Urology infection [Dr. Edmond Wong]

Urology infectionUrology infection
Edmond Wong

Outline
• Definition
• Bacteriology
• Cystitis & urethritis
• Recurrent UTI
• Pyelonephritis, EPN & XGP
• General principles of antibiotic and prophylaxis
• Mx of septicaemia
• TB urinary tract
• Prostatitis
• Epididymal orchitis
• Viral disease of Genital tract (condylomata, AIDS, Herpes)
• Schistosomiasis
• Radiation cystitis
• Chemical cystitis and mx
• Antibiotic prophylaxis in uro procedure

Definition
• Bacteriuria: Presence of bacteria in urine
• Pyuria: presence of WBC in urine
• Sterile Pyuria: Pyuria without bacteriuria
1. Incomplete antimicrobial treatment of UTI
2. Infections caused by Mycobacterium tuberculosis
and other fastidious bacteria, e.g. Chlamydia
trachomatis
3. Urolithiasis and foreign bodies
4. CIS
5. Interstitial cystitis
6. schistosomiasis

Definition
• Cystitis:
– Clinical syndrome of dysuria, frequency & urgency +/-
Bladder pain
• Acute pyelonephritis:
– Syndrome of Fever, Chills & rigor, flank pain ,
bacteriuria + pyuria
• Chronic pyelonephritis:
– Radiological diagnosis
– Scarred , shrunkened kidney (may or maynot result
from recurrence infection)

What is the definition of UTI?
• UTI – Inflammatory response of
urothelium to microorganism invasion,
commonly bacteria , associated with
pyuria and bacteriuria
• Opportunistic infection : infection caused
by non-pathogens (commensals) due to
weakened host defence mechanisms

Definition of UTI
• Isolated UTI:
– Occur at least 6m after the previous UTI
• Recurrent UTI : >=2 UTI in 6m / >=3 UTIs in 1yr
– Bacterial persistence: UTI by same organism
• Nidus (stone, bladder/urethral diverticulum, chronic
prostatitis, colo-vesical fistula)
– Reinfection: by different organisms each time
• Increased susceptibility to UTI, e.g. poor hygiene, sexual
intercourse, post menopause
• > 95% female recurrent UTI is reinfection

Definitions of UTI
• Unresolved infection: not response to txn
1. Bacterial resistence to antibiotic
2. Development of resistance in a previously
susceptible organism
3. Multiple organism
4. Rapid re-infection & overwhelming pathogens
5. Subtherapeutic level of antimicrobial
6. Non-compliance with treatment

Definition of UTI:
• Complicated UTI
– Structurally and functionally abnormal urinary tract
– Underlying disease prone to complicated UTI
1. Male gender , elderly
2. Pregnancy
3. Catheter or stent or instrumentation
4. immunocompromised, DM, hospital acquired infection
• uncomplicated UTI
– No structurally and functionally abnormal urinary
tract
– No underlying disease prone to acquire UTI

How does the urinary dipstick –How does the urinary dipstick –
(blood) work?(blood) work?
• Chromogen indicator : orthotolidine is a peroxidase substrate
• Haemoglobin has peroxidase activity
• Oxidation process take place
• Positive result : BLUE
• False positive (oxidasing agent):
1. Povidone iodine
2. Hypochlorite (bleach)
3. Menstrual blood
4. Dehydration, exercise and myoglobin
• False negative (reducing agent):
– Vitamin C
– Poorly mixed urine
• Dipstick positive but microscopy negative – dilute urine

(WBC) work?(WBC) work?
• Neutrophils produce leucocyte esterase
• Catalyzes the hydrolysis of a indoxyl carbonic acid ester
to indoxyl
• Idoxyl oxidise the diazonium salt chromogen to produce
blue colour
• False positive : vaginal discharge or formalin
• False negative (reducing agent)
1. Vitamin C
2. Dehydration
3. Glycosuria, urobilinogen
4. Test is read too fast (< 2min) or too long (lysis of WBC)
• 30% of infection with negative leucocyte esterase ( =
70% sensitivity)

(nitrites) work?(nitrites) work?
• Gram negative bacteria convert nitrates to nitrites (not usually in
urine)
• Nitrite react with the aromatic amine to form diazonium salt
• Which react with hydroxybenzoquinolone to form pink colour
(Griess reaction) – 4 hours processing
• High specificity but low sensitivity – means +ve  UTI, negative
cannot rule out UTI
• When negative for both nitrites and leukocytes 90% of MSU will
be negative for significant bacteriuria
• When positive for both nitrites and leucocytes, 80% will have
positive cultures on MSU
– More specific but less sensitive to either test alone
• False positive – contamination
• False negative – gram positive bacteria, pseudomonas, ascorbic
acid, and dilute urine, urine in bladder < 4 hours (so only early
morning urine is reliable)

Why is urine pH important?
• Normal urinary pH: 5.5- 6.5
• pH> 7.5  possibility of stone
• Urea splitting organism produce urease: (PKS, PPS)
1. Proteus
2. Klebsiella
3. Staphylococcus
4. Pseudomonas
5. Providencia
6. Serratia
• Induce following reaction:
– Urea  CO2 + NH3 (ammonia)
– NH3 raise pH
– Precipitation of magnesium ammonium phosphate to form
staghorn stone

What are the definitions of
significant bacteriuria?
• Kass first introduced quantitative microbiology in
diagnosis UTI
– Significant bacteriuria ≥ 105
cfu/mL of pure growth
– However, miss 1/3 symptomatic UTI with growth ≥ 103
cfu/mLof pure growth
• > 103
: uncomplicated cystitis in women
• > 104
: uncomplicated pyelonephrisitis in women,
catheter urine in women, men
• Asymptomatic bacteriuria should be treated in children,
pregnant female and immunocompromized patents, prior
to an invasive genitourinary procedure for which there is
a risk of mucosal bleeding, but not DM or elderly patient
(Canada’s study)

What is the implication of
bacteriuria?
• A single in/out uretheral catheterization may be
complicated by bacteriuria in 5% of cases
• Bacteriuria is almost universal when the catheter
is left in situ for longer than 3 days
• 10-20% of patients with pyelonephritis have
bacteriuria
• Bacteriuria without pyuria may be found
– bacterial contamination
– Colonization (asymptomatic bacteriuria)
• Absence of pyuria may cause doubt on the
diagnosis of UTI

Risk factor for bacteriuria
1. Female
2. Low oestrogen state (menopause)
3. Pregnancy
4. Age
5. Institutional state in elderly
6. Indwelling catheters
7. Previous UTI
8. DM
9. Stone disease
10.GU malformation & voiding dysfunction (including
obstruction)

How would you instruct the pt for
MSU?
• Women:
– Spread the labia
– Wash and cleanse the periurethral area with moist gauze from back to
front
– Void first 100-150ml , collect next 10-15ml
• Men:
– Circumcised: no special preparation
– Uncircumcised:
• Retract foreskin , wash glans with soap and rinse with water
• Keep foreskin retracted: collect 10-15ml
• Handling of MSU:
– Culture with hours or refrigerated immediately & culture within 24hr
– Microscopy: 5-10ml urine centrifuge for 5min (2000rpm)
– Culture: 0.1ml urine of split-agar plate
• Blood agar  gram +ve culture
• Eosinmethylene blue (EMB)  gram –ve culture
• Estimate CFU after overnight incubation

What is the gram’s stain?
• Bacterial smear is stained with crystal violet for 1-
2min then pour off
• Then Gram’s iodine for 1-2min then pour off
• Decolorized by acetone
• Washed with water and counterstained with safranin
for 2 mins
• Gram +ve: cell wall that retain the crystal violet dye
– MRSA is a gram +ve coccus. It is present on the skin
of about 40% of people. Over 90% of isolates produce
the penicillin binding protein which makes the strain
resistant to penicillin base antibiotics
• G-ve – pink safranin

