Urinary Tract InfectionUrinary Tract Infection22ndnd Affiliated Hospital Affiliated Hospital

ZJ UniversityZJ University22ndnd Affiliated Hospital Affiliated Hospital

ZJ UniversityZJ University

Yu GongYu Gong

Epidemiology of UTI by Age Group and SexEpidemiology of UTI by Age Group and Sex

HostHost PathogenPathogen

Balance

Host defenses:miscellaneousHost 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

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

Pathogens

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

Fungal PathogensMost such infection occurs in patients :

• with long indwelling Foley catheters

• receiving broad-spectrum antibacterial therapy

• diabetes mellitus

• on corticosteroids

Other Pathogens

• C. Trachomatis

• U. Urealyticum

Chronic UrethritisChronic Prostatitis

Urinary Tract Infection (UTI)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)

Surgical kidneySurgical kidney

Pyelonephritis

Pyelonephritis —— inflammation of

the kidney and its pelvis

Pyelonephritis —— inflammation of

the kidney and its pelvis

PATHOGENESIS

How bacteria reach the urinary tract in

general and the kidney in particular?

Pathogenesis

Two potential routes :

(1) hematogenous infection

bacteremia → kidney

(Descending)

(2) retrograde infection

urethra→bladder→ ureter →kidney

(ascending)

Hematogenous InfectionBecause the kidneys receive 20% to 25% of

the cardiac output, any microorganism that reaches the bloodstream can be delivered to the kidneys.

Hematogenous Infection

Existing infection (skin, respiratory tract)

blood circulation kidney(cortex)

small abscess renal tubular

renal papillary renal pelvis

PATHOGENESIS

Factors predisposing to pyelonephritis

• Urinary Tract Obstruction

• Vesicoureteral Reflux

• Instrumentation of the Urinary Tract

• Pregnancy

• Diabetes MellitusHow long will there be possibility of UTI after urethral catheterization?How long will there be possibility of UTI after urethral catheterization?

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

Clinical Presentation

• fever• back pain• colicky abdominal pain• nausea and vomiting• Sepsis, septic shock

Cystitis

• Suprapubic region pain • frequency, urgent urination, odynuria and dysuria

Clinical Presentation

Complications

• Sepsis

• Peri-renal abscess

• Renal papillary necrosis/Acute renal failure

Laboratory findings

• Urine dipstick

pyuria on microscopic examination

urine WBC

> 3 WBC/high-power field

• Middle stream urine culture

bacterial account > 105cfu/ml

(cfu:clony-forming units)

• blood culture

Treatment

• Rest

• Drinking large amount of water

• Antibiotics: 2 weeks / until symptom free

• Treat related diseases: diabetes, renal stones, etc

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

Catheter-associated UTICatheter-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)

Remove catheter as early as possibleChange catheter Remove catheter as early as possibleChange catheter

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

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

Take radical measures, insted of providing temporary solutions

治标，更要治本

Genitourinary Tuberculosis

Genitourinary Tuberculosis

EpidemiologyEpidemiology

• 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)

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

Pathological renal TBPathological renal TB

Clinical renal TBClinical renal TB

Parenchyma to Collecting systemParenchyma to Collecting system

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

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

Acutely inflamed ureteric orifice Tuberculosis bullous granulations

Hyperemia and tuberculosis ulcer

1. Severe calyceal and parenchymal destruction Multiple stricture of ureter Moth-eaten sign

2. Contracted bladder

RGPRGP

Autonephrectomy

Lateral renal tuberculosis, Contralateral hydronephrosisLateral renal tuberculosis, Contralateral hydronephrosis

Calcification, parenchymal scarring, hydrocalycosis, thickening of the walls of renal pelvis

Painting petal

Extensive tuberculosis of kidney

Antituberculous drugs

Isoniazid(INH), Rifampicin(RFP), Streptomycin(SM), Pyrazinamide(PZA), Ethambutol(EMB), PAS

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

Thank YouThank You