undergraduate, UTI

1. Urology Department
Under-graduate courses
Urinary Tract Infections
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

2. Definition
• UTI is invasion of the urothelium that
results in an inflammatory response.
• A complicated urinary infection carries a
moderate to high risk of sepsis, with
significant morbidity and mortality.
• Bacteriuria is a bacterial urinary tract
infection that occurs without any of the
usual symptoms.
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3. Epidemiology of UTI
• Urinary tract infection (UTI) is the most common
nosocomial infection.
• They are the most common bacterial infection
found in the elderly and the most frequent
source of bacteremia
• The incidence ratio of UTIs in middle-aged
women to men is 30:1.
• UTI is less common in men because the extra
urethral length prevents bacterial colonization of
bladder.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

4. Features of UTI
• Cystitis produces symptoms of frequency,
urgency, dysuria, and suprapubic pain.
• Local symptoms may be absent, particularly in
elderly people.
• Ascending infection causes pyelonephritis,
which typically presents with fever, loin pain, and
malaise
• Functional or structural abnormality may be
detected (complicated UTI).
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

5. Risk factors for complicated urinary
tract infection
• Male sex.
• Urinary tract instrumentation.
• Old age.
• Pregnancy.
• Symptoms for > 7 days.
• Immunosuppression.
• Hematuria.
• Functional or structural abnormality.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

6. Common urinary bacterial pathogens
• Most urinary infection is ascending from the
perineum, displacing commensal organisms.
• The number of bacteria in the bladder is critical
to the development of urinary tract infections.
• Most of bacteria are Gram -ve bacteria.
• In young women, Staphylococcus saprophyticus
is the 2nd most common urinary pathogen and
is almost always related to sexual activity.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

7. Common urinary bacterial pathogens
• Escherichia coli • Providencia spp
• Klebsiella spp • Streptococcus
faecalis
• Proteus spp
• Citrobacter spp
• Pseudomonas spp
• Serratia spp
• Staphylococcus
saprophyticus • Enterococcus
faecalis
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

8. Bacterial adherence
• The process of bacterial cell adhesion is
the key to urinary tract infection
• Bacterial adhesinos produced by pili on
the bacterial surface are important in
pathogenesis, (for example, the P fimbriae
possessed by E coli).
• Adhesions of bacteria to epithelium is
followed by proliferation, invasion, and
initiation of the inflammatory process.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

9. Upper urinary tract infections
• These may be acute or chronic infections
• They are mostely due to ascending
infection and for this reason 75% are
associated with lower urinary tract
symptoms
• Types : 1-Acute pyelonephritis.
2-Chronic pyelonephritis.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

10. Acute pyelonephritis
Pathology:
• It is acute Inflammation of the renal pelvis, calyces and renal
parenchyma .(This is the most common upper urinary tract
infection).
• It is usually due to ascending infection with bacteria entering
the kidney via the ureter, renal pelvis and collecting ducts.
Clinical features:
• The two classic symptoms are pyrexia and loin pain.
• Rigors are common due to the release of bacteria into the
bloodstream and septicemia may occur, especially if infection
is associated with obstruction..
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

11. Acute pyelonephritis
Investigations and diagnosis
•Labs
1. urine analysis for leucocytes, bacteria and casts.
2. Blood cultures should be taken from all patients with
clinical suspicion of septicemia.
•Radio
1.plain abdominal x-ray may show a calculus or absence of
the psoas shadow on the affected side.
2.U/S will detect hydronephrosis (if obstruction assosiated).
3.IVU may show enlargement of the infected kidney with poor
concentration of the dye
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

12. Acute pyelonephritis
Complications
1-Pyonephrosis
The result of infection in an obstructed
kidney.
Prompt drainage under antibiotic cover is vital to prevent
irreversible renal damage.
This is best achieved by percutaneous nephrostomy
performed under local or general anaesthesia.
If there is no improvement with drainage; it is best to
perform a nephrectomy.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

13. Acute pyelonephritis
2- perinephric abscess
Initially, the infection is confined to Gerota’s fascia
but may then rupture to reach adjacent psoas
muscle, bowel or skin.
Surgical drainage under antibiotic cover is required.
If function in the affected kidney is very poor,
nephrectomy is the treatment of choice.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

14. Acute pyelonephritis
Treatment
Antibiotic therapy is the mainstay of treatment for
uncomplicated acute pyelonephritis.
 IV antibiotics in the initial stages to control
infection then changed to Oral antibiotics for at
least 2 weeks (to prevent recurrence).
 In the severely ill and septicemic patient,
emergency resuscitation may be required to
treat circulatory collapse.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

15. Chronic pyelonephritis
Pathology
• can be obstructive or non-obstructive
• Both give rise to recurrent infection and
renal scarring.
• Non-obstructive causes may be vesico-ureteric reflux and
infection in childhood or persistent bacteriuria between
repeated acute pyelonephritis in adults.
Clinical features
• recurrent symptomatic UTIs or subclinical with bacteriuria
detected on routine urine screening.
• Occasionally, presents at an advanced stage with chronic
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renal Failure.
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

16. Chronic pyelonephritis
Complications
• End-stage renal failure accounting for 15% of adult
cases and 30% of childhood cases.
Investigations and diagnosis
• US, IVU , CT Scan and renography may show cortical
scarring which overlies a deformed calyx.
Treatment
• Aims to eliminate inf. and prevent further renal damage.
• Symptomatic infections should be treated with an
appropriate antibiotic
• long-term low-dose antibiotics should be considered.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

17. Lower urinary tract infections
Acute bacterial cystitis
Pathology
• usually the result of ascending infection from perineum.
• It is much more common in women:
1. shorter female urethra.
2. position which is readily contaminated
with fecal organisms.
1. In postmenopausal women, atrophic vaginitis.
• In men and children, infection is more likely to be
associated with some Abnormality of the urinary tract.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