Why patient will have UTI?
• An interaction of susceptibility of host &
virulence of organism
• Pathogenicity: ability of an organsim to
cause disease
• Virulence: degree of pathogenicity
– Characteristics of uropathogens to colonised
and flourish within the host

Bacterial virulence factors?
• Directed against external agents (i.e
antimicrobial resistence)
– Inherited chromosomally (intrinsic resistance of
proteus to nitrofurnatoin)
• Enzyme inactivation: beta-lactamase which hydrolyses the
beta-lactam bone within penicillin gp of antibiotic
• Secrete by S. aureus , gonorrhoea & enterobacteria
– Acquired chromosomally (mutations)
• Alter the antibiotic target & receptor activity
– Acquire extra-chromosomally (plasmids)

Direct against host:
1. General: extracellular capsule prevent phagocytosis (E coli)
2. Toxin, e.g. haemolysin
3. Enzyme, e.g. urease
4. Antihumoral factors, e.g. IgA inactiviting protein by gonorrhoea and
Proteus
5. Adherence mechanism – afimbrial or fimbrial types (E.coli)
– Afimbrial adhesin – Dr adhesins (UTI in children and pregnancy)
– Fimbriase: 100 pili, 5nm diameter , 2um long
– Type P fimbriae (mannose resistant) have adhesions that bind to renal
urothelium and are associated with >90% of pyelonephritis
– Type P fimbriae are more virulent and more adhesive than type 1 fimbriae
– Type 1 fimbriae (mannose sensitive) binds to elements of bladder urothelium
and are associated with cystitis
– Type 1 fimbriae are also referred to as mannose sensitive. This means that
fimbriae have the ability to adhere to and agglutinate guinea pig erythrocytes.
Such an event is inhibited by mannose
– S pili – both bladder and kidney infection
6. Others
– Penetration of host by schistosoma apine
– Intrinsic resistance of Proteus to nitrofurantoin

What are normal host defence
mechanisms against UTI?
1. Normal commersal flora of vaginal introitus and periurethral
area
– Lactobacilli reduced uropathogens to colonise by lowering pH
as a result of converting glycogen to lactic acid (lower pH)
2. Vaginal oestrogen and IgA
3. Normal antegrade flow of urine
4. Characteristic of urine (high osmolality, low pH, Urea , etc)
5. Mechnical integrity of mucous membrane
6. Normal exfoliation of urothelial cells
7. Tamm-horsfall protein by ascending limb of loop of Henle –
bind type 1 pili & prevent attachment
8. GAG (Glycosiaminoglycan) layer

Route of infection
• Ascending infection (majority)
– Bacteria colonize perineum, vagina & distal urethra
– Ascend to bladder (cystitis)
– Ascend to kidney (pyelonephritis), encourage by
reflux
• Hematogenous (uncommon):
– Staph aureus, candida, fungaemia & TB
• Via lymphatics:
– Inflammatory bowel disease
– Retroperitoneal abscess

Anbitiotic Formulary
• TMP-SMX—inhibits dihydrofolic acid reductase
– Enterococcus and Pseudomonas are resistant
• Nitrofurantoin—mechanism unknown
– Pseudomonas and Proteus resistant, not useful in upper tract infections,
development of resistance very low
• Cephalosporins—1st
to 3rd
generation increases Gram negative and
anaerobic coverage
• Aminopenicillins—effective enterococcus, 30% resistance
development in common uropathogen isolates.
• Aminoglycoside—combined with ampicillin 1st
line therapy for
urosepsis, nephrotoxic
• Flouroquinolone—DNA gyrase inhibitor, enterococcus resistant,
damages cartilage in animal studies

Uncomplicated Cystitis
• Absence of physiologic or anatomic
abnormalities & no recent urologic surgery
• 30% of women between age 20-40 have had a
UTI
– 80% E. coli
– 15% S. Saprophyticus
• Rarely occurs in men
– Uncircumcised
– HIV

• Microscopic analysis
is more sensitive than
dip-stick testing
– Bacteriuria
– Pyuria
– Hematuria
Symptoms:
– Dysuria, frequency,
urgency, small urine
volumes, suprapubic
pain
• Differential Diagnosis:
– Vaginitis
– Urethral infection /
urethritis
– STD

• Pretherapy urine Cx
only for the following:
– Dx in doubt
– Symptoms longer than
7 days
– Older than age 65
– DM
– Pregnancy
– All males
• Treatment (3-days):
– TMP-SMX
– TMP alone
– Nitrofurantoin
– Fluoroquinolones (use
for patients with allergy to
less costly drugs or with
high risk of infection with
resistant organism)
– Amoxicillin-
Clavulanate during
pregnancy

Urethritis
• Inflammation of urethra
• Men: STD with dysuria + urethral discharge
• Gonococcal urethritis (GU)
– gram-negative diplococcus Neisseria gonorrhoea (incubation 10 day)
– concomitant infection with Chlamydia trachomatis
– Investigation: urethral swab for C/ST
– Treatment:
• ceftriaxone 125 mg IM in a single dose
• cefixime 400 mg orally in a single dose
• plus treatment for chlamydia
• Quionolone is not recommended
• Non gonococcal urethritis (NGU)
– Chlamydia trachomatis (incubation 1–5 weeks)
– Azithromycin, 1 g as a single oral dose
– Doxycycline, 100 mg orally twice a day for 7 days
– Transmission to females results in increased risk of pelvic inflammatory
disease, abdominal pain, ectopic pregnancy, infertility, and perinatal
infection

• Gonococci located intracellularly as Gram-
negative diplococci
• Ciprofloxacin (gonococci) and doxycycline
(chlamydial) for 2 weeks if young
epididymoorchitis
• Fluoroquinolones are contraindicated in
adolescents (< 18 years) and pregnant women

Recurrent UTI inRecurrent UTI in
femalefemale

Female refer for recurrent UTI ,
what is your approach?
• History:
– Age
– Isolated or recurrent UTI?
– Trace all previous MSU result
– Re-infection or persistence?
– Number of confirmed UTI in
one year
– Cystitis or pyelonephritis?
– Complicated or uncomplicated
infection?
– Hematuria (CIS)
• PMH:
– Marital and obs hx
– OCP
– STD
– DM
– TB
– Stone
– Constipation
– Neurological illness
– Previous UTI in childhood
• Family hx of UTI
– ABO bld gp Ag non-secretors
– Lewis non-secretor
– P bld gp secretors

PE
• Abd:
– Palpable kidney
– Palpable bladder
– Loin pain
• Vaginal examine:
– State of oestrogenisation
– Genital prolapse
– Urethral diverticulum
• Focused neurological examination

Despite all investigation, no
cause of infection identify, what
can you explain to her ?

