Urinary Tract Infections Guide

Urinary Tract InfectionsUrinary Tract Infections
DR.TARIK ELDARATDR.TARIK ELDARAT
MD UROLOGISTMD UROLOGIST
Friday, September 27, 2013

Today’s GoalsToday’s Goals
 Be able to define the various types of UTIsBe able to define the various types of UTIs
 Describe the classic signs of pyelonephritisDescribe the classic signs of pyelonephritis
 Be able to determine if a urine culture is positiveBe able to determine if a urine culture is positive
 Know the types of imaging needed and who needsKnow the types of imaging needed and who needs
imagingimaging
 Explain why we care so much about early diagnosis andExplain why we care so much about early diagnosis and
prompt treatmentprompt treatment

DefinitionsDefinitions
 UTI—inflammatory response of the urothelium toUTI—inflammatory response of the urothelium to
bacterial invasion.bacterial invasion.
 Uncomplicated—Healthy patient with normal urinaryUncomplicated—Healthy patient with normal urinary
tract.tract.
 Complicated—compromised patient or one with aComplicated—compromised patient or one with a
functional or structural abnormality.functional or structural abnormality.
 RecurrentRecurrent
– Reinfection—infection from different bacteria outside the urinaryReinfection—infection from different bacteria outside the urinary
tract.tract.
– Persistent—focus from within the urinary tract that is neverPersistent—focus from within the urinary tract that is never
eradicated.eradicated.

Bacteriuria: the presence of bacteria in the urine
Significant bacteriuria: 105
organism or more per milliliter
Pyuria: the presence of white blood cells in urine
Pyuria with 5 or more cells per microscopic
high-power field: reliable indicator of UTI
The absence of such pyuria does not reliably
exclude UTI

 Pyuria alone=inflammationPyuria alone=inflammation
 Bacteriuria without pyuria=colonizationBacteriuria without pyuria=colonization
 Epithelial cells=contaminationEpithelial cells=contamination

The normal urinary tract is sterile
for many reasons:
Eradication of bacteria by urinary and mucous
flow:
secretory peptides target cytoplasm of
bacteria
Urothelial bactericidal activity
Urinary secretory IgA
Blood group antigens in secretion alter
bacterial adhesion

DefensesDefenses
 Primary DefensePrimary Defense
– Flow of UrineFlow of Urine
– VoidingVoiding
 Secondary DefenseSecondary Defense
– LactoferrinLactoferrin
– pHpH
– IgAIgA
– IL-6IL-6
– IL-8IL-8
– Tamm-HorsfallTamm-Horsfall

ClassificationClassification
 Isolated—first infections or those isolated by 6 months(30-Isolated—first infections or those isolated by 6 months(30-
40% of women).40% of women).
 Unresolved—insufficient treatmentUnresolved—insufficient treatment
– ResistanceResistance
– Development of resistanceDevelopment of resistance
– Two species one is resistantTwo species one is resistant
– Rapid reinfection before completion of therapy onRapid reinfection before completion of therapy on
initial organisminitial organism
– Azotemia(poor concentration of drug)Azotemia(poor concentration of drug)
– Papillary necrosis + azotemiaPapillary necrosis + azotemia
– Staghorn Calculi(mass and concentration of bacteriaStaghorn Calculi(mass and concentration of bacteria
too great)too great)Friday, September 27, 2013

EpidemiologyEpidemiology
 7 million office visits annually(1.2% female, 0.6% male)7 million office visits annually(1.2% female, 0.6% male)
 Prevalence increases with hospitalization, disease, numberPrevalence increases with hospitalization, disease, number
of infections,of infections,
 Susceptible females—2 infections in 6 months = 66%Susceptible females—2 infections in 6 months = 66%
chance of developing infection in the next 6 months.chance of developing infection in the next 6 months.
 Prophylaxis changes the time to recurrence not the chanceProphylaxis changes the time to recurrence not the chance
of recurrence.of recurrence.
 Pregnancy increases the clinical acuity of infections.Pregnancy increases the clinical acuity of infections.

PathogenesisPathogenesis
 Ascending—predominant routeAscending—predominant route
– Impairment of peristalsis enhancesImpairment of peristalsis enhances
infection(endotoxin from G- Bacteria,infection(endotoxin from G- Bacteria,
pregnancy, obstruction)pregnancy, obstruction)
– Pelvic Pressure enhancesPelvic Pressure enhances
infection(obstruction, VUR)infection(obstruction, VUR)
 Hematogenous—rareHematogenous—rare
 Lymphatic—very rare(RP abscess)Lymphatic—very rare(RP abscess)Friday, September 27, 2013

