear accelerator delivers
focused radiation beams from outside the body to the tumor and
surrounding areas.
Internal Radiation Therapy (Brachytherapy):
Brachytherapy involves placing a radioactive source directly
into or near the tumor.
Combined Therapy:
Radiation therapy can be combined with chemotherapy
(chemoradiation) to enhance the effectiveness of treatment.
Chemotherapy can make cancer cells more sensitive to radiation.