s

1. UTI in Adults and
Children
( Lecture # 5 )

2. URINARY TRACT INFECTION
IN ADULTS
Incidence
 UTI (urinary tract infection) - common, affecting all ages and
both sexes
 the most common but one infections (the first - breath
infections)
Clinical syndromes associated with UTI:
septicaemia (urosepsis)
renal infection
 pyelonephritis
 pyonephrosis
 renal abscess
 peri- et paranephric abscess

3. URINARY TRACT INFECTION
IN ADULTS cont. …
 cystitis - bacterial, abacterial
 prostatitis
 urethritis
 epididymitis, epididymo-orchitis

4. Methods of introducing UTI
 Ascending infection - via urethra to bladder,
reflux of infected urine up to ureter and/or
spread of organisms along peri-ureteric
lymphatics
 infection via a fistula (e.g. vesico-colic)
 heamatogenous infection (via renal artery)

5. Aetiology and pathogenesis
 the urinary tract is normally sterile above the distal
urethra
 the chiefly defence mechanisms:
hydrokinetic = the dilution of bacteria by the
flow of urine
mucosal = mainly secretion of immunoglobulin
A (Ig A) and phagocytic capability of the
urothelium itself

6. Factors predisposing to infection
 UTI - commoner in women:
 due to shorter urethra
 opening of urethra at the vaginal vestibule, which is
readily contaminated with faecal organism
 in many young women, infection are precipitated by
sexual intercourse, bacteria-laden secretion from the
perineum entering the urethra during sexual activity (so
called honey- moon cystitis)
 In either sex UTI may develop:
 Incomplete bladder emptying (residual urine) due to
outflow obstruction (BPH, urethral stricture … )

7. Factors predisposing to infection cont. …
 Bladder diverticula
 Neuropathic bladder
 Upper urinary tract stasis due to obstruction of
ureter, megaureter, stones
Vesico-ureteric reflux interferes with both ureteric
and bladder emptying and is commonly
accompanied by infection

8. Factors predisposing to infection cont. …
Calculi, bladder tumours and foreign bodies (e. g.
catheters) are predispose to infection, as may
instrumentation of the urinary tract
Factors that suppress the immune response
(diabetes mellitus, cytotoxic or
immunosuppressive agents)

9. Common urinary pathogens
I. Ascending infection Bacteria
 Gram-negative - Escherichia coli - klebsiella spp
proteus spp - pseudomonas spp
 Gram-positive cocci - streptococcus faecalis -
staphylococcus aureus
 chlamydia trachomatis
 L-organism - ureaplasma urealyticum,
mycoplasma hominis
 Fungi - candida spp

10. Common urinary pathogens cont. …
II. Haematogenous infection
 Bacteria - mycobacterium tuberculosis
 Fungi
 Parasites - schistosoma spp
 Viruses - cytomegalovirus, adenovirus type 11

11. Clinical manifestation
Symptoms
 Lower UTI
 Voiding symptoms - frequency, urgency, micturition with discomfort,
burning sensation (= dysuria)
 Occasionally haematuria
 Upper UTI
 loin pain
 Systemic disturbance - fever, sweating, rigors
 Some patients have lower UTI as well (often upper UTI follow lower
UTI)
Physical signs
 Fever and tachycardia
 Tenderness in the loin and in the suprapubic region

12. Clinical manifestation cont. …
Diagnosis
 the presence of pus cells on microscopy
 the presence of significant number (over 10 5 per
ml) of organism in a mid-stream specimen of urine
(MSU)
 microbiology laboratories determines antibiotic
sensitivities
 specialised microbiological techniques may be
required in certain circumstances (e. g. Tuberculosis,
fungal infection, viral infection)

13. Clinical manifestation cont. …
Further investigation
 Cystitis in young sexually active women investigation is
not required for the first attack unless it is accompanied
by haematuria or loin pain
 investigation is indicated in this group of women for
recurrent infections, in older women, pregnant women,
children, men, diabetes mellitus, neuropathy, known
urinary stones or urinary tract anomaly - urinary tract
ultrasound, if indicated IVU, blood count, the serum
urea and creatinine

14. Clinical manifestation cont. …
Treatment
 Antibiotics commonly used to treat UTI :
 Nitrofurantoin
 Co-trimoxazol (sulfamethoxazol + trimethoprim) and
trimethoprim alone
 Ampicillin, amoxycillin, co-amoxycillin (clavulic acid +
amoxicillin)
 Gentamicin
 Quinolones (norfloxacin, ciprofloxcin)

15. Treatment cont. …
 Cefalosporins
 High fluid intake and regular emptying of the
bladder to promote hydrostatic clearance of
bacteria
 Attention to personal hygiene for women with
recurrent infection
 In patients with collections of infected urine or
pus (e.g. pyonephrosis, perinephric abscess)
drainage is usually required

16. UPPER URINARY TRACT
INFECTIONS
 Acute renal infection
 Most result from ascending infection (75% of
patients have preceding lower-tract symptoms)
 Some they are result of haematogenous spread
 There is important to distinguish between infection
alone and infection combined with upper-tract
obstruction; the latter combination may lead to rapid
obstruction of renal tissue unless prompt drainage of
the obstructed kidney is established

17. Pathology
Acute pyelonephritis
 Acute inflammation of the pelvic epithelium, with
bacteria entering the collecting duct and fornices to
produce inflammation of the renal parenchyma
Renal carbuncle
 An abscess in the renal parenchyma and is usually
due to haematogenous spread of organisms
 (Typically staph. aureus from foil, infected infusion
site, contaminated needles in drug addicts)

