1. 1. UROGENITAL INFECTIONS BY PROF/ GOUDA ELLABBAN
2. 2. ORGANISMS THAT CAUSE URINARY TRACT INFECTION Non-specific organisms: E. coli (common) Klebsiella (common) Staph. aureus (rare) Specific organisms: Gonococci (not uncommon) Schistosoma hematobium (rare) Mycobacteria tuberculosis (rare)
3. 3. ROUTES OF INFECTIONS Ascending Infection Through the urethra Hematogenous Infection Through the kidneys Through the prostate
4. 4. ASCENDING INFECTION More common in females because of The short urethra Close proximity of the urethra to the vagina Organisms that cause ascending infection Non-specific (e. coli, klebsiella) Specific (gonococcus, chlamydea)
5. 5. HEMATOGENOUS INFECTION (rare) Non-Specific Organisms Staph. aureus (commonest) Kidney renal cortical abscess (renal carbuncle) Prostate prostatitis Specific Organisms Schistosoma hematobium Tubercle bacilli
6. 6. CYSTITIS Acute cystitis Acute onset of severe symptoms It usually resolves completely within 2-5 days with adequate antimicrobial therapy Chronic cystitis Mild but persistent symptoms Predisposed by presence of chronic infravesical obstruction with retained urine in the bladder (chronic retention); e.g. BPH Treatment must include removal of infravesical obstruction
7. 7. CYSTITIS (cont.) Urinary symptoms Irritative urinary symptoms: burning, frequency (day and night), urgency Hematuria (usually microscopic, but occasionally gross) Diagnosis Urine analysis: pyuria (WBC in significant amount) Treatment Appropriate antibiotic based on urine culture and sensitivity (ampicillin, quinolones are usually effective) In chronic cystitis, any obstructive lesion must be removed
8. 8. PYELONEPHRITIS Acute pyelonephritis Acute onset of severe symptoms it usually resolves completely within 4-8 days with adequate antimicrobial therapy Chronic pyelonephritis Mild but persistent symptoms Predisposed by presence of chronic obstructive uropathy in the ureter, bladder neck or urethra Treatment must include removal of any obstructive lesion
9. 9. PYELONEPHRITIS (cont.) Clinical presentation Dull aching renal pain Fever, malaise, nausea, vomiting (only in acute pyelonephritis) Diagnosis Urine analysis: pyuria (WBC in significant amount) Treatment Appropriate antibiotic based on urine culture and sensitivity (ampicillin, quinolones are usually effective) In chronic pyelonephritis, any obstructive lesion must be removed
10. 10. ACUTE PROSTATITIS Symptoms Acute onset of fever with severe irritative and obstructive urinary symptoms DRE (digital rectal examination): a very tender, firm and swollen prostate Diagnosis Urine analysis: pyuria (WBC in significant amount) Prostatic secretions obtained by prostatic massage: absolutely contraindicated from fear of septicemia Treatment Appropriate antibiotic (ampicillin, quinolones) Given empirically
11. 11. CHRONIC PROSTATITIS Etiology Same organisms as for acute prostatitis Chronic low grade and persistent bacterial infection Clinical Presentation Mild irritative urinary symptoms Pain referring to the anterior urethra, lower abdomen, peri-anal region, testis or perineum DRE: prostate is very firm and mildly painful Diagnosis Prostatic secretions by prostatic massage: WBC >15WBC/HPF Treatment Antibiotics based on culture and sensitivity of the expressed prostatic secretions
12. 12. EPIDIDYMO-ORCHITIS Acute epididymo-orchitis Bacterial spread from the urethra and along the vas to the epididymis and testis Acute onset of severely painful huge tender firm scrotal swelling Differential diagnosis with testicular torsion by Doppler ultrasound Treatment: parental antibiotics, pain killers and bed rest Chronic epididymo-orchitis Chronic non-specific epididymo-orchitis does not occur Chronic specific epididymitis: T.B. (review under Specific Infections)
13. 13. MALE GENITAL GONORRHEA Cause Ascending infection of gonococcal bacilli in the urethra following sexual intercourse with an infected partner Presentation Yellow urethral discharge in the acute stage (differential diagnosis: prostatorrhea: colorless urethral discharge; not a disease) Complications Chronic urethritis, chronic prostatitis Stricture of the bulbous urethra Treatment Medical treatment: tetracyclines, quinolones Surgical treatment of urethral stricture: endoscopic visual urethrotomy, or excision of the strictured urethral segment