Why do women increase risk of recurrent
infection?
Susceptibility to infections
1. Increased number of receptors sites for
uropathogen
2. Shorter urethra
3. Close proximity to anus
4. Asymptomatic bacteriuria in pregnant women
5. Large PVR in older women
6. Genital prolapse
7. P blood group secretor / ABO blood group non-
secretor / Lewis non-secretor
8. HLA-A3 phenotype

What are the risk factors ofWhat are the risk factors of
recurrent UTI?recurrent UTI?
1. Reduce antegrade flow of urine (low fluid intake, BOO, neurogenic bladder)
2. Sexual intercourse
3. Use of spermicides
4. Urinary and fecal incontinence
5. Atrophic vaginitis
• Raz (NEJM 1993) published a small randomized trial of 93 post menopausal female
with recurrent urinary tract infections and reported a significant reduction in the
frequency of UTI’s in ladies treated with topical estriol
6. History of UTI
7. Immumocompromised, e.g. DM / HIV

Mx of recurrent UTI : general
measure
Aim: control symptom & reduce frequency of infection
• High fluid intake
• Void before and after sexual intercourse (vigorous
activity may “milk” the bacteria to the bladder)
• Avoid using detergents in her bath
• Avoid using spermicidal contraceptive
• Apply lactobacilli to vagina to keep her urine acidic
• Apply oestrogen to atrophic vagina to restore normal
vaginal environment and recolonisation with lactobacilli
• Cranberry juice (proanthocyanidin) – block bacterial
adherence to urothelium, 20% reduction risk of
infection

Treatment strategies
• < 3 UTI / year: patient initiated therpay
• > 3 UTI/ year: prophylaxis for 6/12
• Post-coital single dose therapy

Mx: Antibiotic
3 regimens available:
• Low dose long-term continuous antibiotics:
– Eliminate introitoal and enteric reservoir, does not cause resistant
– Trimethoprim (100mg) , cephalexin (250mg) ,nitrofurantoin(50mg) QD
– Break thru infection txn with course of A/B, then restart prophylaxis
– 6-12 months, 95% reduction of recurrence, but 60% reinfected after
stopping the antibiotics
• Postcoital antimicrobial prophylaxis
– Ciprofloxacin 125 mg once daily
– Nitrofurantoin 50 mg once daily – lower systemic absorption and less
microbial resistance, but avoided in pyelonephritis as tissue level in
kidney is low
– Avoid amoxicillin and cephalosporin which change fecal flora
• Intermittency self-start therapy:
– Recurrent uncomplicated cystitis
– 3-day course regimen of an antimicrobial with MSU beforehand
– If failed > send MSU for proper culture
– 1 week course if symptom persist or for men

• Trimethoprim:
– Eradicate gram –ve aerobic from gut and vaginal fluid (eradicate
source)
– Batericidal concentration in urine
– Adverse: GI disturbance, mylotoxicity, erythema multiforme,
TEN, photosensitivity
– Cautions in renal impairment
• Nitrofurantonin:
– No effect on gut flora
– High concentration in urine  elimination of bacteria
– Would not induce bacterial resistance
– Adverse: Pulmonary fibrosis , peripheral neruopathy,
agranulocytosis , liver damage
• Cefalexin:
– Would not induce resistance
– Adverse: GI upset , allergic rxn
• Fluoroguinolones :
– Short course eradicate enterobacteria from faecal & vaginal flora
– Adverse reaction: tendon rupture in 48 hour (esp with
concomittent use of steriod) , GI , Steven-Johnson syndrome

Mx if bacterial persistent
• Identify potential cause:
– KUB (stone)
– Renal USG (hydronephrosis, stone)
– FR + RU
– IVU or CTU
– FC (bladder stone, Ca bladder, urethral or
BNS , fistula)
• Txn: treat underlying cause

Acute and chronicAcute and chronic
pyelonephritispyelonephritis

Acute pyelonephritis
• Inflammation of the kidney and renal pelvis
• Presentation:
– Fever, chills rigor
– Flank pain and tenderness
– Lower UTI symptom
– Unilateral or bilateral
• Ddx: cholecystitis, pancreatitis, diverticulitis, apendicitis
• Risk factor:
– Female
– VUR, Urinary tract obstruction or Neuopathetic bladder
– DM, immunocompromised state
– Congenital malformation
– Pregnancy
– Catheter and instrumentation

• Pathology:
– Patchy infiltration of neutrophil & bacteria in
parenchyma
– Inflammatory band extending to cortex
– Small cortical abscess (80%)
• Organism: E.coli , enterococci, klebsiella ,
proteus, pseudomonas
• Investigation:
– Bld
– KUB
– MSU
– USG if derange RFT

Radiologic Findings
• Generalized renal enlargement
– Overall length of 15cm
– 1.5cm greater length on the the affected side
• Focal renal enlargement
– Renal mass
• Cortical striations during the nephrogram
phase of the urogram (perinephric
stranding)
• Dilatation of ureter/pelvis

Treatment
• Not systemically unwell : oral
cirprofloxacin 500mg BD for 10 days
• Systemically unwell:
– IVF
– IV antibiotic (quinolone +/- gentamicin)
• Change to oral antibiotic after afebrile
• Complete antitbiotic for 14 days intotal

Is it necessary to perform
upper tract imaging?
• If the patients remain febrile after 72 h of
treatment
• Evaluation of the upper urinary tract with
ultrasound should be performed to rule out
abscess, urinary obstruction
• CTU: pyonephrosis, perinephric abscess ,
emphysematous pyelonephritis, Stone
• Chronic pyelonephritis – scarred shrunken
kidney

What is the antibiotic of
choice?
• Augmentin is not recommended as a drug of first
choice for empirical oral therapy of acute
pyelonephritis. It is recommended when
susceptibility testing shows a susceptible Gram-
positive organism
• In communities with high rates of fluoroquinolone-
resistant and extended-spectrum β-lactamase
(ESBL)-producing E. coli, initial empirical therapy
with an aminoglycoside or carbapenem has to be
considered until susceptibility testing demonstrates
that oral drugs can also be used

Chronic Pyelonephritis
• Dx: Radiologic, Pathologic
– Radiographically scarred & shrunken
• Often no history of UTI
– Bacterial antigens detectable in renal tissue
• Unpredictable association between
infection and renal scarring
• Early antimicrobial treatment decreases
scarring

• Associated with reflux nephropathy
– Scarring associated with reflux of infected urine
– No scarring with reflux of sterile urine
• 55 Adults with reflux nephropathy
– UTI diagnostic event in 80%
– 20% with enuresis
– 50% with elevated serum creatinine
– 38% had hypertension
– 35% had proteinuria

Chronic Pyelonephritis -
Diagnosis
• Often discovered incidentally
• Azotemia, hypertension, fatigue
• UA: WBC, proteinuria
• Decreased ability to concentrate urine

• IVU
– Small, atrophic kidney
– Scarring with calyx
clubbing
• VCUG in children

Renal Abscess - Etiology
• Majority are secondary to ascending
gram-negative infection
– Associated tubular obstruction (due to prior
infection or calculi)
• Skin carbuncles or IVDU may lead to
gram-positive abscess formation
• Complicated UTI with associated stasis
due to calculi or neurogenic bladder.

Renal Abscess – Clinical Sx /
Labs
• Symptom:
– Fever , chill , pain
– weight loss, malaise
• Lab: Marked leukocytosis
• UA may be normal, unless there is
communication between abscess and
collecting system

Renal Abscess – Radiologic
findings
• CT of early abscess:
– Renal enlargement
• CT of late abscess:
– Fibrotic wall
– Obliteration of
adjacent tissue planes
– Ring-enhancing
• U/S shows
hypoechoic mass

Renal Abscess - Treatment
< 3 cm: IV ABx & observation
- Serial exam with U/S or CT until resolution
3-5 cm: Percutaneously drain
>5 cm: Surgical I&D

Pyonephrosis
Infected hydronephrosis
associated with
suppurative
destruction of the
kidney parenchyma &
in which there is total
or nearly total loss of
renal function.

Pyonephrosis - Diagnosis
• F/C/Pain
• Lack of bacteriuria indicates complete
ureteral obstruction
• Urographic findings – obstruction
• Infected hydronephrosis always shows
good ultrasonic transmission;
pyonephrosis shows persistent echoes or
a fluid-debris level

Pyonephrosis - Treatment
• Antimicrobial drugs
• Drainage of the infected pelvis (ureteral
cath or perc drain)
• Identify & treat source of infection after
patient becomes hemodynamically stable

Perinephric Abscess
• Located within Gerota’s fascia
• 56% mortality rate
– Delay in Dx (misdiagnosed as acute pyelo)
• Due to hematogenous seeding or from
renal extension of ascending UTI
– Use of antimicrobial therapy has decreased
the chance of hematogenous seeding from
wound and skin infections.

Perinephric Abscess -
Diagnosis
• No pathognomonic abnormalities on any
radiologic examination.
• Decreased renal mobility is the most
specific finding – (Insp/Expir films).
• U/S or CT Scan – Dx &/or Treat
• Treatment: Drainage (surgical vs. perc)

Perinephric Abscess vs. Acute Pyelo
• >5 days of symptoms
prior to hospitalization
• Fevers persist beyond
4 days
• <5 days of symptoms
prior to hospitalization
• No fevers beyond 4
days after appropriate
antibiotics started

What are the definitions of
infection?

What is Systemic inflammatory
response syndrome (SIRS) ?
• Response to infection (sepsis) or non-infection (burn, pancreatitis)
• 2 of the criteria require

What is the pathogenesis of
sepsis?
• Endotoxin release by G-ve bacteria
• Trigger release of mediators, like cytokine,
activation of kinin system, complement
system and fibrinolytic system
• Activation of white cell and macrophages
• Widespread microvascular injury, tissue
ischemia & clinical manifestation

Pt is very unwell , what to do?
• ICU
• Consideration of vasopressor, inotropes,
steriod
• Radiological investigation to identified
source and complication

EmphysematousEmphysematous

Case
• F/40
• Good PH
• HPI:
– Acute left loin pain
– Low grade fever
– Vomiting (secondary to paralytic ileus)
• PE:
– BP 120/60, p 110, temp 37.8
– Abd soft, left loin mild tenderness, no mass,
• KUB: no stone
• Urine stix: nitrate+, WBC+, RBC +
• Bedside USG: no hydronephrosis/stone
• CBC: WCC 14, Hb 12
• RFT Cr 100, CaPO4, urate normal

Case
• Imp: Acute pyelonephritis
• IV zinacef
• Progress
– Low grade fever and tachycardia
– Left loin pain slightly improved
– Not septic looking
• DDx?
• Ix?

EPN causes and pathogenesis
• Acute necrotizing infection of the renal parenchyma and
its surrounding tissues by gas forming organism
• Presence of gas in the renal parenchyma, collecting
system or perinephric tissue
• Most common: Escherichia coli in 70% and Klebsiella
• Others:
– Proteus mirabilis, Group D Steptococcus and CNS
– Anaerobic and rare: Clostridium septicum, Candida albicans,
Cryptococcus neoformans and Pneumocystis jiroveci
• Bacteriaemia: found in 50% EPN, same species as
urine/pus
• Severe, acute pyelo that fails to improve during the initial
3 days of treatment

EPN pathogenesis
• Female: Male = 6:1
• Factors
– High glucose level (DM)
– Gas-forming microbes
– Impaired vascular blood supply
– Reduced host immunity
– Urinary tract obstruction (stone)
• Mechanism
– G-ve facultative anaerobes e.g. E coli produce gas via
fermentation of glucose  high levels of nitrogen, oxygen, CO2
and H2 accumulating at inflammatory site  gas may extended
the inflammatory site to subcapsular, perinephric and pararenal
spaces

EPN histopathology
• Abscess formation
• Foci of micro and
macro-infarction
• Vascular thrombosis
• Numerous gas-filled
spaces
• Area of necrosis
surrounded by acute
and chronic
inflammatory cells
implying septic infarction

EPN presentation
• Age: 40-50
• S/s = pyelonephritis
– dysuria, fever/rigors, nause,
vomiting, flank pain
• Impaired consciousness
• Septic shock
• PE:
– Loin tenderness (most
common)
– Crepitus around renal area
or scrotum
• NOT respond to
pyelonephritis Tx
• Ix:
– Leucocytosis (70-80%
reported case)
– Thrombocytopenia (15-20%)
– Acute renal dysfunction
– Acid-base disturbance
– Hyperglycaemia
– Microscopic / gross
haematuria
– Severe proteinuria

EPN diagnosis
• Radiological Dx
– Gold standard: CT
• CT: more sensitive and
define extent of EPN by
identifying features of
parenchymal
destruction
• USG accuracy 69%,
KUB 65%
– KUB: abnormal gas
shadow in renal bed

EPN classification
• Base on CT feature
• Wan: used in 2 meta-analysis, prognostic value,
type 1 > 60% mortality, type2 > 20% mortality
• Huang and Tseng: for Mx
• One classification proposed by Wan et al
– Type I : parenchymal destruction with either an
absence of fluid collection or presence of streaky or
mottled gas (mortality 60%)
– Type II : renal or perinephric fluid collection with
bubbly or located gas or gas in the collecting system
(mortality 20%)

EPN prognostic factors
• Falagas et al J Uro
2007
• Poor PF:
1. SBP <90
2. Impaired consciousness
3. Increase serum Cr
4. Thrombocytopenia
5. Bil EPN
6. Medical Mx with Abx
alone
7. Wan’s Type I (air only, no
fluid)
• Factors NOT increased
mortality
– DM
– Stone
– E. coli
– K. pneumaiae
– Age >50
– Female
– Hx of UTI
– Alcoholism

EPN management
• High index of suspicion in pt fail medical treatment
for acute pyelonephritis
• Active resuscitation
• Medical Mx (MM)
– O2, IVF, Acid base balance, Abx, good glycaemic
control
– Keep SBP >100 with IVF +/- inotropes
– Empirical Abx: AG, b-lactamase inhibitor, CS,
quinolones, till c/st a/v
– Renal support if ARF
– ICU care if multiorgan support need

EPN Management
• Percutaneous drainage PCD + MM
– 1st
shown in Hudson et al. J Urol 1986
– Meta-analysis (Somani BK et al. J Urol 2008):
• PCD + MM as most successful Mx (30-100%) with lowest
mortality 13.5%, subsequent nephrectomy mortality 6.6%
– Significant reduction in mortality (nephrectomy mortality 40-50%)
– Preserve function of affected kidney in ~70% cases
– For pt with localized areas of gas + functioning renal tissue
– Multiple catheters for loculated/multiple abscess
– Tube can be flushed with Abx solutions

EPN: PCD + MM
• Huang and Tseng classification
– Class 1 (gas in collecting system only): PCD + MM
– Class 2 (parenchymal gas only): PCD +MM
– Class 3 (3A peripheric gas, 3B pararenal gas):
• Depend on risk factors:
– diabetes, thrombocytopenia, acute renal failure, altered
level of consciousness, shock
• 0-1 risk factor: PCD+MM survival rate 85%
• >=2 risk factors: failure 90%  nephrectomy
– Class 4 (soliatory kidney/Bil EPN):
• PCD + MM
– If failed to respond: Nephrectomy + ICU + renal support

Huang and
Tseng
classification
Class 1 Pelvicalyceal gas only
Class 2 Parenchymal gas only
Class 3A Perinephric gas
Class 3B Pararenal gas
Class 4 Solitary kidney/Bil
EPN
Risk factors:
1.DM
2.PLT
3.ARF
4.GCS
5.Shock

XanthogranulomatousXanthogranulomatous

• KUB and CT scan of a patient with vague
R flank pain and ballottable mass
• What is the diagnosis? (3)
• Under microscopy, what is a characteristic
feature in this condition? (2)

• KUB : multiple renal stones in R kidney
• CT : classic “bear’s paw” appearance,
lower cut showing stones inside dilated
calyces
• Dx : Right xanthogranulomatous
pyelonephritis (3)
• Lipid-laden macrophages (Xanthoma
cells) (2)

XanthogranulomatousXanthogranulomatous
PyelonephritisPyelonephritis
• Chronic renal infection that results in local or
diffuse (2 types) renal destruction.
• Almost all cases are unilateral
• A nonfunctioning, enlarged kidney associated with
obstructive uropathy secondary to nephrolithiasis
• Female in their 5th to 7th decade
• 75% have positive urine cultures and 90% have
positive tissue culture
• The commonest organisms isolated are Proteus or
E.coli
• 83% of patients have associated nephrolithiasis
• 50% such stones are of staghorn stones