18. Pathology cont. …
 Pyonephrosis
 Infection within an obstructed kidney rapid
destruction of kidney
 Perinephric abscess
 It result form any of the above infective processes
 Initially the infection is confined by Gerota’s fascia
(= perinephric abscess), but may rupture through
this (= paranephric abscess) and to reach the skin (in
Petit’s lumber triangle) , the psoas muscle or the
bowel; it may even rupture through the diaphragm
to reach the pleura and lungs

19. Pathology cont. …
Clinical symptoms
 Loin pain, fever, tachycardia, scoliosis in sever cases
 Mass may be palpable in the loin
 Septicaemia and shock
Investigation
 Urine should be examined for pus cells and bacteria
(urine culture), blood culture (all patients with
pyrexia or clinical suspicious of septicaemia)
 Ultrasound
 urinary tract, liver, spleen, a plain abdominal X-ray,
chest X-ray, IVU

20. Management
Septicaemic patient
 rapid intravenous fluid replacement
 intravenous hydrocortisone or methylprednisolone
 parenteral bactericid antibiotics
 Subsequent management depend on the pattern of
infection, basic treatment is are antibiotics .

21. Management cont. …
Acute pyelonephritis
 antibiotics for 7-14 days, guided by the result of
urine culture and sensitivity
Renal carbuncle
 drainage
 by aspiration of the abscess under ultrasound or CT
control
 by open surgery

22. Management cont. …
Pyonephrosis
 Drainage by percutaneous nephrostomy or with a
ureteric catheter passed retrogradely from the
bladder at cystoscopy
 After improvement ascendant pyelography or
descendent pyelography (nephrostogram)
identification of obstruction
 renal scintigraphy determines remaining renal
function

23. Management cont. …
 treatment of obstruction (e. g. ureteroscopy for
ureterolithiasis, nephrectomy if kidney function is by
scintigraphy under 10 (15) %)
Perinephric abscess
 surgical drainage or nephrectomy, if function in the
affected kidney is very poor

24. Chronic pyelonephritis
 combination of renal scarring and urinary infection
 it may follow vesico-ureteric reflux and infection
 repeated episodes of acute pyelonephritis
 differential diagnosis of other types of interstitial
nephritis or hypoplasia of kidney is difficult
Treatment
 Eradication of infection to prevent further renal
damage. Nephrectomy, if:
 renal function is under 10 (15) %
 sever secondary hypertension

25. Xantogranulomatous pyelonephritis
 The result of granulomatous reaction within
kidney to chronic infection
Treatment
 nephrectomy

26. LOWER URINARY TRACT
INFECTIONS
Acute bacterial cystitis
 usually result of ascending bacterial infection from the
perineum
 particularly common in women (due to short urethra)
Clinical features:
 Frequency and urgency of micturition with dysuria
 There may be suprapubic pain, urine often has a fishy smell
or may be blood stained = haemorrhagic cystitis)
 Association of loin pain and fever suggest spread of infection
to the kidney (acute pyelonephritis)

27. LOWER URINARY TRACT
INFECTIONS cont. …
Management
 MSU (including urine culture) before treatment to confirm
the diagnosis
 Antibiotics for a 5 days period this can be changed, if
necessary, on the basis of antibiotics sensitivity tests
 Analgetics and spasmolytics (the best in combination e.g.
Algifen®)
 Resolution of symptoms = MSU to repeat at 2 weeks and at
3 months to ensure eradication of infection

28. Chronic and recurrent bacterial
cystitis
Clinical symptoms
 Similar to acute cystitis
 Histologically cystic changes ( cystitis cystica) and squamous
metaplasia
Treatment
 In women self-help advice
 Increase fluid intake
 Pass urine every 2 hours
 Regular washing of the vulva and vaginal introitus
 Wipe from front to back after bowel actions

29. Treatment cont. …
 Empty the bladder after sexual intercourse (if the symptoms
are precipitated by sex)
 Infection ( antibiotics )
 Long-term low dose antibiotics (6-12 months), e. g. furantoin
100 mg daily, trimethoprim 100 mg twice daily, co-trimoxazol
one tablet (480 mg) one or twice daily
 Immunotherapy ( e.g. Uro-Vaxom® )
 In women, whose infections are precipitated by sexual
intercourse, voiding and single dose of antibiotics after
intercourse may be prevent infection developing

30. Chronic and recurrent bacterial
cystitis cont. …
Abacterial cystitis
 Trauma, toxic drugs (e. g. severe haemorrhagic
cystitis is caused by cyclofosfamid), chemicals,
irradiation, viruses and related organism such as
chlamydia trachomatis
Interstitial cystitis
 Special type of chronic abacterial cystitis. Well
recognise syndrome of unknown aetiology.
 Diagnosis and treatment are very complicated.

31. ASYMPTOMATIC BACTERIURIA
 1-2 % schoolgirls, 3-5% of adult women, 0.5%
schoolboy, 0.5% of adult male
Management
 Exclude some abnormalities of the urinary tract
 Active treatment – pregnant woman due to 30% risk
of developing acute pyelonephritis
 Other treatment is doubtful

32. URINARY TRACT INFECTION
IN CHILDREN
Two special problems:
 1. Symptoms of urinary infection in small children may be
non-specific
 2. Collection of urine, particularly in small girls, may be
difficult
By coincidence UTI a anomalies of urinary tract - 3
groups of children with UTI:
 1. Anomalies, which can be lead to rapid deterioration in
renal function - reflux, obstruction
 2. Relatively harmless anomalies - duplication of upper tract,
bladder anomalies
 3. Normal urinary tract