BLADDER INFECTION

Acute Cystitis Definition: refers to urinary infection of the lower urinary tract, particularly the bladder. Sex Predilection: F>M 1° Mode of infection: ascending from the periurethral/vaginal and fecal flora Diagnosis is made clinically

Acute Cystits: Presentation and Findings Frequent Findings: Irritative voiding symptoms (dysuria, frequency, urgency) Other common symptoms: low back and suprapubic pain, hematuria, cloudy/foul- smelling urine Fever and systemic symptoms: rare Urinalysis: (+) WBC, (+) Hematuria Urine Culture: confirm the diagnosis E. coli – most common Others: G(-) Klebsiella and Proteus; G(+) S. saprophyticus and Enterococcus.

Management Pharmacologic Short course oral antibiotics – Trimethoprim-sulfamethoxazole, Nitrofurantoin, and Fluoroquinolones – Duration: 3-5 days – fluoroquinolones with long half-lives (fleroxacin, pefloxacin, and rufloxacin) may be suitable for single-dose therapy

Recurrent Cystitis/UTI Presentation and Findings: – Cause: bacterial persistence or reinfection with another organism Note: it’s important to identify the cause Bacterial Persistence – remove the infected source Reinfection – Preventive therapy

Radiographic Imaging Bacterial Persistence – Radiologic imaging is indicated – US – provide a screening evaluation of the GUT – IVP, Cystoscopy, CT may sometimes be necessary – Frequent, recurrent UTI – bacterial localization studies Bacterial Reinfection – Evaluate for evidence of vesicovaginal or vesicoenteric fistula – Otherwise, radiologic examination is not necessary

Management Depends on the cause: – Surgical removal of the infected source, i.e. urinary calculi – treat persistence – Reinfection: Surgical repair of fistulas, prophylactic antibiotics Recurrent UTI/cystitis related to sexual activity: – Frequent emptying of the bladder and a single dose of antibiotic taken after intercourse Alternative Tx for recurrent cystits/UTI – Intravaginal estriol, lactobacillus vaginal suppositories, cranberry juice

Malacoplakia Uncommon inflammatory disease of the bladder – manifesting as plaques or nodules made up of large histiocytes (von Hansenmann cells) and laminar inclusion bodies (Michaelis-Gutmann bodies) – Can also affect ureters, kidneys

Presentation and Findings Patients – F>M with history of UTI – With chronic illness or immunosuppressed Signs and Symptoms – Bladder: Irritative voiding symptoms – urgency and frequency; and hematuria – Ureter and Kidney: fever, flank pain, flank mass – Both kidneys: s/sx of azotemia and renal failure

Radiologic Findings US/CT – May demonstrate a mass in the bladder and and evidence of obstruction. – KIDNEY: focal, diffuse, hypodense parenchymal masses on CT Biopsy – Differentiates malakoplakia from malignancy

Management Pharmacologic Primarily consists of antibiotic therapy with high intracellular levels: – TMP-SMX and fluoroquinolones – Bethanecol and Ascorbic Acid – enhance phagolysosomal activity Lower urinary tract involvement: – Antibiotic alone Non-pharmacologic Involvement of ureter or kidney: – surgical excision Prognosis is poor and mortality is high in patients who have bilateral renal involvement regardless of treatment

Prostate Infections

ANATOMY Chestnut-shaped fibromuscular and glandular organ Inferior to bladder 20g; 3cm diameter produces prostate fluid

PROSTATE INFECTIONS I. Acute Bacterial Prostatitis II. Chronic Bacterial Prostatitis III. Granulomatous Prostatitis IV. Prostate Abscess

I. Acute Bacterial Prostatis Inflammation of the prostate associated w/ a UTI From urethral infection or reflux of infected urine Luekocytes are seen within the surrounding acini of the prostate in response to infection Edema and hyperemia developed Prolong infection – necrosis and abscess

Presentation and Findings More common in adults esp. <50 (Collins et al, 1998) abrupt onset fever, chills, malaise, arthralgia, myalgia, lower back/rectal/perineal pain urinary symptoms (frequency,urgency, dysuria) Urinary retention DRE - tender, enlarged glands that are irregular and warm

ACUTE BACTERIAL PROSTITIS LABS Urinalysis - WBCs and occasionally hematuria Serum Blood Analysis – leukocytosis Prostate-specific antigen DEFINITIVE DX microscopic examination and culture of the prostatic expressate culture of urine obtained before and after prostate massage – single organism E. coli – most causative agent OTHERS: Proteus, Klebsiella, Enterobacter,Pseudomonas, and Serratia spp.

ACUTE BACTERIAL PROSTITIS RADIOLOGIC IMAGING Rarely indicated Bladder ultrasonography – useful in determining the amount of residual urine MANAGEMENT Pharmacologic – Trimethoprim and Fluoroquinolones (4–6 weeks) – Ampicillin and an aminoglycoside for gram-negative bacteria and enterococci Non-pharmacologic – Patients w/ urinary retention 2 nd to acute prostatis - suprapubic catheter

II. Chronic Bacterial Prostatis CLINICAL PRESENTATION more insidious onset characterized by relapsing, recurrent UTI caused by the persistence of pathogen in the prostatic fluid despite antibiotic therapy dysuria, urgency, frequency, nocturia, and low back/perineal pain DRE: often normal; occasionally, tenderness, firmness, or prostatic calculi

Chronic Bacterial Prostatis LABS Urinalysis - a variable degree of WBCs and bacteria Serum Blood Analysis – no leukocytosis Prostate-specific antigen DEFINITIVE DX microscopic examination and culture of the prostatic expressate using the 4-cup test E. coli – most causative agent

The 4-cup Test Preparation: -Require Px to have a full bladder -Retract foreskin of uncircumcised men -Clean glans with soap/water or povidone-iodine Collection: -Collect first 10ml of voided urine (VB1) -Discard next 100ml -Collect next 10ml of voided urine (VB2) -Massage prostate and collect prostate expressate (EPS) -Collect first 10ml of voided urine after massage (VB3) -Immediately culture and microscopically examine all specimens Interpretation: -All specimens <10 3 CFU/ml = not bacterial prostatitis -VB3 or EPS >10 x CFU of VB1 = chronic bacterial prostatitis -VB1 > other specimens = urethritis or specimen contamination -All specimens >10 3 CFU/ml = treat for UTI and repeat test

ACUTE BACTERIAL PROSTITIS RADIOLOGIC IMAGING Rarely indicated Transrectal ultrasonography – if prostatic abscess MANAGEMENT Pharmacologic – Antibiotic similar to acute bacterial prostatis but for 3- 4 months – TMP-SMX 1 single-strength tablet daily, nitrofurantoin 100 mg daily, or ciprofloxacin 250 mg daily Non-pharmacologic – Transurethral resection of the prostate - refractory disease

III. Granulomatous Prostatis Etiology: bacterial, viral, or fungal infection, the use of bacillus Calmette-Guerin therapy malacoplakia, or systemic granulomatous diseases affecting the prostate 2/3 of cases have no specific cause 2 types of Non-specific granulomatous prostatitis: 1.Non-eosinophilic – abnormal tissue response to extravasated prostatic fluid 2.Eosinophilic – more severe, allergic response of prostate to some unknown antigen

Granulomatous Prostatis CLINICAL PRESENTATION fever, chills, and obstructive/irritative voiding symptoms urinary retention eosinophilic granulomatous prostatitis - severely ill and have high fevers DRE - hard, indurated, and fixed prostate, difficult to distinguish from prostate carcinoma

Granulomatous Prostatis LABS Urinalysis – no evidence of bacterial infection CBC – leukocytosis; marked eosinophilia DEFINITIVE DX: biopsy of prostate MANAGEMENT Pharmacologic – Antibiotic therapy and corticosteroids Non-pharmacologic – Transurethral resection of the prostate - patients who do not respond to treatment and have significant outlet obstruction.

IV. Prostate Abscess result from complications of acute bacterial prostatitis High risk: – Diabetes – those receiving chronic dialysis – immunocompromised patients, undergoing urethral instrumentation, who have chronic indwelling catheters Clinical Presentation – Similar Symptoms as acute bacterial prostatitis – History of acute bacterial prostatitis with good initial response to antibiotics but recurrence of symptoms during Tratment – DRE: tender and swollen prostate; fluctuance 16% px

Prostate Abscess RADIOLOGIC IMAGING transrectal ultrasonography or pelvic CT scan is crucial for diagnosis and treatment MANAGEMENT Pharmacologic – Antibiotic therapy Non-pharmacologic – Transrectal drainage – Transurethral resection and drainage

URETHRITIS

Urethritis Infection / inflammation of the urethra Categorized into: – Neisseria gonorrhea – Other organisms Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, and Herpes Simplex Virus – Acquired through sexual intercourse

URETHRITIS PRESENTATION AND FINDINGS urethral discharge and dysuria Obstructive voiding symptoms - patients with recurrent infection 40% of patients with gonococcal urethritis are asymptomatic DIAGNOSIS examination and culture of the urethra

URETHRITIS RADIOLOGIC IMAGING Retrograde urethrogram - indicated in patients with recurrent infection and obstructive voiding symptoms MANAGEMENT Pharmacologic – Gonococcal: ceftriaxone (250 mg intramuscularly); fluoroquinolones (ciprofloxacin 250 mg or norfloxacin 800mg) – Non-gonococcal: tetracycline or erythromycin (500 mg 4 times daily) or doxycycline (100 mg twice daily) for 7–14 days Non-pharmacologic – Prevention! – Protective sexual practices

URETHRITIS Female: urethral dischargeMale: urethral discharge

EPIDIDYMITIS

Epididymitis Infection / inflammation of the epididymis ascending infection of the lower urinary tract Men <35 y/o  STDs (N. gonorrhoeae and C. trachomatis) Children & older men  urinary patogens (E. coli) Homosexual men  E. coli may spread to involve the testis

Epididymitis Presentation & Findings – Severe scrotal pain that may radiate to the groin or flank – Scrotal enlargement or reactive hydrocele – Urethritis, cystitis or prostatitis – PE: enlarged and red scrotum Thickened spermatic cord

Epididymitis Presentation and Findings – Urinalysis: WBCs and bacteria in the urine or urethral discharge – Serum blood analysis: leukocytosis Radiologic Imaging – Scrotal Doppler UTZ or radionuclide scanning – Epididymitis: enlarged epididymis with increased blood flow

Epididymitis Management Pharmacologic – Oral Antibiotics and NSAIDS – Treatment of sexual partners in STD Non-pharmacologic – Bed rest, scrotal elevation & NSAIDS – helpful in reducing the duration of symptoms – Sepsis or severe infection  hospitalization & parenteral antibiotic therapy – Abscess  open drainage – Chronic, relapsing epididymitis & scrotal pain  epididymectomy

Epididymitis

EPIDIDYMITIS & URETHRITIS IN HIV PATIENTS caused by N. gonorrhoeae and C. trachomatis E. coli is more common HIV-infected patients with suppurative or antibiotic-resistant epididymitis - infection with fungi or mycobacteria should be considered it is recommended that HIV-infected patients abstain from sexual intercourse until 7 days after treatment is completed.

REFERENCE: Smith’s General Urology 17 th Edition Images from