Xanthogranulomatous PyelonephritisXanthogranulomatous Pyelonephritis
• Presentation: 70% flank pain, 70% fever/chills, 60% flank mass
• Histologically
– Accumulation of lipid-laden foamy macrophages (xanthoma
cells)
– Inflammatory process begins within the pelvis and calyces &
subsequently extends into and destroys renal parenchymal and
adjacent tissues.
– Can be confused with RCC even on frozen section
• Treatment :
– if malignancy suspected / kidney diffusely destroyed – open
nephrectomy
– very stuck and high risk of vessels and visceral injury
• Imaging triad (seen in 50-80%) :
– Unilateral renal enlargement
– no / poor function
– A large calculus in the renal pelvis
• Classic “Bear’s paw sign” on CT

How to diagnosis urinary TB?How to diagnosis urinary TB?
• Presentation:
– Previous TB exposure
– Loss of appetite
– Fever, night sweat
– Loin pain , hematuria and suprapubic pain
• Physical examination:
– Temp , LN
– Chest , abdomen , genital (bead like cord)
• Bld , EMU, CXR, KUB, USG + RU

• EMU – more concentrated as TB is secreted
intermittently
1. Ziehl-Neelsen stain to look for acid fast bacilli
1. Bacterial smear is stained with carbol fuchsin for 2 minutes,
then decolorised with HCL and ethanol which then restained
with crystal violet  view under oil immersion
2. Acid-fast bacilli  pink, non acid fast bacilli  purple
3. Not suitable for gram stain as high lipid content of cell wall
2. Lowenstein-Jensen is an egg based solid culture medium
used to identify TB
3. Culture in a liquid medium takes 2-3 days whereas in a solid
medium takes 6-8 weeks
4. PCR to amplify the specific DNA by in-vitro enzymatic
replication
• Pathogensis – caseating granuloma (Langhan’s giant cells
surrounded by lymphocytes and fibroblast)  fibrosis +
calcification  autonephrectomy
• TB epididymis is likely from hematogenous spread as it is usually
isolated finding

How to diagnosis urinary TB?How to diagnosis urinary TB?
• Tuberculin: purified protein deverivative to prove TB status.
– Positive  confirmed exposure to TB
– Negative  exclude the diagnosis
• CXR: lung primary focus in 50% of cases with urogenital TB
• KUB shows calcification in 50% of cases
• CT or IVU is abnormal in 60-90% of cases
1. Small shrunken kidneys (autonephrectomy)
2. Infundibular stricture (pathognomonic)
3. Calyceal distortion + calcification
4. Papillary necorisis
5. Multiple ureteric stricture : commonly at lower third of ureter
6. Distortion of ureteric orifice – VUR (Golf-Hole app)
7. Contracted calcified bladder: Bullous edema , ulcearation and
hemorrhage (Thimble bladder)
8. Calcified vas (beaded), seminal vesicle or prostate

What is the treatment of TB?
• Isoniazid, rifampicin, ethambutol and
pyrazinamide for 2 months
• Isoniazid and rifampicin for 4 months
• Steroid for ureteric stricture that do not respond
to anti-TB drugs
• Cycloserine is used to inhibit the growth of BCG
sepsis within 24 hours
– But if will lower seizure threshoid

What is the complication of
the drugs?

Acute bacterial prostatitis
• Infection of the prostate asso with LUT infection & generalized
sepsis
• Risk factor:
– UTI
– Acute epididymitis
– Catheter , post TURP
– Intraprostatic ductal relfux
– Phimosis
– Prostate stone
• Presentation:
– Systemic illness
– Preineal and SP pain
– Irritative LUTS
– AROU
– Prostate is exteremely tender

• Investigation:
– Bld + c/st
– MSU
• Txn:
– Antibiotic: Cirpo 500mg BD for 2-4 week
– Pain relief
– Catheter
– Prostate abscess: dx by TRUS or CT
– Drainage: percutaneous or TUR

Men present with recurrent UTI
• History:
– Associate LUTS
– Stone disease
– Diverticulum +/- fistula: pneumaturia, recurrent diarrhoea ,
rectal bleeding , fecaluria
– Chronic prostatitis : Dysuria, hematuria, Perineal/suprapubic
discomfort, Ejaculatory problems
• PE:
– Abd + kidney
– Suprapubic region
– External genitalia and prostate
• Investigation:
– MSU
– KUB
– USG
– FR + RU
– Specific test : Stemey + NIH-CPSI

UTI in men
• Men should receive, as minimum therapy,
a 7-day antibiotic regimen
• Minimum treatment duration of 2 weeks is
recommended, preferably with a
fluoroquinolone if prostatic involvement
• Prophylactic antibiotics reduce the risk of
bacteriuria and septicemia by 70% and
80% respectively after TURP
– Berry: Prophylactic antibiotics in TURP J Urol
2002

Prostatitis
• Definition: Infection or inflammation of prostate
• Chronic prostatitis:
– Clinical syndrome characterize by pain in perineum, pelvis, suprapubic
area or external genitalia
– Variable degree of voiding or ejaculatory disturbance
• Dx of exclusion : to rule out BPH , stricture, UTI
• Pathophysiology poorly understood:
1. Infection
2. Chemical irritation
3. Dysfunctional high-pressure voiding
4. Intraductal reflux
5. Altered immunity
– Proposed inflammatory process cause tissue edema &
intraprostatic pressure  local hypoxia  mediator
induced tissue damage altered neurotransmission in
sensory nerve  pain and other symptom

What is the definition ofWhat is the definition of
prostatitis?prostatitis?
>10 WBC /HPF
Prostadynia – pain without positive culture or inflammatory component

What is stamey test?What is stamey test?

Meares and Stamey
• Drink 400ml of water 30min before the test
• 4 sterile specimen container: VB1, VB2, EPS, VB3
• Expose glans penis and retract foreskin
• Cleanse the glans with soap
• 1st
10-15ml urine: VB1
• Pass next 100-200ml into toliet
• 2nd
10-15ml urine: VB2
• Patient bend forward & hold container marked EPS near
urethral meatus
• Massage prostate until few drops of prostatic secretion
are collected : EPS
• Void and collect the 10-15ml urine: VB3

Interpretation of Stamey test
• +ve VB1: Urethritis
• +ve VB2: Cystitis
• Chronic prostatitis
– II: +ve c/st in EPS & VB3
– IIIa: -ve c/st in EPS & VB3, +ve WBC
– IIIb : -ve c/st in EPS & VB3 , -ve WBC
• Modification of Stamey test:
– Pre & post-message test (PPMT) [Nickel]
– +ve post-message c/st  chronic prostatitis

ProstatitisProstatitis
• NIH – CPSI (National Institutes of Health- Chronic Prostatitis
Sympotm Index)
– Measure the severity of chronic prostatitis
– 9 item questionnaire with 3 main domains (pain, urinary symptoms and
QOL)
– Pain (location, frequency , severity)
– Voiding (obstructive and irritative)
– QOL
– For assess need of treatment and monitor response
• MTOPS study suggests that prostatitis may be a predictor of BPH
progression
• Nickel and coworker report a 2% incidence of bladder CIS in
patients with clinical prostatitis and they therefore recommend urine
cytology when investigating men with suspected prostatitis

Management
• According to predominant symptom & QOL
• Discuss about benign nature of the condition
• Lock of evidence in favour of any treatment
• Goal should be symptom control rather than
eradication
• Conner stone:
– Antibiotic
– Anti-inflammatory
– Alpha-blockers