PathogensPathogens
 NosocomialNosocomial
– E. Coli—50%E. Coli—50%
– KlebsiellaKlebsiella
– EnterobacterEnterobacter
– CitrobacterCitrobacter
– SerratiaSerratia
– PseudomonasPseudomonas
– S. epidermitisS. epidermitis
 Community-AcquiredCommunity-Acquired
– E. Coli—85%E. Coli—85%
– ProteusProteus
– KlebsiellaKlebsiella
– E. faecalisE. faecalis
– Staph.Staph.
Saprophyticus(10%Saprophyticus(10%
of young sexuallyof young sexually
active females)active females)

Community-Acquired UTICommunity-Acquired UTI
E.coli
K.pneumoniae
Proteus
S.saprophyticus
S.epi &
gm - enterics
Enterococcus

Nosocomial UTINosocomial UTI
catheter associatedcatheter associated
Short Term Long Term
E.coli
E.coli
Pseudomonas
Pseudomonas
Proteus
Proteus
Enterobacter
Candida
Providencia
Morganella
S.aureus
Enterococcus

Causative organismsCausative organisms
 Gram +ve: Enterococci, StaphylococcusGram +ve: Enterococci, Staphylococcus
saprophyticus.saprophyticus.
 Gram –ve:Gram –ve: Escherichia coliEscherichia coli,, ProteusProteus
species,species, Pseudomonas aeruginosaPseudomonas aeruginosa,,
KlebsiellaKlebsiella strains.strains.
 Also: Mycobacterium tuberculosisAlso: Mycobacterium tuberculosis

Escherichia coliEscherichia coli
 E. coli (serotypes: 02, O4, O6) which areE. coli (serotypes: 02, O4, O6) which are
fimbrinated strains adhering to uro-fimbrinated strains adhering to uro-
epithelial cells, leading to colonization andepithelial cells, leading to colonization and
infection is the commonest cause of urinaryinfection is the commonest cause of urinary
tract infections.tract infections.

Gram negative bacilliGram negative bacilli
 Pseudomonas, Proteus, and KlebsiellaPseudomonas, Proteus, and Klebsiella
infections often follow catheterization andinfections often follow catheterization and
gynecological surgery (nosocomialgynecological surgery (nosocomial
pathogen).pathogen).
 Infection with proteus may be complicatedInfection with proteus may be complicated
by phosphate stone formation as it is ureaby phosphate stone formation as it is urea
leads to alkaline pH.leads to alkaline pH.

S. saprophyticusS. saprophyticus
 Infection more common in young women.Infection more common in young women.

What parts of the urinary
tract can get infected?
Urethra - Urethritis
Urinary bladder – Cystitis
Ureters – Ureteritis
Kidneys - Pyelonephritis

IncidenceIncidence
 1-3% of all GP consultations1-3% of all GP consultations
 5% of women each year with symptoms. Up5% of women each year with symptoms. Up
to 50% of women will suffer from ato 50% of women will suffer from a
symptomatic UTI during their lifetime.symptomatic UTI during their lifetime.
 UTI in men is much rarerUTI in men is much rarer
 A proportion of patients may beA proportion of patients may be
symptomatic in the absence of infection -symptomatic in the absence of infection -
called 'urethral syndrome'called 'urethral syndrome'

What are the signs and symptoms
of UTI?
Cystitis
Frequency
Urgency
Dysuria – painful voiding
Pain or discomfort in
suprapubic or perineal
area or lower back
Cloudy or foul-smelling
urine

CausesCauses
 The most common cause is bacterial infectionThe most common cause is bacterial infection
– Eschericia coli is the pathogen in 70% ofEschericia coli is the pathogen in 70% of
uncomplicated case of lower urinary tract infections.uncomplicated case of lower urinary tract infections.
– Other organisms include Proteus mirabilis, KlebsiellaOther organisms include Proteus mirabilis, Klebsiella
pneumoniae, Staphylococcus saprophyticus,pneumoniae, Staphylococcus saprophyticus,
Staphylococcus aureus and Pseudomonas species.Staphylococcus aureus and Pseudomonas species.
 Urethral Syndrome -not associated with anyUrethral Syndrome -not associated with any
infectioninfection
 Rarely kidney or bladder stones, prostatism,Rarely kidney or bladder stones, prostatism,
diabetesdiabetes

PreventionPrevention
 Drinking plenty of fluids helps preventDrinking plenty of fluids helps prevent
cystitis in the first place.cystitis in the first place.
 If cystitis follows sexual intercourse, someIf cystitis follows sexual intercourse, some
advise passing urine soon after to try andadvise passing urine soon after to try and
prevent it.prevent it.
 There is no evidence to suggest a linkThere is no evidence to suggest a link
between lower urinary tract infection andbetween lower urinary tract infection and
use of bath preparationsuse of bath preparations

Beware!Beware!
 PregnantPregnant
 Under age 12Under age 12
 MalesMales
 Systemically ill (fever, sickness, backache)Systemically ill (fever, sickness, backache)
 Catheterised patientsCatheterised patients
 Kidney or bladder stonesKidney or bladder stones

