Urinary tract Infaction UTI means infection of any part of urinary tract (Kidney, Ureter, Bladder or Urethra) UTI means infection of any part of urinary tract (Kidney, Ureter, Bladder or Urethra) Defined by the presence of more than a hundred thousand organisms per ml in midstream sample of urine. Defined by the presence of more than a hundred thousand organisms per ml in midstream sample of urine. Dr S Chakradhar 1

Common organisms : E. coli, proteus, pseudomonas, klebsiella, Enterococcus fecalis, Staphylococcus saprophyticus or Staph epidermidis E. coli, proteus, pseudomonas, klebsiella, Enterococcus fecalis, Staphylococcus saprophyticus or Staph epidermidis Predisposing condition Urinary obstruction Urinary obstruction Pregnancy Pregnancy Vesicouretic reflux Vesicouretic reflux Sex & age – Common in female between 1 st year to 40 years of age Sex & age – Common in female between 1 st year to 40 years of age Common in male in advanced age due to prostatic hypertrophy Common in male in advanced age due to prostatic hypertrophy Diabetes mellitus Diabetes mellitus Immunosuppression & immunodeficiency Immunosuppression & immunodeficiency Instrumentation like cauterization Instrumentation like cauterization 2 Dr S Chakradhar

Routes of spreads : Ascending transurethral route Ascending transurethral route From the lower UT is the commonest From the lower UT is the commonest At first there is colonisation of the distal urethra & introitus in female by coliform bacteria At first there is colonisation of the distal urethra & introitus in female by coliform bacteria Hematogenous Hematogenous Through blood stream e.g. septicaemia Through blood stream e.g. septicaemia Lymphatics Lymphatics Direct extension from vesico colic fistula Direct extension from vesico colic fistula Dr S Chakradhar 3

Classification Lower urinary tract infection (Urethritis, Cystitis, Prostatitis) Lower urinary tract infection (Urethritis, Cystitis, Prostatitis) Upper urinary tract (Pyelonephritis) Upper urinary tract (Pyelonephritis) Complicated UTI Complicated UTI Is considered to be present when there are underlying factors that predispose to ascending bacterial infection. Is considered to be present when there are underlying factors that predispose to ascending bacterial infection. Uncomplicated UTI Uncomplicated UTI Occurs without underlying abnormality or impairment of urine flow. Occurs without underlying abnormality or impairment of urine flow. Dr S Chakradhar 4

Clinical features: Fever, rigor. Vomiting Fever, rigor. Vomiting Increased frequency, urgency, dysuria (scalding pain during passage of urine ) Increased frequency, urgency, dysuria (scalding pain during passage of urine ) Intense desire to pass more urine Intense desire to pass more urine Suprapubic pain during and after micturation in case of cystitis. Suprapubic pain during and after micturation in case of cystitis. Urine may be cloudy. Sometimes gross hematuria. Urine may be cloudy. Sometimes gross hematuria. There may be slight or no systemic disturbance. There may be slight or no systemic disturbance. Dr S Chakradhar 5

Investigation: TC, DC, ESR, Hb TC, DC, ESR, Hb Urine culture and sensitivity Urine culture and sensitivity Culture suggesting>100,000 of the same organism/ml indicate UTI. Culture suggesting>100,000 of the same organism/ml indicate UTI. IVU, micturating urethrography IVU, micturating urethrography USG USG Cystoscopy Cystoscopy Dr S Chakradhar 6

Management Maintain good urine flow by increasing fluid intake. Maintain good urine flow by increasing fluid intake. Appropriate Antibiotics : Ciprofloxacin, Coamoxyclav, Norfloxacin, Cephalosporins are commonly used. Appropriate Antibiotics : Ciprofloxacin, Coamoxyclav, Norfloxacin, Cephalosporins are commonly used. For uncomplicated treatment is given for 3 days and for complicated 7-14 days. For uncomplicated treatment is given for 3 days and for complicated 7-14 days. Potassium citrate mixture 10ml in a glass of water three times a day, It alkalinizes the urine and relieves dysuria. Potassium citrate mixture 10ml in a glass of water three times a day, It alkalinizes the urine and relieves dysuria. If severe symptoms bladder relaxants (Flavoxate 200 mg TID) can be used. If severe symptoms bladder relaxants (Flavoxate 200 mg TID) can be used. Dr S Chakradhar 7

Prophylactic measures Plenty of fluid intake Plenty of fluid intake Frequent emptying of bladder Frequent emptying of bladder Double micturation at bed time Double micturation at bed time Emptying bladder before & after intercourse Emptying bladder before & after intercourse Application of 0.5% cetrimide cream to preurethral area before intercourse Application of 0.5% cetrimide cream to preurethral area before intercourse Urine culture should be repeated after treatment Urine culture should be repeated after treatment Dr S Chakradhar 8

UPPER URINARY TRACT INFECTION 9 Dr S Chakradhar

ACUTE PYELONEPHRITIS It is characterized by an acute inflammation of the parenchyma & pelvis of the kidney. Pathology Usually enlarged due inflammatory PMNs and edema. Usually enlarged due inflammatory PMNs and edema. Infection is focal and patchy, beginning in the pelvis, medulla and extending into the cortex Infection is focal and patchy, beginning in the pelvis, medulla and extending into the cortex Dr S Chakradhar 10