Chronic bacterial prostatitis RxChronic bacterial prostatitis Rx
• NSAID/Antibiotics at least 6 weeks - empirical treatment
suggested by European consensus group
• E Coli positive in prostate massage in asymptomatic patient
should be treated
• Quinolone and tetracycline – good penetration
• Moxifoxacin – good in G+ve
• Macrolide – good for chlamydia
• Tetracyclin for sub-clinical infection : Chlamydia & ureaplasma
• Nitrofurantoin and penicillin – poor penetration
• Add alpha blocker for 3m if no response by 6week
• Finasteride can cause a 50% improvement in the symptoms
of about 50% of patients with type 3 prostititis
• Muscle relaxant – diazepam or baclofen
• Tricyclic antidepressant: Amitriptyline
• Prostatic message if not responsive
– Expression of prostatic secretion, relief of pelvic muscle spasm,
physical disruption of protective biofilm and improve circulation
– Some symptomatic relief in ~1/4 to 1/3 patients

Scrotal pain and fever
• Ddx: Trauma , testicular torsion , epididymo-orchitis
• History
– Trauma
– < 35 yo STD: Chlamydial or gonococcal
– In old: UTI cause by E coli
– UTI : dysuria, frequency , urgency , SP pain
– Systemic illness
– Long term use of amiodarone (chemical epididymitis)
• P/E:
– Cannot diff from torsion
– Scrotal pain radiate to groin
– Erythema or scrotal skin
– Thickening of spermatic cord, reactive hydrocele
– Urethral discharge
– Elevation of scrotum relieved pain in epididymo-orchitis (Prehn’s
sign)

• Investigation:
– MSU
– Gram staining and C/st of urethral swab (Gram –ve intracellular
diplococci)
– Chlamydia: detect DNA by PCR on first void urine
– Basic blood test
• Treatment:
– Bed rest, scrotal suppor
– Analgesic
– Antibiotic: Cipro 500mg BD (cover gonococccal) + Doxycycline
100mg BD (cover Chlamydia) x 2 weeks
– If allergic to doxycycline  azithromycin 1g x1
– If elderly  likely E coli : Ciprofloxacin only
– Order USG if not resolved (abscess)
– FR + RU exclude underlying LUTS
• Complication:
– Abscess, infarction , chronic pain , infertility
• Mumps orchitis: 30% post-pubertal male, 3 day after
parotitis, 30% bilateral , result in testicular atrophy and
infertility

What is the biofilm?What is the biofilm?
• Complex aggregation of organisms on
solid substrate, protected by extracellular
mucopolysaccharide matrix in an aqueous
environment
• Or , structured community of micro-
organisms and their extracellular products
form on the surface of any biomaterial

UTI in pregnancyUTI in pregnancy

Anatomic & Physiologic
Changes
• 1cm increase in renal length
• Smooth muscle atony of collecting system
– Progesterone & Uterus size
• Bladder displaced superior & anterior
• 30-50% increase in GFR
– Evaluate renal Fx if Cr >0.8 or BUN >13
– Normal to have proteinuria up to 300mg/24
hours

UTI
• Incidence of male UTI - 1%
• Incidence of female UTI – 5%
• Incidence of female UTI after
menopause – 20%
• High fluid intake/voiding every 4 hrs/
post-coital voiding/perineal hygiene
• -ve urine c/st to confirm eradication of
bacteria

Asymptomatic Bacteriauria
• All women should be screen at week16
• Definition:
– Asymptomatic + 10 5
(CFU) of a single pathogen / ml of urine
– But 102
CFU can also be counted as significant
• Asymptomatic bacteriuria in pregnancy – ~5%
• Risk of acute pyelonephritis: in 3rd
trimester
– 1-4% in all pregnant women
– 20-40% in untreated bacteriuria
• Treatment is necessary  1% if treated

• 3-day course of therapy
• Reculture urine 1-2 days after treatment
• Use parenteral agents to treat acute pyelonephritis

Antibiotics
Safe:
• Penicillin: OK
• Cephalosporin: OK
• Marcolide - Erythromycin (bacteriostatic): OK
Use with cautions:
• Nitrofurantoin: avoid in third trimester
– Fetal hemolytic anemia in G6PD deficiency mother
– hepatotoxicity, lung toxicity, inadequate urine concentration if GFR<60
• Aminoglycoside (bacteriostatic): CI in 2nd
and 3rd
trimesters
– can cross placental barrier: fetal ototoxicity & nephrotoxicity
– Used only for short periods for severe acute pyelonephritis threatening
materal-fetal prognosis
• Sulphonamide : contraindicated in third trimester
– Risk of neual tube defect in 1st
trimester due to anti-folate mechanism
– Risk of fetal anemia in G6PD def mother
• Triamethoprim : contraindicated in first trimester

Contraindicated:
• Fluoroquinolone (bacteriostatic):
contraindicated as toxicity to fetal cartilage and
joints, tendon damage
• Chloramphenicol: contraindicated in third
trimester as “grey-baby” syndrome
• Tetracycline (bacteriostatic): contraindicated
as hepatotoxicity, deposit in teeth and bone
• Recurrent UTI in pregnancy – cephalexin 125mg
daily

• USG findings: focal or diffuse hyperechogenicity,
thickening of renal pelvis and ureteral dilation
• Higher risk if asymptomatic bacteriuria / VUR
(correction of VUR cannot prevent UTI during
pregnandy) / history of renal scarring
• Complications associated with bacteria during
pregnancy
– Prematurity, low birth weight, prenatal mortality
– Maternal anemia
• Hospitalization and parental antibiotics

Pregnancy and VUR
• Higher chance of pyelonephritis if previous VUR or
history of renal scarring
• History of renal scarring
– Higher chance of HT (3.3 fold)
– Pre-eclampsia (7.6 fold)
– Obstetric intervention
• Higher chance of pre-eclampsia if bilateral scarring
or impaired creatinine level
• Despite previous reimplantation in childhood, still
higher risk of UTI, but not miscarrage

(Spontaneous renal rupture)
• No cause vs upper tract obstruction vs
tumour like AML
• Lumbar or abdominal pain / shock
• US : retroperitoneal hematoma
• JJ / PCN if obstruction
• Unstable hemodynamically: nephrectomy

Before having babies…
• Consider stone treatment before
pregnancy
• Consider AML treatment

How to use gentamicin?
• Bactericidal – inhibit ribosomal protein synthesis
• 3-7mg/Kg
• Check level after the 3rd dose
• <1mg/l  give the same dose
• 1-2mg/l  reduce the dose by 25% and check the level before
next dose
• 2mg/l  omit one dose and check the level
• Bad with Frusemide (increase nehrotoxicity)
• Good for pseudomonas, enterococcus and staphylococcus
• Daily dose is usually used
• Can be used in patient with renal impairment with dose modification
• Ototoxicity cause more commonly vestibular damage than
deafness, 2/3 patients present as tinnitus
• Nephrotoxicity and impaired neuromuscular transmission

UTI in renalUTI in renal
impairmentimpairment

What is the antibiotic in renal
impairment?

Catheter related UTICatheter related UTI

• Up to 25% of hospitalized patients undergo urinary catheterization.
• indwelling urinary catheters are a leading cause of nosocomial
infection and have been associated with both morbidity and
mortality.
• Up to 30% of catheterized patients can have genitourinary or
systemic symptoms related to catheter-associated UTI (CAUTI)
• Up to 4% may develop catheter-related bacteraemia
• Once the catheter has been removed some patients with
asymptomatic CAUTI continue to have bacteriuria or become
symptomatic
• To prevent or reduce this type of catheter-related morbidity, many
clinicians have a policy of administering a short course of
prophylactic antibiotics on catheter withdrawal for all or selected
groups of patients.
• Currently, the most appropriate agents for the empirical
management of CAUTIs seem to be co-amoxiclav, ciprofloxacin and
nitrofurantoin.

What is the recommendation of
catheter insertion and choice of
catheter?