InvestigationInvestigation
 Urine dipstickUrine dipstick
– can be done in the surgery and will be positive for nitrates andcan be done in the surgery and will be positive for nitrates and
leucocytes (leukocyte esterase test). This helps to differentiateleucocytes (leukocyte esterase test). This helps to differentiate
those with UTI from the 50% with urethral syndrome.those with UTI from the 50% with urethral syndrome.
 Urine microscopy and culture reveals significant bacteruriaUrine microscopy and culture reveals significant bacteruria
(usually >105 /ml).(usually >105 /ml).
 Asymptomatic bacteruriaAsymptomatic bacteruria
– is present in 12-20% of women aged 65-70 years and does notis present in 12-20% of women aged 65-70 years and does not
impair renal function or shorten life so no treatmentimpair renal function or shorten life so no treatment
– in 4-7% of pregnant women and associated with prematurein 4-7% of pregnant women and associated with premature
delivery and low birth weight and always requires treatment.delivery and low birth weight and always requires treatment.

Differential DiagnosisDifferential Diagnosis
 Urethral syndromeUrethral syndrome
 Bladder lesion e.g. calculi, tumour.Bladder lesion e.g. calculi, tumour.
 Candidal infectionCandidal infection
 Chlamydia or other sexually transmitted disease.Chlamydia or other sexually transmitted disease.
 UrethritisUrethritis
 Drug induced cystitis (e.g. withDrug induced cystitis (e.g. with
cyclophosphamide, allopurinol, danazol,cyclophosphamide, allopurinol, danazol,
tiaprofenic acid and possibly other NSAIDs)tiaprofenic acid and possibly other NSAIDs)

Complications and PrognosisComplications and Prognosis
 Ascending infection can occur, leading to development ofAscending infection can occur, leading to development of
pyelonephritis, renal failure and sepsis.pyelonephritis, renal failure and sepsis.
 In children, the combination of vesicoureteric reflux andIn children, the combination of vesicoureteric reflux and
urinary tract infection can lead to permanent renalurinary tract infection can lead to permanent renal
scarring, which may ultimately lead to the development ofscarring, which may ultimately lead to the development of
hypertension or renal failure. 12-20% of children alreadyhypertension or renal failure. 12-20% of children already
have radiological evidence of scarring on their firsthave radiological evidence of scarring on their first
investigation for UTI.investigation for UTI.
 Urinary tract infection during pregnancy is associated withUrinary tract infection during pregnancy is associated with
prematurity, low birth weight of the baby and a highprematurity, low birth weight of the baby and a high
incidence of pyelonephritis in women.incidence of pyelonephritis in women.
 Recurrent infection occurs in up to 20% of young womenRecurrent infection occurs in up to 20% of young women
with acute cystitis.with acute cystitis.

Management Issues - GeneralManagement Issues - General
 50% will resolve in 3 days without50% will resolve in 3 days without
treatmenttreatment
 No evidence to support “drink plenty”No evidence to support “drink plenty”
 It is reasonable to start treatment withoutIt is reasonable to start treatment without
culture if the dipstick is positive for nitratesculture if the dipstick is positive for nitrates
or leucocytes.or leucocytes.
 MSU if dipstick negative but suspicionMSU if dipstick negative but suspicion

Management Issues - GeneralManagement Issues - General
 Culture is always indicated inCulture is always indicated in
– MenMen
– Pregnant womenPregnant women
– ChildrenChildren
– Those with failure of empirical treatmentThose with failure of empirical treatment
– Those with complicated infectionThose with complicated infection

Self careSelf care
 Drink slightly acid drinks such as cranberryDrink slightly acid drinks such as cranberry
juice, lemon squash or pure orange juicejuice, lemon squash or pure orange juice
(poor trial evidence for this)(poor trial evidence for this)
 Try a mixture of potassium citrate availableTry a mixture of potassium citrate available
from your pharmacist (little evidence butfrom your pharmacist (little evidence but
widely recommended)widely recommended)

AntibioticsAntibiotics
 Trimethoprim is an effective first line treatment.Trimethoprim is an effective first line treatment.
 Cephalosporins are as effective as trimethoprimCephalosporins are as effective as trimethoprim
but more expensive and more likely to disrupt gutbut more expensive and more likely to disrupt gut
flora.flora.
 Nitrofurantoin is as effective as trimethoprim butNitrofurantoin is as effective as trimethoprim but
more expensive and frequently causes nausea andmore expensive and frequently causes nausea and
vomitingvomiting
 The 4-quinolones (ciprofloxacin, norfloxacin,The 4-quinolones (ciprofloxacin, norfloxacin,
ofloxacin) are effective in the treatment of cystitis.ofloxacin) are effective in the treatment of cystitis.
To preserve their efficacy, they should not usuallyTo preserve their efficacy, they should not usually
be used as first line therapybe used as first line therapy

