1. UTI and incontinence

2. Urinary Tract Infections (UTI) Prevalence Most common bacterial infection malefemale First year of life1.5%1% 1 to 82%8% 20 to 401%30% Over 6040%50%

3. UTI Upper UTI pyelonephritis, pyonephrosis, kidney abscess Lower UTI cystitis, prostatitis, epididymo-orchitis

4. UTI Pathogenesis Ascending Hemotogenous to kidney Host immunity – age, DM Microorganism virulence Prostate with antibacterial secretion Colonisation of vagina with uropathogens Bladder emptying Abnormal urinary tract – reflux, obstruction Short urethra and sexual activity in female

5. UTI Micro-organism Gram negative bacteria Commonest E. Coli 70 – 90% Gram positive Yeast and fungus Viral Specific infection - mycobacteria

6. UTI Uncomplicated and Complicated Uncomplicated UTI No structural or functional disease Complicated UTI With structural or functional disease reflux, obstruction, neurological, DM higher chance of getting renal damage, septicaemia

7. UTI Symptoms Acute cystitis suprapubic pain, frequency, dysuria, urgency Acute pyelonephritis loin pain, fever, frequency, dysuria Acute prostatitis suprapubic/perineal pain, frequency, fever, dysuria, slow streeam Acute epididymo-orchitis scrotal swelling and pain, fever

8. UTI Diagnosis History & Physical Examination Mid-stream urine microscopy for pyuria male 5WBC/HPF, female 10WBC/HPF (cell counter method dip-stick leukocyte esterase test) pyuria can be due to other inflammatory conditions bladder stone, radiation, chemotherapy, autoimmune disease, interstitial cystitis

9. UTI Diagnosis MSU culture for bacteria culture plate method dip-slide method >10 5 /ml sensitivity of 50% and specificity of 99% (most Urology centres reported to 10 3 /ml) suprapubic aspiration, urethral catheterisation - invasive dip-stick test for nitrite for screening of bacteriuria

10. UTI Diagnosis Abacterial pyuria partially treated UTI virus other inflammatory conditions TB

11. UTI Treatment Cystitis uncomplicated - 3 days oral drugs complicated – 7 to 10 days drugs Pyelonephritis 2 weeks drugs if bacteraemia – parenteral then to oral Prostatitis 6 weeks drugs Epididymo-orchitis 10 – 14 days drugs

12. UTI Investigations Uncomplicated cystitis cost-effective, most would treat patients on clinical diagnosis Complicated infection to check for structural or functional abnormalities renal functional test urine for asymptomatic bacteriuria ultrasound / intravenous urography /radiological tests treatment of underlying problems DM, obstructive causes, reflux

13. Acute Pyelonephritis Vs Pyonephrosis Acute pyelonephritis Infection of renal parenchyma Medical infection Acute pyonephrosis Infection of stagnant urine Surgical infection Differentiation by ultrasonography moderate to severe hydronephrosis in acute pyonephrosis and effectively drained by percutaneous drainage

14. Acute Epididymo-orchitis Vs Acute Torsion of Testis Testes can stand ischaemia for 6 hours All testes would be dead after ischaemia for 24 hour Acute surgical condition Differentiation by Doppler ultrasound decrease vascular blood supply to torsion emergency surgical correction

15. Urinary Incontinence Prevalence UK malefemale 15 – 445-7% 45 – 648-15% 15 – 643% >657-10%10-20%

16. Urinary Incontinence Classification Genuine stress incontinence Urge incontinence Mixed stress and urge incontinence Overflow incontinence Continuous incontinence (terminal dribble vs post-micturition dribble)

17. Genuine Stress Incontinence Involuntary loss of urine during coughing, exertion Most common cause of incontinence in female Due to weakness of pelvic floor and could not support the proximal urethra inside the pelvic cavity pregnancy, vaginal delivery, pelvic surgery, congenital Some may be due to weakness of external urethral sphincter TURP, radical prostatectomy

18. Urge Incontinence Involuntary loss of urine after sudden urge feeling Second commonest cause of incontinence in female Due to detrusor instability idiopathic – aging, BPH if neurological causes found, called detrusor hyperreflexia

19. Overflow Incontinence Sporadic involuntary loss of urine Slow stream, frequency, palpable bladder Due to bladder underactivity hypotonia, DM, drugs, pelvic mass, chronic obstruction

20. Continuous Incontinence Continuous loss of urine Due to fistula congenital ureteric fistula after surgery or trauma vesico-vagina fistula, uretero-vaginal fistula

22. Post-micturition Dribble Leaking of small amount of urine up to few minutes after micturition Due to storing of some urine in the proximal bulbous urethra after micturition Terminal dribble Slow dribble at the end of micturition Due to bladder outflow obstruction

23. History & Examination Micturition pattern Obstetrical history Neurological problems Surgery Drugs Abdominal masses, palbable bladder Vaginal prolapse Marshall test for stress incontinence

24. Investigations MSU Bladder diary Pad test – verify and quantify leakage Uroflowmetry – obstructed flow Cystometry – detrusor instability, detrusor contraction pressure Urethral pressure profile Radiological tests

25. Treatment of Genuine Stress Incontinence Pelvic floor exercise to strengthen the pelvic floor muscle Surgery to suspend the bladder neck Due to sphincter weakness Sling procedure Injection of material at sphincter level Sphincter prostheses implantation

26. Treatment of Urge Incontinence Bladder training Anticholinergic drugs Correction of underlying problems e.g. BOO

27. Treatment of Overflow Incontinence Correction of underlying cause eg BOO Intermittent catheterisation Catheter drainage

28. Treatment of Urinary Fistula Surgical repair of corresponding abnormalities