How to prevent catheter
related UTI?

What is the treatment of
catheter related UTI?

Spinal cord injury patients
• 33% have bacteriuria
• UTI is the most common urologic complication &
the most common cause of fever in these
patients
• Risk factors:
– Bladder overdistention
– Elevated intravesical pressure
– VUR
– Impaired voiding
– Instrumentation

Clinical presentation &
Bacteriology
• Majority are asymptomatic
• Symptoms:
– Abdominal discomfort
– Urinary leakage
– Lethargy / Malaise
– Cloudy, malodorous urine
• E. coli isolated in only ~20%
• Enterococci, P. mirabilis, Pseudomonas

Management
• SP cath delay onset of bacteriuria, when
compared with indwelling urethral cath
• CIC allows for lowest risk of complications
• Urine culture prior to therapy
• Oral fluoroquinolone is 1st
line

Emphysematous cystitis
• Necklace appearance of gas beads in
bladder wall diagnostic of emphysematous
cystitis
• due to infection by gas forming organisms
(commonest E Coli) in an
immunocompromised patient (usually DM)

EC
• DDx:
– Instrumentation
– Fistula to hollow viscus
– Tissue infarct with necrosis
– Infection
• EC more common in
– Middle aged diabetic women
(M: F = 1:6)
• Predisposing factors
– DM (66%), Chronic UTI,
indwelling urethral catheter,
urinary stasis due to BOO,
neurogenic bladder
• Various s/s
– Asymptomatic, pneumaturia,
irritative voiding, acute
abdomen to severe sepsis
• Pathogens:
– E. coli (58%)
– Others: K. pneumoniae, P.
aeruginosa, Proteus mirabilis,
Candida albicans and C.
tropicalis, Aspergillus fumigatus,
Staphylococcus aureus, Group D
Streptococcus, Enterococcus
faecalis, Enterobacter aerogenes
and Clostridium perfringens and
Cl. welchii.
• Pathogenesis:
– like EPN,
– non-diabietic: urinary albumin as
substrate

EC
• Radiological Dx
– KUB: curvilinear area of
radiolucency delineating
the bladder wall with or
without intraluminal air
– CT: more sensitive, define
extent and severity,
differentiate vesicoenteric
fistula, intraabdominal
abscess, adjacent
neoplastic disease, EPN
• Histopathology
– Gross:
• Bladder wall thickening
with vesicles of varying
size
– Microscopic:
• multiple gas-filled
vesicles predominantly
within the bladder
mucosa, lined by
flattened fibrocytes and
multinucleated giant
cells

EC management
• MM:
– Abx, bladder drainage, DM control, correct
underlying comorbidities
• If fail to respond/severe necrotizing
infection (10%)
– Consider partial cystectomy, cystectomy or
surgical debridement
– EC alone Mortality 7%
– EC + EPN Mortality 14%

What is endotoxin?What is endotoxin?
• Lipopolysaccharide complex related to the outer
membrane of gram negative bacteria
• Gram negative sepsis
• Their lipid component is the toxic one (Lipid A)
and the polysaccharide element is the
immunogenic one (O-antigen)
• Endotoxins are heat stable to boiling point

Papillary necrosisPapillary necrosis

What is papillary necrosis?What is papillary necrosis?
• Possible causes of papillary necrosis is
POSTCARD
• Pyelonephritis, Obstruction. Sickle cell,
Tuberculosis, Cirrhosis, Analgesic, Renal
vein thrombosis, Diabetes

Viral disease of the genital
tract

 Painful ulcer
 Diagnosis? (1) Chancroid
 Causative agent? (1) Haemophilus ducreyi
Q3

ChancroidChancroid
• Presentation: painful nonindurated ulcer + tender unilateral
inguinal adenopathy
• Characteristic suppurative inguinal adenopathy
• Haemophilus ducreyi :
– fastidious (difficult to culture)
– short, fine, gram-negative streptobacilli
– FDA approved: PCR assays
• Treatment:
– Ciprofloxacin, (500 mg orally BD for 3 days)
– Erythromycin , (500 mg orally TID for 7 days)
– Azithromycin, (1 g as a single oral dose )
– Ceftriaxone, (250 mg as a single intramuscular dose )
– Tetracycline

Male 30 with painless ulcer over coronal
sulcus

Genital
• What is the diagnosis?
– Chancre, ulcer typically painless, indurated and with
raised border. Regional lymphadenopathy appear in
one week.
• What is the causative agent?
– Treponema pallidum (spirochetes), confirmed by dark
field examination
• What is the treatment?
– Penicillin – good prognosis if treated. If not treated >
neurosyphillis/dementia/gumma

Male 25 with lesion over glans. Biopsy done.

Genital
– Condyloma acuminatum
• What is the causative agent?
– Human papillomavirus types 6,11.
– Dysplastic types are caused by type 16, 18.
(premalignant)
– Podophyllin, cautery after biopsy or surgical excision
or CO2 laser

Condyloma
acuminatum of
scrotum

25 year old man with ulcer over glans.

Genital
– Granuloma inguinale - Irregular painful ulcer with
purulent base. No inguinal lymphadenopathy, but
subcutaneous granulomatous process
– Dx: identification of “Donovan Body” on stained
smear
• What is the cause?
– Calymmatobacterium granulomatis
– Tetracycline/ampicillin , septrin or erythromycin

25 year old man with painful lesions
over penile skin

Genital
– Genital herpes.
– Usually herpes simplex virus type 2 infection
– Acyclovir, long term suppression may be
required if recurrence. Prevent transmission
with barrier contraception

Male 25, itchy lesion over penile
skin. Biopsy done

Genital
– Molluscum contagiosum – small papules, may
express cheesy-like material
• What are the diagnostic features on histology
exam?
– Molluscum bodies in cells (Basophilic inclusion filled
with the virus) in biopsy
– Viral infection by poxvirus, transmitted by sexual
contact
– Self limited. Healed without scars. Podophyllin or
cauterisation

Schitosomiasis (Biharzia)
• Cause: trematode called Schitosoma
haematobium
• Endemic : Africa , Egypt, middle east
• Pathology :
– Fresh water snails release infective form of the
parasite (cercariae)
– Penetrate skin and migrate to live (schitosomules)
where they mature
– Adult form migrate to vesical vein
– Lay egg (containing miracidian larvae)  leave body
by pentrating the bladder and enter urine

• 2 phase:
– Active: where adult worm laying eggs
– Inactive: when adult die and reaction to remaining egg
• Clinical presentation:
1. “Swimmer’s itch” : local inflammation by cercarial penetration
(24hr)
2. Katayama fever (acute schistosomiasis):
• Egg lying : induce fever, urticaria, LN, Hepatosplenomegaly
3. Acute inflammation phase: egg penetrate & excreted in urine :
hematuria, frequency and terminal dysuria
4. Chronic active phase:
• Low egg laying
• Nephritic syndrome by deposition of IG complex in glomeruli
5. Chronic inactive phase: no viable egg
• Symptom of obstructive uropathy

Diagnosis + MxDiagnosis + Mx
Diagnosis:
1. Midday urine: continue egg
2. Bladder and rectal biopsy : identify egg
3. Serology test: ELISA
4. Cystoscopy: identifies egg in trigone (Sandy Patches)
5. CT or IVU: calcified , contracted bladder with obstrucitve uropathy
6. USS: hydronephrosis and thicken bladder wall
Treatment is pharmacological with praziquental
• 20 mg/kg in 2 divided does 4-6 hours apart on the same day
• Single dose of praziquental may be effective
• Praziquental is effective against all species of schistosoma and all
stages of the disease. It will cure 85-100% of cases. When it fails to
cure the disease a second course of praziquental could be tried
• Complications - Bladder contracture, ureteric obstruction, squamous
cell ca bladder