AntibioticsAntibiotics
 3 days of antibiotic is as effective as 5 or 7 days3 days of antibiotic is as effective as 5 or 7 days
 Single dose antibiotic results in lower cure ratesSingle dose antibiotic results in lower cure rates
and more recurrences overall than longer courses.and more recurrences overall than longer courses.
 In relapse of infection (i.e. reinfection with theIn relapse of infection (i.e. reinfection with the
same bacteria), treatment with antibiotic for up tosame bacteria), treatment with antibiotic for up to
6 weeks is recommended.6 weeks is recommended.

T r e a t m e n t o f R e c u r r e n t C y s t i t i s
T r e a t l o n g e r ( 2 - 6 w e e k s )
R e l a p s e
S e e k o c c u l t s o u r c e o f i n f e c t o n
U r o l o g i c e v a l u a t i o n
D a i l y o r t h r i c e
w e e k l y p r o p h y l a x i s
N o r e l a t i o n t o c o i t u s
P o s t c o i t a l
p r o p h y l a x i s
T e m p o r a l l y
r e l a t e d t o c o i t u s
³ 3 U T I / y r
P a t i e n t i n i t i a t e d t h e r a p y
³ 2 U T I / y r
U r o l o g i c e v a l u a t i o n n o t
r o u t i n e l y i n d i c a t e d
R e i n f e c t i o n
D i a p h r a g m a n d s p e r m i c i d e
C o n s i d e r c h a n g i n g c o n t r a c e p t i v e
m e t h o d
R e c u r r e n t C y s t i t i s

Antibiotics for UTI in PregnancyAntibiotics for UTI in Pregnancy
 Cephalosporins and penicillins are recommendedCephalosporins and penicillins are recommended
in pregnancy because of their long term safetyin pregnancy because of their long term safety
recordrecord
 Nitrofurantoin is also likely to be safe duringNitrofurantoin is also likely to be safe during
pregnancypregnancy
 Quinolones, Trimethoprim and Tetracyclines areQuinolones, Trimethoprim and Tetracyclines are
not recommended for use during pregnancynot recommended for use during pregnancy
 Seven days of treatment is required.Seven days of treatment is required.
 Urine should be tested regularly throughoutUrine should be tested regularly throughout
pregnancy following initial infection.pregnancy following initial infection.

Fever
Nausea and vomiting
More pronounced malaise
Pain in the back
(+) CVA tenderness
Acute
pyelonephritis

Acute PyelonephritisAcute Pyelonephritis

Clinical ManifestationsClinical Manifestations
 Classic signs of cystitisClassic signs of cystitis
– EnuresisEnuresis
– FrequencyFrequency
– DysuriaDysuria
– HesitancyHesitancy
– Suprapubic discomfortSuprapubic discomfort
 Classic signs of pyelonephritisClassic signs of pyelonephritis
– +/- UTI signs+/- UTI signs
– ChillsChills
– NauseaNausea
– Flank painFlank pain
In
older children and
adults

But… In InfantsBut… In Infants
 Fever! Fever!!Fever! Fever!!
Fever!!!Fever!!!
 Lack classic signsLack classic signs
 IrritabiltyIrritabilty
 Poor feedingPoor feeding
 VomitingVomiting
 DiarrheaDiarrhea
Present in <1/2 of infants with UTIs

Risk factorsRisk factors
 Female (30%:10%)Female (30%:10%)
– Shorter urethral lengthShorter urethral length
– Urethral opening close to the anusUrethral opening close to the anus
– Exposure to spermicideExposure to spermicide
» Has antimicrobial activity, disrupt the periurethralHas antimicrobial activity, disrupt the periurethral
flora contentflora content

Risk Factors: continuedRisk Factors: continued
 Factors that prohibitFactors that prohibit
complete emptying ofcomplete emptying of
the bladderthe bladder
– ConstipationConstipation
– cystocele, rectocele,cystocele, rectocele,
uterine prolapse,uterine prolapse,
urinary calculi, BPHurinary calculi, BPH
 Estrogen deficiencyEstrogen deficiency
 Oral antimicrobialsOral antimicrobials
 ImmobilityImmobility
 Poor hygienePoor hygiene
 Poor toileting habitsPoor toileting habits
 Fecal incontinenceFecal incontinence
 CatheterizationCatheterization
 Diabetes mellitusDiabetes mellitus
 DehydrationDehydration

DiagnosisDiagnosis
 Urine CollectionUrine Collection
– SuprapubicSuprapubic
AspirationAspiration
– CatheterizedCatheterized
specimenspecimen
– VoidedVoided
specimenspecimen
 UrinalysisUrinalysis
– Sensitive toSensitive to
colonies ofcolonies of
30K/ml or less30K/ml or less
– Bacteria seenBacteria seen
on microscopyon microscopy
with no growthwith no growth
may be vaginalmay be vaginal
floraflora

Specimen collectionSpecimen collection
 Samples should be collected before the startSamples should be collected before the start
of antibiotics.of antibiotics.
 Transport within 2 h. if delay is suspectedTransport within 2 h. if delay is suspected
then refrigeration at 4C or boric acid.then refrigeration at 4C or boric acid.
 Mid stream urine.Mid stream urine.
 Adhesive bags; in infants.Adhesive bags; in infants.

