1. Mark Lynch Clinical Lead Urology CUH Mlynch100@doctors.org.uk Mark.lynch@croydonhealth.nhs.uk Mark.lynch@stgeorges.nhs.uk

2. UTI ADHERERNCE MECHANISMS FIMBRIAE type I – mannose sensitive, adhere to uroplakins Ia and Ib on urothelium P type – mannose insensitive Pap (P pili associated with pyelonephritis) – 4 proteins (F, A, G, E) PapG is receptor component 3 subtypes (I, II, III) PapG subtype II associated more with pyelonephritis PapG subtype III associated more with cystitis

3. UTIs UTI Infection Complicated or not Recurrent Management Infection and stones – hand in hand

4. UTIs or cystitis 30% of women have at least one UTI in their lifetime Rare in Men – investigate Recurrent UTIs in women warrant investigation $1.6Bn / year in US Forman B, Am J Med 2002

5. UTIs – risk factors Host immunity vs. Bacterial virulence Host – Bacterial flora – Immunity and comorbidity – Stasis – Foreign body Bacterial virulence – Fimbriae and Pili – Antimicrobial resistance

6. UTI – excluding a cause Complicated: – Structural or functional abnormality or underlying disease to increase infection… DM, renal insufficiency Urological (DxT, childhood Hx), neurological Pregnancy, voiding dysfunction – All men

7. UTIs – bacterial resistance E.Coli and coliforms – 80% Staph. Sap. – 10% Klebsiella, Enterobacter, Proteus.. – Note foreign travel – Recent in hospital care Ronald, A Am J Med 2002

9. Recurrent UTI - referral UTIs that fail to respond to appropriate antibiotics. >2 UTI in 6 months >3 in one year In reality – balance of risk and impact

10. Recurrent UTI - management History (Current, childhood, family, risk factors…smoking) Examination – including pelvic examination MSU, bladder diary, GFR, USS, Flexi / Cystoscopy +EUA Pathology: Anatomical, functional, TCC, Stones

11. Recurrent UTI - management

12. UTIs Very common Confirm the infection and sensitivities Refer complicated and/or recurrent UTIs Beware red flags Multi modality approach to treatment Questions… UTIs… Pathways… Anything else Urological…

14. Renal Colic and Stones 10% risk, 50% recurrence risk at 10 years Risk factors include: – Geography – Diet – Anatomical – M>F – Fluid intake – Genetics (Cysteinuria)

15. Renal Colic and Stones at CUH Pain relief History Examination Gold standard ED management – CT KUB – Early diagnosis – Early treatment – Stone clinic F/U – Access to tertiary care

16. Renal Colic and stones at CUH CUH – Laser lithotripsy – ESWL – Dedicated stone clinic – Seamless link with SGH SGH – PCNL – URS (day case)