These are the eggs of 3 species of Schistosoma
 Which of the above species is related to bladder cancer?
(1)
 In what form does this species infect human in water? (1)
A B C

• A : Schistosoma japonicum
• B : Schistosoma haematobium
• C : Schistosoma mansoni
• B (1)
• Cercariae (1)
– The flatworm cercaria is found in river water and will penetrate
unbroken human skin, typically through the web between toes,
to enter the peripheral systemic vein
– The eggs will penetrate through the bladder wall and will be
found in the urine

Urinary schistosomiasisUrinary schistosomiasis
• Urinary schistosomiasis is most commonly
caused by schistosoma hematobium. This
is endemic in Africa and middle east. It
produces the characteristic end spined
eggs but this is not the only species with
end spined eggs
• Schistosoma japonicum is endemic in the
far east
• Schistosoma Mansoni in Latin America

 What is the diagnosis? (1)
 What is the acute phase of this disease called? (2)

• Characteristic egg-shell calcification outlining urinary
bladder
• Dx : Schistosomiasis (1), DDX: TB
• Katayama fever (2)
– Coincides with egg laying
– Active phase is characterized by urinary symptoms such as
hematuria and terminal dysuria. Cystoscopically there may be
inflammatory polypoid lesions in the bladder and eggs in the
urine
– The chronic inactive phase,although asymptomatic, will slowly
progress into obstructive uropathy and may be complicated by
bladder cancer

Hydatid diseaseHydatid disease

Hydatid diseaseHydatid disease
• Also known as echinococcus, is a tapeworm parasite infection
• The intermediate host is the sheep and the final host is the dog.
• Kidneys can be affected in about 5% of cases
• The disease is bilateral in 6% of cases
• In the kidney the upper and lower poles of the kidneys are more
commonly affected (80%) than the midpole of the kidney
• The renal cysts are not symptomatic until late in the disease
• Common symptoms are flank pain (80%) and flank mass (40-75%)
• USG and CT scans show thick wall multiloculated cysts
• KUB shows calcifications in 30% of cases
• Bld: peripheral eosinophilia & +ve hydatid complement fixation test
• Medical: Albendazole
• The mainstay of treatment is surgical excision of he cysts with 1st
sterilized with formalin or alcohol

• Angiokeratoma of Fordyce (1)
• No malignant potential (1)

Angiokeratoma of Fordyce
• Vascular ectasias of dermal blood vessels
• Visible on the penis and scrotum of adult men
• 1- to 2-mm red or purple papules with associated
generalized scrotal redness
• Benign condition without systemic manifestations
• Rare cause of troublesome scrotal bleeding Can
be seen in patients with Fabry's disease : rare
glycogen storage deficiency
• Treatment :
– Usually unnecessary
– Success achieved using YAG, KTP/ argon laser
photocoagulation in select cases

Physical findings of a sexually inactive 20-yr-old male
 Diagnosis ? (2)
 Is it associated with HPV infection? (1)

• Pearly penile papules (PPP) (2)
• No relationship with HPV. Benign lesion
(1)

PPP
• White, dome-shaped, closely spaced small
papules at glans penis
• Arranged circumferentially at corona
• Histology : angiofibromas similar to lesion TS
• 14-48% of young adults (uncircumcised)
• NO association with HPV infection/ cervical CIN
• Mx: Reassurance
• Local destruction: CO2 laser, cryotherapy

 These ulcers in a sexually-inactive 20-yr-old man
are painful and recurrent.
 Diagnosis ? (3)
Q29

• Pictures showing multiple scrotal, perianal
ulcers as well as oral aphthous ulcers
• Behçet’s disease (3)

Behçet’s disease
• Classified as a form of vasculitis
• Initially found along Silk Road, now found everywhere in the world
• No gender difference in epidemiology, mean age of onset ~30yrs
• Clinical manifestation:
– Mucous membrane manifestation
• Oral aphthosis (nearly in every patient)
• Genital aphthosis (60-100% of patients) : Scrotal and vulval ulceration,
sometimes on shafts of penis
– Skin manifestation
• Skin aphthosis / pustulosis
• Pathergy phenomenon (skin hypersensitivity to trauma, considered a
diagnostic test)
– Ocular manifestation
• Anterior and posterior uveitis, retinal vasculitis
– Arthritis, Meningoencephalitis, Vascular involvement (DVT), gastrointestinal
aphthosis
• Diagnostic criteria: International Criteria for Behçet’s disease (ICBD)
• Genetic background: HLA-B51 may be associated
• Treatment: Colchicine 1mg daily is 1st
line

 This is the result of a chronic infective process
 Name three possible micro-organisms responsible. (3)
 Name one vector of transmission of the above micro-
organisms (1)
Q30

• Picture showing penoscrotal elephantiasis
1. Wucheraria Bancrofti (1)
2. Brugia Malayi (1)
3. Onchocerca volvulus (1)
4. Vectors
• (W. bancrofit, B. malayi) Mosquito eg. Culex spp
• (O. volvulus) Black fly of Simulium spp
• Dx: Thick film , serology or biopsy
• Presentation:
– Funiculoepididymitits, orchititis
– Hydrocele
– Scroal and penile elephantitis
• Treatment:
– Medical: Diethylcarbamazine
– Surgerical excision of fibrotic & edematous tissue

This is an STD
 What is the diagnosis? (1)
 What is the causative organism? (1)
 Name two other diseases this organism is
responsible for (0.5 each)
Q47

• Lymphogranuloma venereum (LGV) (1)
• Chlamydia trachomatis (serotype L1, L2,
L3) (1)
1. Trachoma (serotype A, B, Ba, C) (0.5)
2. Non-gonococcal urethritis (serotype D to K)
(0.5)

Lymphogranuloma VenereumLymphogranuloma Venereum
• STD caused by Chlamydia trachomatis types L1, L2 & L3
• Transient painless ulcer on the penis, anus or vulvovaginal area that
goes unnoticed  painful unilateral suppurative inguinal adenopathy
and constitutional symptoms that occur 2-6wks after resolution of the
ulcer
• Groove sign: large inguinal and femoral LN separated by inguinal
ligament. Secondary LN lesions in lymphogranuloma venereum
• Mainly clinical diagnosis
• Culture positive <50% cases
• Can be diagnosed using antibody titre
• Tx: Doxycycline 100mg BD or erythromycin 500mg QID for three weeks
at least

Photo
• This elderly woman complained of severe
symptoms of cystitis of sudden onset.

Q
• A. What abnormality is shown?
– herpes zoster (1/2)
• B. What are the typical cystoscopic
appearances?
– hemitrigonal vesicles (1/2)

Q. CT
• These are CT and ultrasound scans of a
74 year old man with urinary retention and
fever of 38.6

Q
• A. What is the diagnosis?
– prostatic abscess (1)
• B. How should his retention be managed?
– suprapubic catheterisation and drainage of
abscess (1)

Antibiotic prophylaxis in urology
• Brief course of antibiotic administer before
or at the start of an intervention
• To minimize the infectious complications
of the procedure
• Possible side effect & microbial resistance
patterns are potential risk

• Yes with high level of evidence:
– TURP (decrease bacteriuria & infectious complication)
– Prostate biopsy (reduce bacteriuria but no conclusive evidence
on reducing symptomatic UTI or other infectious complication)
• Yes with moderate to low evidence:
– Cystoscopy (not require in the absence of risk factor)
– Therapeutic URS
– Open /lap uro intervention (clean-contaminated & contaminated)
• Not required in:
– Urodynamic study (except with increase risk e.g neurogenic
bladder, transplant patient, immunocompromised , VUR)
– TURBT
– ESWL (in uncomplicated case & pre-op –ve c/st)
– URS (diagnostic)
– PCNL (when pre-op –ve c/st)
– Open /lap uro intervention (clear surgery)

Urology infection [Dr. Edmond Wong]

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