Clinical features Sudden onset pain in both loins radiating to iliac fossae and suprapubic area. Sudden onset pain in both loins radiating to iliac fossae and suprapubic area. Urinary symptoms like frequency and dysuria Urinary symptoms like frequency and dysuria Fever is usually present. It may be associated with chills, rigor, and vomiting. Fever is usually present. It may be associated with chills, rigor, and vomiting. Tenderness in the renal angle and lumbar region. Tenderness in the renal angle and lumbar region. Dr S Chakradhar 11

Investigation – look up UUTI Management Ciprofloxacin, Norfloxacin, Co-Amoxyclav are common drugs used. Ciprofloxacin, Norfloxacin, Co-Amoxyclav are common drugs used. Total duration of the therapy is 1-2 weeks. Total duration of the therapy is 1-2 weeks. Severe cases require IV therapy Severe cases require IV therapy General measures – same as lower UTI General measures – same as lower UTI Dr S Chakradhar 12

Complications: Chronic Pyelonephritis Chronic Pyelonephritis Sepsis and shock Sepsis and shock Papillary necrosis particularly DM & UT obstruction it may lead to acute renal failure Papillary necrosis particularly DM & UT obstruction it may lead to acute renal failure Pyonephrosis – suppurative exudate fills the renal pelvis calyces & ureter when there is total complete obstruction Pyonephrosis – suppurative exudate fills the renal pelvis calyces & ureter when there is total complete obstruction Perinephric abscess – suppurative inflammation extends through the renal capsule into perinephric tissue Perinephric abscess – suppurative inflammation extends through the renal capsule into perinephric tissueD/D: 1. Acute Appendicitis 2. Salpingitis 3. Cholecystitis 4. Diverticulitis 5. Perinephric abscess. Dr S Chakradhar 13

Chronic Pyelonephritis It may be unilateral or bilateral. It may be unilateral or bilateral. It occurs in 2 forms Chronic Obstructive P There is recurrent bouts of acute inflammation superimposed on diffuse or localized obstructive lesions – pregnancy There is recurrent bouts of acute inflammation superimposed on diffuse or localized obstructive lesions – pregnancy Reflux associated pyelonephritis (reflux nephropathy) It starts early in childhood. There is urinary infection on congenital vesicouretal reflux It starts early in childhood. There is urinary infection on congenital vesicouretal reflux Dr S Chakradhar 14

Pathology: Are usually scarred – asymmetry Are usually scarred – asymmetry Coarse, discrete corticomedullary scar overlying a blunted or deformed calyx Coarse, discrete corticomedullary scar overlying a blunted or deformed calyx Dr S Chakradhar 15

Clinical Features: Recurrent attacks of Frequency, Dysuria, Aching Lumbar pain Recurrent attacks of Frequency, Dysuria, Aching Lumbar pain Usually patient comes with Lassitude, Tiredness, Vague ill health, Usually patient comes with Lassitude, Tiredness, Vague ill health, Symptoms of uraemia Symptoms of uraemia Arterial hypertension Arterial hypertension Pyuria, Proteinuria Pyuria, Proteinuria Dr S Chakradhar 16

Investigations:Management Antibiotics according to culture and sensitivity report Antibiotics according to culture and sensitivity report Usually Ciprofloxacin Usually Ciprofloxacin Total duration : 3-6 months Total duration : 3-6 months Remove if there is presence of obstruction Remove if there is presence of obstruction Vesicoureteric reflux spontaneously disappears in adult life Vesicoureteric reflux spontaneously disappears in adult life General measures General measures Dr S Chakradhar 17

RENAL TUBERCULOSIS It is a consequence of miliary TB It is a consequence of miliary TB Most heal, but in some, infection persists and spreads to the papillae, with the formation of cavitating lesions and the discharge of mycobacteria into the urine. Most heal, but in some, infection persists and spreads to the papillae, with the formation of cavitating lesions and the discharge of mycobacteria into the urine. Infection of the ureters and bladder commonly follows, with the potential for the development of ureteral stricture and a contracted bladder. Infection of the ureters and bladder commonly follows, with the potential for the development of ureteral stricture and a contracted bladder. Dr S Chakradhar 18

Clinical Features Typical features of TB Typical features of TB Frequency of micturation & Dysuria, Frequency of micturation & Dysuria, Hematuria, pyuria Hematuria, pyuriaInvestigation TC, DC, ESR, Hb TC, DC, ESR, Hb Cystoscopy Cystoscopy Urine RME Urine RME Culture of acid-fast bacilli from early morning urine specimens Culture of acid-fast bacilli from early morning urine specimens Chest X ray, mantoux test Chest X ray, mantoux test Excretory urography, USG Excretory urography, USG Renal biopsy. Renal biopsy.Treatment ATT with steroid ATT with steroid Dr S Chakradhar 19

Excretory urography in a patient with renal tuberculosis shows an irregular cavity at the upper pole calyx of the right kidney. Note the multiple tiny calcifications in the liver, spleen, and right adrenal gland due to calcified tuberculous granuloma. Dr S Chakradhar 20

Lobar calcification in a large destroyed right kidney in a patient with renal tuberculosis. Note the involvement of the right ureter. Dr S Chakradhar 21

Dr S Chakradhar 22