The Positive CultureThe Positive Culture
 SuprapubicSuprapubic
– Any number of pathogensAny number of pathogens
– Should be completely sterileShould be completely sterile
 TransurethralTransurethral
– 101033
colony forming unitscolony forming units
 Clean catchClean catch
– 101055
colony forming unitscolony forming units

Know the Adequacy of YourKnow the Adequacy of Your
TestsTests
 ““standard urinalysis”standard urinalysis”
– Urine dipstickUrine dipstick
– MicroscopyMicroscopy
 ““enhanced urinalysis”enhanced urinalysis”
– MicroscopyMicroscopy
– Gram stainGram stain
– 84% sensitivity84% sensitivity
 Neither is sensitive enough to rule out UTINeither is sensitive enough to rule out UTI
Nitrites
Leukocyte esterase
15% of UTIs missed if culture not done

UTI - Who should be studied?UTI - Who should be studied?
 Acute pyelonephritisAcute pyelonephritis AllAll febrile UTIsfebrile UTIs
 Males of any age with first UTIMales of any age with first UTI
 Girls younger than 3 years with first UTIGirls younger than 3 years with first UTI
 Girls older than 3 years with second UTIGirls older than 3 years with second UTI
 Girls older than 3 years with first UTI with:Girls older than 3 years with first UTI with:
– Family history of UTIsFamily history of UTIs
– Abnormal voiding patternAbnormal voiding pattern
– Poor growthPoor growth
– HypertensionHypertension
– Abnormalities of urinary tractAbnormalities of urinary tract
– Failure to respond promptly to therapyFailure to respond promptly to therapy

Clinical ManifestationsClinical Manifestations
Feature Cystitis Pyelonephritis Urosepsis
Dysuria,
frequency
+ + or - + or -
Suprapubic pain + + or - + or Ğ
Fever,
tachycardia,
hypotension etc.
- + +
CVA tenderness - + + or -
Duration of
symptoms (days)
1 Ğ 7 1 Ğ 2 <1 - 1

Imaging TechniquesImaging Techniques
 IndicationsIndications
– Evaluation ofEvaluation of
obstructionobstruction
– Persistence ofPersistence of
fever after 5-6fever after 5-6
days of treatmentdays of treatment
– DiabetesDiabetes
MellitusMellitus
– TB, fungus, ureaTB, fungus, urea
splittingsplitting

Pyelonephritis by MRIPyelonephritis by MRI

Intrarenal abscess by CTIntrarenal abscess by CT

Perinephric abscess by CTPerinephric abscess by CT

A 3y/o boy has fever, shaking chills, and flank painA 3y/o boy has fever, shaking chills, and flank pain
consistent with a diagnosis of pyelonephritits.consistent with a diagnosis of pyelonephritits.
Of the following, the BEST procedure to performOf the following, the BEST procedure to perform
immediately to define the anatomy of the genitourinaryimmediately to define the anatomy of the genitourinary
tract is:tract is:
– A. cystoscopyA. cystoscopy
– B. intravenous pyelographyB. intravenous pyelography
– C. radioisotopic renographyC. radioisotopic renography
– D. renal ultrasonographyD. renal ultrasonography
– E. voiding cysourethrogramE. voiding cysourethrogram

Emphysematous PyelonephritisEmphysematous Pyelonephritis
 1898 in JAMA: pneumaturia1898 in JAMA: pneumaturia
 An acute necrotizing infection cause by gasAn acute necrotizing infection cause by gas
formationformation
 Incidence: middle-aged or elderlyIncidence: middle-aged or elderly
 Diabetes (90%), or obstructive renal unitDiabetes (90%), or obstructive renal unit
 Female-to-man = 6:1Female-to-man = 6:1
 Left kidney: 60%Left kidney: 60%
 Mortality: 20~80%Mortality: 20~80%

Emphysematous PyelonephritisEmphysematous Pyelonephritis
/ Pathogenesis/ Pathogenesis
 Acute bacterial and fungal infection:Acute bacterial and fungal infection:
-- E. Coli: 70~90%-- E. Coli: 70~90%
-- Klebsiella, Proteus, Clostridium and-- Klebsiella, Proteus, Clostridium and
CandidaCandida
 Gas in upper urinary tract:Gas in upper urinary tract:
-- iatrogenically via upper tract manipulation-- iatrogenically via upper tract manipulation
-- fistula to bowel-- fistula to bowel
-- ascending infection-- ascending infection

Emphysematous Pyelonephritis /Emphysematous Pyelonephritis /
pathogenesispathogenesis
 Gas extension: renal and hepatic veinGas extension: renal and hepatic vein
 Diabetics predisposed to gas formation:Diabetics predisposed to gas formation:
-- high glucose level throughout tissue-- high glucose level throughout tissue
-- diabetic microangiopathic disease-- diabetic microangiopathic disease
-- immunodeficient-like state-- immunodeficient-like state

clinical findingsclinical findings
 Unilateral: 90%Unilateral: 90%
 Clinical findings:Clinical findings:
-- fever and pyuria: 80%-- fever and pyuria: 80%
-- flank or abdominal pain: 70%-- flank or abdominal pain: 70%

clinical findingsclinical findings
 Huang et al:Huang et al:
-- 48 cases-- 48 cases
-- 46 cases: diabetics-- 46 cases: diabetics
-- mortality: initial presentation-- mortality: initial presentation
1). thrombocytopenia1). thrombocytopenia
2). acute renal insufficiency2). acute renal insufficiency
3). Proteinuria3). Proteinuria
4). Mental status change4). Mental status change
5). Shock5). Shock
-- no affect: age, sex, site of infection and glucose-- no affect: age, sex, site of infection and glucose
levellevel

Radiological findingsRadiological findings
 CT: modality of choiceCT: modality of choice
-- excellent sensitivity and precise-- excellent sensitivity and precise
localization of gaslocalization of gas
 Abdomen radiograph: poor sensitivityAbdomen radiograph: poor sensitivity
(33%)(33%)

ManagementManagement
 Traditionally: requiring emergent nephrectomyTraditionally: requiring emergent nephrectomy
 Minimally invasive drainage: acceptableMinimally invasive drainage: acceptable
-- equivalent success to surgery-- equivalent success to surgery
 Release obstructionRelease obstruction
 Quinolone therapyQuinolone therapy
 Huang: thrombocytopenia, acute renalHuang: thrombocytopenia, acute renal
insufficiency, mental status change and shockinsufficiency, mental status change and shock
-- <2: percutaneous drainage + IV antibiotics-- <2: percutaneous drainage + IV antibiotics
-- ≥2: emergency nephrectomy-- ≥2: emergency nephrectomy

XanthogranulomatousXanthogranulomatous
pyelonephritispyelonephritis
 XGP: chronic suppurative atypical renalXGP: chronic suppurative atypical renal
parenchymal infectionparenchymal infection
 Imitator: RCC, abscess and inflammatoryImitator: RCC, abscess and inflammatory
diseasedisease
 Associated: renal calculi and chronicAssociated: renal calculi and chronic
urinary tract infectionurinary tract infection
 Majority involve: non-functional kidneyMajority involve: non-functional kidney

XGP / IncidenceXGP / Incidence
 0.6% of all surgically proven renal infection0.6% of all surgically proven renal infection
 Women : men = 4:1Women : men = 4:1
 More commonly in diabeticsMore commonly in diabetics
 5th ~ 7th decades5th ~ 7th decades
 Almost always unilateralAlmost always unilateral

XGP / PathogenesisXGP / Pathogenesis
 Not been elucidatedNot been elucidated
 Play a role:Play a role:
-- urinary tract anomalies, obstruction, chronic-- urinary tract anomalies, obstruction, chronic
infection, renal ischemia, immunodeficiency andinfection, renal ischemia, immunodeficiency and
abnormal lipid metabolismabnormal lipid metabolism
 Diagnosis: made by histological examination ofDiagnosis: made by histological examination of
surgically removed kidneysurgically removed kidney
 Characteristic: foamy macrophageCharacteristic: foamy macrophage
 Culture: proteus mirabilus (50%), E. Coli (20%)Culture: proteus mirabilus (50%), E. Coli (20%)

XGP / Clinical findingsXGP / Clinical findings
 Quite nonspecific:Quite nonspecific:
-- anemia, malaise, leukocytosis, pyuria, flank-- anemia, malaise, leukocytosis, pyuria, flank
pain or flank masspain or flank mass ……
 Children: weight loss or failure to thriveChildren: weight loss or failure to thrive
 Associated:Associated:
-- renal calculi: 75%-- renal calculi: 75%
-- CPN: 78%-- CPN: 78%

XGP / Radiological findingsXGP / Radiological findings
 Renal ultrasound: hypoechoic massRenal ultrasound: hypoechoic mass
 Advent CT: accurate with sensitivity (90%)Advent CT: accurate with sensitivity (90%)
-- poor enhancing mass, thickened-- poor enhancing mass, thickened
GerotaGerota’’s fascia and bears fascia and bear’’s paw signs paw sign