18. Acute bacterial cystitis
Clinical features
Symptoms Signs
 Frequency  usually unremarkable.
 Dysuria  occasionally, upper tract
 Urgency involvement
 Urge incontenece  abnormality predisposing
 Suprabupic pain to the infection.
 Hematuria (+/-).
 Occasionally fever and
rigors from (bacteremia).
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

19. Acute bacterial cystitis
Investigations and diagnosis
Lab
1-dipstick test.
 leucocyte esterase test detects pus cells
 nitrate reductase test detects bacteria that reduce
nitrate to nitrite.
2-urine analysis of midstream urine (MSU) confirms a
UTI [if >105 bacterial forming colonies (CFU) /ml].
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

20. Acute bacterial cystitis
Investigations and diagnosis
Further investigations if there 3 repeated episodes
of cystitis in women or a single episode in men:
 Serum creatinine and electrolytes
 KUB and Renal ultrasound for stones, scarring
 Bladder US for residual volume and uroflowmetry.
 cystoscopy in patients with very frequent infections
(fistula??)
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

21. Acute bacterial cystitis
Treatment
1- Increased fluid intake
2- A suitable antibiotic started immediately and
given for a 5-day period; changed if necessary,
on the basis of antibiotic sensitivity tests.
• If the initial course of antibiotics produces
resolution of symptoms the MSU should be
repeated at 2 weeks and again at 3 months to
ensure that infection has been eradicated.
©
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

22. Preventing UTIs in women
1-Wear cotton underwear
2-Always wipe from front to back after micturition or
defecation.
3-Drink plenty of fluids.
4-Empty bladder after intercourse & Wash genitala
regularly
5-occasionally long-term antibiotics for frequent infs.
6-Treatment of atrophic vaginitis in post-menopausal
women with hormone replacement
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

23. Chronic cystitis
Pathology
• recurrent bacterial infections, or inadequet treatment.
Causes of chronic cystitis
• Toxic drugs and chemicals e.g. cyclophosphamide
• Radiotherapy
• Viruses e.g. adenoviruses
• Parasitic infections e.g. schistosomiasis
• Interstitial cystitis
• Colovesical fistula
• Chronic irritation, (schistosomiasis, long-term Catheters or calculi).
©
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

24. Chronic cystitis
Clinical features
• same as the acute infections but tend to be
chronic in nature (day and night).
• Pneumaturia indicates a colovesical fistula.
Complications
Bladder cancer ( due to squamous metaplasia in
Long-standing inflammation).
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

25. Chronic cystitis
Investigations and diagnosis
• Lab : Urine cytology
• Rad : KUB & U/S to identify any underlying problems.
• For the cause :
# cystoscopy allows examination and biopsy of the bladder to
exclude malignancy.
# Barium enema may demonstrate colovesical fistula.
Treatment: (interstitial cystitis is difficult to treat )
• Any underlying cause should be treated where possible.
• bladder instillations may help including dimethylsulphoxid
(effective temporarily)
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

26. Prostatitis
Pathology
• Bacterial prostatitis: acute or chronic bacterial infection
• non-bacterial prostatitis: in absence of bacterial growth
Clinical features
Symptoms
• General : generalized malaise and fever.
• localized : pain in the perineum and
suprapubic areas with frequency and urgency of micturition.
Signs
• DRE shows tender prostate ( DRE is contraindicated in
prostatic abscess).
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

27. Prostatitis
 Investigations :
 Lab :
• Serum prostatic specific antigen (PSA) levels is raised.
• Demonstrations of bacteria in the post-prostatic massage of urine or
expressed prostatic secretions
 Rad :
• .Transrectal ultrasound
 Complications :
• Prostatic abscess can develop which is best drained transurethrally
rather than rectally to avoid the possibility of creating a prostato-
rectal fistula.
• Chronic pain is a feature of chronic prostatitis and this may be
exacerbated to prostatic carcinoma as a diagnosis.
©
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

28. Prostatitis
Treatment :
• Antimicrobial drugs for at least 6 weeks to prevent the development
of chronic bacterial prostatitis.
 N.B:
• Chronic bacterial prostatitis is one of the most common causes of
relapsing urinary tract infection
• Non-bacterial prostatitis is more common than bacterial prostatitis,
although the etiology is unknown and the treatment often empirical
and of variable effectiveness. A trial of tetracycline, alpha-adrenergic
blockers and skeletal muscle relaxantscan be tried
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

29. Epididymitis and orchitis
Pathology
• Infection may involve epididymis alone (epididymitis), the
testis alone (orchitis) or both organs (epididymo-orchitis).
• The majority of cases of epididymitis have an infectious
etiology, from urethra, prostate or bladder.
Clinical features
• pain and swelling of the scrotum.
• urethral discharge.
• Symptoms of UTI .
• The epididymis and testis are swollen and impossible to
distinguish Between them.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

30. Epididymitis and orchitis
Investigations and diagnosis
The main differential diagnosis of epididymitis (and orchitis) is
torsion of the testis .
• Microscopic examination of the urine and/or urethral
discharge may differentiate epididymitis from torsion.
• Doppler ultrasonography evaluate blood flow to scrotum:
 epididymitis is associated with increased blood flow
whereas torsion results in decreased blood flow.
• if there is any doubt about the diagnosis the testicles
should be explored.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

31. Epididymitis and orchitis
Treatment
• symptomatic treatment: bed rest, scrotal
elevation and analgesics.
• Antibiotics should always be given for up to 6
weeks to prevent relapse.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

32. Thank You
By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS