1. Urinary Tract Infection 2 nd Affiliated Hospital ZJ University 2 nd Affiliated Hospital ZJ University Yu Gong

2. Epidemiology of UTI by Age Group and Sex

3. Host Pathogen Balance

5. Host defenses: miscellaneous Multi-layer transitional cells Urinary immunoglobulins : Tamm-Horsfall protein Spontaneous exfoliation of uroepithelial cells with bacterial detachment Mechanical flushing of micturition Multi-layer transitional cells Urinary immunoglobulins : Tamm-Horsfall protein Spontaneous exfoliation of uroepithelial cells with bacterial detachment Mechanical flushing of micturition

6. Come with a rush, go with a flush!

7. Pathogens

8. Bacteria of UTI Bacterial Species Outpatients (%) Inpatients (%) Escherichia coli 89.2 52.7 Proteus mirabilis 3.2 12.7 Klebsiella pneumoniae 2.4 9.3 Enterococci 2.0 7.3 Enterobacter aerogenes 0.8 4.0 Pseudomonas aeruginosa 0.4 6.0 Proteus species 0.4 3.3 Serratia marcescens 0.0 3.3 Staphylococcus epidermidis 1.6 0.7 Staphylococcus aureus 0.0 0.7 Opportunistic pathogens

9. Fungal Pathogens Most such infection occurs in patients : with long indwelling Foley catheters receiving broad-spectrum antibacterial therapy diabetes mellitus on corticosteroids

10. Other Pathogens C. Trachomatis U. Urealyticum Chronic Urethritis Chronic Prostatitis

11. Urinary Tract Infection (UTI) Upper UTI － pyelonephritis (renal abscess, perinephric abscess, Surgical kidney) Lower UTI － cystitis ( urethritis ) Upper UTI － pyelonephritis (renal abscess, perinephric abscess, Surgical kidney) Lower UTI － cystitis ( urethritis )

12. Surgical kidney

13. Pyelonephritis

14. Pyelonephritis —— inflammation of the kidney and its pelvis

15. PATHOGENESIS How bacteria reach the urinary tract in general and the kidney in particular?

16. Pathogenesis Two potential routes : (1) hematogenous infection bacteremia → kidney (Descending) (2) retrograde infection urethra→bladder→ ureter →kidney (ascending)

17. Hematogenous Infection Because the kidneys receive 20% to 25% of the cardiac output, any microorganism that reaches the bloodstream can be delivered to the kidneys.

18. Hematogenous Infection Existing infection (skin, respiratory tract) blood circulation kidney(cortex) small abscess renal tubular renal papillary renal pelvis

19. PATHOGENESIS Factors predisposing to pyelonephritis Urinary Tract Obstruction Vesicoureteral Reflux Instrumentation of the Urinary Tract Pregnancy Diabetes Mellitus How long will there be possibility of UTI after urethral catheterization? How long will there be possibility of UTI after urethral catheterization?

20. Diabetes Mellitus 3-4 times UTIs in DM than in non-diabetes Diabetic neuropathy and vascular injury affects bladder emptying(paralytic bladder) hyperglycemia impact host immuno system

21. Clinical Presentation fever back pain colicky abdominal pain nausea and vomiting Sepsis, septic shock

22. Cystitis Suprapubic region pain frequency, urgent urination, odynuria and dysuria Clinical Presentation

23. Complications Sepsis Peri-renal abscess Renal papillary necrosis/Acute renal failure

24. Laboratory findings Urine dipstick pyuria on microscopic examination urine WBC > 3 WBC/high-power field Middle stream urine culture bacterial account > 10 5 cfu/ml (cfu:clony-forming units) blood culture

26. Treatment Rest Drinking large amount of water Antibiotics: 2 weeks / until symptom free Treat related diseases: diabetes, renal stones, etc

27. Antibiotic therapy Objective - prevention of sepsis - eradication of organism - prevention if recurrences Medications - trimethoprim-sulfamethoxazole(SMZ) - fluoroquinolones - ampicillin

29. Catheter-associated UTI Over 1 million catheter-associated UTIs occur in the US each year Risk factors: duration of catheterization: mostly at 72 hours after catheterization (Bacteria film) Over 1 million catheter-associated UTIs occur in the US each year Risk factors: duration of catheterization: mostly at 72 hours after catheterization (Bacteria film)

30. Remove catheter as early as possible Change catheter

31. Any abnormalities of structural, or functional causes should be excluded when UTI was diagnosed and treated.

32. Take radical measures, insted of providing temporary solutions 治标，更要治本

33. Genitourinary Tuberculosis

35. Epidemiology 8~10 million new active cases of TB each year(WHO) TB is the most common opportunistic infection in AIDS patients(WHO) 8~10 million new active cases of TB each year(WHO) TB is the most common opportunistic infection in AIDS patients(WHO)

36. Transmission and Development Genitourinary TB is caused by metastatic spread of the organism through bloodstream during initial infection (hematogenous). Kidney is usually the primary organ infected in urinary disease Primary site for infection of genital system is often the epididymis in men and the fallopian tubes in women

37. Pathological renal TB Clinical renal TB Parenchyma to Collecting system

38. Clinical Features Most patients are aged 20~40 years Some cases with Pulmonary tuberculosis Bladder is always the spokesman for renal TB Urologist should always consider the diagnosis of genitourinary TB in a patient presenting with vague, long-standing urinary symptoms for which there is no obvious cause

39. Diagnosis Urine examination (Sterile pyuria, pH<7, WBC, RBC, Pro) Urine : Acid-fast bacilli (AFB) Blood: TB-Antibody Imageology (Ultrasonography, Plain film, IVU, RGP, CU, CTU, ) Cystoscopy and Biopsy

40. Acutely inflamed ureteric orifice Tuberculosis bullous granulations

41. Hyperemia and tuberculosis ulcer

45. 1.Severe calyceal and parenchymal destruction Multiple stricture of ureter Moth-eaten sign 2. Contracted bladder

46. RGP

47. Autonephrectomy Lateral renal tuberculosis, Contralateral hydronephrosis

48. Calcification, parenchymal scarring, hydrocalycosis, thickening of the walls of renal pelvis Painting petal

49. Extensive tuberculosis of kidney

50. Antituberculous drugs Isoniazid(INH), Rifampicin(RFP), Streptomycin(SM), Pyrazinamide(PZA), Ethambutol(EMB), PAS

51. Surgery 1. Excision of diseased tissue (Partial )Nephrectomy, Abscess Drainage, Epididymectomy 2. Reconstructive Surgery Ureteral stricture, Augmentation cystoplasty, Urinary conduit diversion(Bricker’s procedure, ileum conduit), orthotopic Neobladder

52. Thank You