XGP / ManagementXGP / Management
 Absolutely no medical therapyAbsolutely no medical therapy
 Open surgical nephrectomy: standard careOpen surgical nephrectomy: standard care
 XGP kidney: extension to hilium and contiguousXGP kidney: extension to hilium and contiguous
organorgan
-- laparoscopic surgery: not apply-- laparoscopic surgery: not apply
 Bercowsky:Bercowsky:
-- laparoscopic nephrectomy: 60%-- laparoscopic nephrectomy: 60%
complications vs opencomplications vs open
 Focal variety of XGP: nephron sparing surgeryFocal variety of XGP: nephron sparing surgery

Acute Uncomplicated Pyelonephritis in WomenAcute Uncomplicated Pyelonephritis in Women
 Mild-to-moderate illnessMild-to-moderate illness
– Outpatient therapyOutpatient therapy
– Fluoroquinolone 7 - 14 daysFluoroquinolone 7 - 14 days
 Severe illnessSevere illness
– Hospitalization requiredHospitalization required
– Parenteral cephalosporin, fluoroquinolone orParenteral cephalosporin, fluoroquinolone or
aminoglycoside, after afebrile - oral therapy (10 - 14aminoglycoside, after afebrile - oral therapy (10 - 14
day total)day total)
 Pregnancy - avoid fluoroquinolonesPregnancy - avoid fluoroquinolones

UTI ImagingUTI Imaging
 Renal ultrasoundRenal ultrasound
 IVUIVU
 Voiding cystourethrogramVoiding cystourethrogram
 DMSA or glucoheptonate scanDMSA or glucoheptonate scan
 CT – rarely neededCT – rarely needed

VCUG - fluoro
B/L Reflux
R – grade IV
L – grade III
DMSA
L upper pole perfusion defect
At site of inflammation or scar

 What determines a positive urine culture?What determines a positive urine culture?
 Suprapubic?Suprapubic?
 Transurethral?Transurethral?
 Clean-Catch?Clean-Catch?
 Why do we care so much about prompt diagnosis andWhy do we care so much about prompt diagnosis and
treatment?treatment?
Suprapubic
Any number of pathogens
Transurethral
103
colony forming units
Clean catch
105
colony forming units
27-64% of those with pyelonephritis develop renal scarring
13-15% of end stage renal disease
Due to
Undiagnosed/Untreated UTI in childhood

Principles of Antimicrobial TherapyPrinciples of Antimicrobial Therapy
 Treatment of UTI should result in sterileTreatment of UTI should result in sterile
urine.urine.
 Antimicrobial levels in urine.Antimicrobial levels in urine.
 Resistant clones present 5-10% of casesResistant clones present 5-10% of cases
with empiric treatment.with empiric treatment.

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

TreatmentTreatment
 Cystitis—3 DaysCystitis—3 Days
– 7 Days if duration of7 Days if duration of
symptoms, Diabetes, agesymptoms, Diabetes, age
greater than 65, orgreater than 65, or
pregnancypregnancy
 PyelonephritisPyelonephritis
– WomenWomen
» 7 days uncomplicated7 days uncomplicated
without sepsiswithout sepsis
» Inpatient 10-14 daysInpatient 10-14 days
 Comlicated PyelonephritisComlicated Pyelonephritis
– 14-21 day course14-21 day course
 ProphylaxisProphylaxis
– Endocarditis—Amp/GentEndocarditis—Amp/Gent
or Vanc/Gentor Vanc/Gent
– Indwelling catheter—2Indwelling catheter—2
Doses(prior susceptibility)Doses(prior susceptibility)
– Catheter removal—preopCatheter removal—preop
and 72 hours afterand 72 hours after
– TURP—Pre and Post OpTURP—Pre and Post Op

Candidates for ProphylaxisCandidates for Prophylaxis
 Women with ≥ 3 symptomatic uncomplicatedWomen with ≥ 3 symptomatic uncomplicated
infections per 12 monthsinfections per 12 months
 Pregnant women with asymptomaticPregnant women with asymptomatic
bacteriuria or previous symptomatic UTI isbacteriuria or previous symptomatic UTI is
pregnancypregnancy
 Men with recurrent UTIsMen with recurrent UTIs

Prostatitis

Prostatitis: classificationProstatitis: classification
 Acute vs. chronic vs. prostatodyniaAcute vs. chronic vs. prostatodynia
 Source of infectionSource of infection
– Ascending urethral infection, urinary reflux, extensionAscending urethral infection, urinary reflux, extension
of rectal infection, or hematogenous spreadof rectal infection, or hematogenous spread
 BacterialBacterial
– E. coli, Proteus, Klebsiella, Pseudomonas, enterococci,E. coli, Proteus, Klebsiella, Pseudomonas, enterococci,
Chlamydia, UreaplasmaChlamydia, Ureaplasma
 Other agentsOther agents
– Viral, fungal, andViral, fungal, and TrichomonasTrichomonas

Prostatitis: classificationProstatitis: classification
Bacteriuria Localized
prostate
infection
Inflammatory
response
Abnormal
prostate
exam
Systemic
illness
Acute
bacterial
prostatitis
+ + + + +
Chronic
bacterial
prostatitis
+ + + - -
Prostato-
dynia - - +/- +/- -

Prostatic massageProstatic massage
 AVOID IN ACUTE PROSTATITISAVOID IN ACUTE PROSTATITIS
 4 tube approach4 tube approach
– VB1: urethral urinary sampleVB1: urethral urinary sample
– VB2: bladder urinary sampleVB2: bladder urinary sample
– EPS: expressed prostate secretionsEPS: expressed prostate secretions
– VB3: post-massage urinary sampleVB3: post-massage urinary sample
» >10 WBC/hpf abnormal>10 WBC/hpf abnormal
» >5,000 colonies/mm abnormal>5,000 colonies/mm abnormal
 2 tube approach2 tube approach

Acute bacterial prostatitisAcute bacterial prostatitis
 HistoryHistory
– Lower urinary tract obstruction, perineal pain,Lower urinary tract obstruction, perineal pain,
dysuria, and feverdysuria, and fever
– Systemic symptomsSystemic symptoms
 PhysicalPhysical
– Tender, warm, boggy, swollen prostateTender, warm, boggy, swollen prostate
– Massage isMassage is NOTNOT indicated in acute prostatitisindicated in acute prostatitis

Acute bacterial prostatitisAcute bacterial prostatitis
 ManagementManagement
– Outpatient therapyOutpatient therapy
» Bactrim, ampicillin, or quinolone for 4 – 6 weeksBactrim, ampicillin, or quinolone for 4 – 6 weeks
» Bedrest, analgesics, antipyretics, stool softenersBedrest, analgesics, antipyretics, stool softeners
– Inpatient therapyInpatient therapy
» Parental antibiotics: ampicillin and gentamycinParental antibiotics: ampicillin and gentamycin
» Avoid urethral catheterization for retentionAvoid urethral catheterization for retention
» Urology consultUrology consult

Chronic bacterial prostatitisChronic bacterial prostatitis
 HistoryHistory
– Bladder outflow obstructionBladder outflow obstruction
– Dysuria; perineal, low back, or testicular painDysuria; perineal, low back, or testicular pain
– Hematuria, hematospermia, painful ejaculationHematuria, hematospermia, painful ejaculation
 Physical examinationPhysical examination
– Variable prostate examVariable prostate exam
 Relapsing UTI in men is the hallmark of chronicRelapsing UTI in men is the hallmark of chronic
bacterial prostatitisbacterial prostatitis
– GNR most common; alsoGNR most common; also Enterococcus and S. saprophyticusEnterococcus and S. saprophyticus

Chronic bacterial prostatitisChronic bacterial prostatitis
 ManagementManagement
– Difficult to eradicate given poor penetration ofDifficult to eradicate given poor penetration of
antibiotic into the non-inflamed prostateantibiotic into the non-inflamed prostate
– Bactrim and fluoroquinolonesBactrim and fluoroquinolones
» Doxycycline and macrolides second-lineDoxycycline and macrolides second-line
– Prolonged treatment requiredProlonged treatment required
– Recheck prostatic fluid after treatmentRecheck prostatic fluid after treatment
– Alpha-blockers to reduce symptomsAlpha-blockers to reduce symptoms
– Suppressive therapySuppressive therapy

Prostatitis: complicationsProstatitis: complications
 Renal parenchymal infectionRenal parenchymal infection
 BacteremiaBacteremia
 Prostate abscessProstate abscess
– ImmunocompromisedImmunocompromised
– FB; obstructionFB; obstruction
 Prostatic stonesProstatic stones
– Nidus for persistentNidus for persistent
infectioninfection

ProstatodyniaProstatodynia
 HistoryHistory
– Persistent pelvic, suprapubic, infrapubic, scrotal,Persistent pelvic, suprapubic, infrapubic, scrotal,
inguinal, or perineal paininguinal, or perineal pain
– Lower tract obstruction and dysuriaLower tract obstruction and dysuria
– Absence of systemic symptomsAbsence of systemic symptoms
 Physical exam usually unremarkablePhysical exam usually unremarkable
 No bacteria identified and no evidence ofNo bacteria identified and no evidence of
inflammation presentinflammation present
 Limited course of antibiotics, alpha blockadeLimited course of antibiotics, alpha blockade

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