14. 14. UROGENITAL BILHARZIASIS Bilharzial cystitis (commonest) Bilharzial ureteritis (2nd common; only in the lower third) Bilharzial urethritis (rare) Bilharzial genital lesions (esp. the seminal vesicles; very rare) The kidneys and upper 2 thirds of the ureters are NEVER directly affected by bilharzia
15. 15. ACUTE BILHARZIAL CYSTITIS Symptoms Symptoms of cystitis (burning, frequency, urgency) Terminal hematuria Urine analysis Living bilharzial ova Treatment Oral tablets (Praziquantel; 40mg/kg in a single dose) Good prognosis
16. 16. CHRONIC BILHARZIAL CYSTITIS (AND URETERITIS) Thousands of bilharzial ova are retained in the suburothelium and die The dead bilharzial ova in the suburothelium undergo calcification, and appear as linear calcification
17. 17. CHRONIC BILHARZIAL CYSTITIS COMPLICATIONS Fibrosis of the bladder muscles Chronic bladder ulcer (localized fibrosis in the detrusor with ischemic atrophy of the overlying mucosa) Contracted bladder (fibrosis of the entire detrusor) Chronic irritation of the urothelium Metaplasia (to squamous epithelium) Leukoplakia (squamous metaplasia with hyperkeratosis) Carcinoma
18. 18. CHRONIC BILHARZIAL URETERITIS COMPLICATIONS Stricture of the lower third of the ureter Caused by fibrosis of the ureteral muscle by the bilharzial reaction Vesico-ureteral reflux Caused by derangement of the uretero-vesical junction by the bilharzial reaction
19. 19. TREATMENT OF COMPLICATIONS Chronic bladder ulcer: partial cystectomy Bladder neck obstruction: endoscopic incision of the bladder neck Contracted bladder: ileocystoplasty or colocystoplasty Bladder cancer: radical cystectomy Stricture of the ureter: resection of the strictured segment, and anastomosis of the 2 healthy ends of the ureter Vesico-ureteral reflux: re-implantation of the ureter in the bladder by an anti-reflux technique
20. 20. UROGENITAL TUBERCULOSIS Incidence Age (20-40 years); Sex (same) Mode of infection (hematogenous) From the lungs (2ry infection) or from other organs (3ry infection) Kidneys and prostate are first affected (infection then spreads to other urogenital organs) Pathology Tuberculomatous reaction
21. 21. KIDNEY INVOLVEMENT Acute stage Acute tuberculous pyelonephritis Usually no symptoms Chronic stage Chronic interstitial nephritis with papillary necrosis Autonephrectomy: kidney lost its continuity with: the urinary tract from complete ureteral stricture, and the circulation from end arteritis obliterans Mild renal pain (late presentation)
22. 22. ACUTE TUBERCULOUS CYSTITIS Tubercle bacilli move from the kidney (in the acute stage), along the ureter, and to the bladder causing acute tuberculous cystitis and positive urinary symptoms Urinary symptoms are the first complaint by the patient: Frequency of micturition (+++) Urgency (+) Burning (+) Hematuria (+) Kidney pain is a late symptom that appears during the chronic stage of pyelonephritis
23. 23. CHRONIC TUBERCULOUS CYSTITIS Linear calcification: a symptomless condition Chronic ulcers: burning and frequency Contracted bladder: severe frequency Widely refluxing ureteric orifices (golf hole appearance): hydronephrosis and UTI
24. 24. CHRONIC TUBERCULOUS URETERITIS Stricture of the ureter at the lower third In bilharzial ureteritis: the same Entire ureter is dilated, rigid, straight, and has a thick wall In bilharzial ureteritis, the dilated ureter is tortuous and has a thin wall
25. 25. GENITAL TUBERCULOSIS Vas deferens involvement Very rare Beading of the vas Chronic epididymitis Very rare It is symptomless or causes mild pain Induration of the epididymis
26. 26. UROGENITAL TUBERCULOSIS DIAGNOSIS Urine analysis Pyuria Urine culture for non-specific organisms: negative (sterile pyuria) Urine culture for tubercle bacilli: positive Biopsy from the bladder or kidney Tuberculomatous reaction seen in biopsy specimen
27. 27. UROGENITAL TUBERCULOSIS INVESTIGATIONS KUB: calcification of the renal parenchyma, linear calcification of the bladder wall IVU: ureteral stricture, contracted bladder, non-functioning kidney (autonephrectomy) Ascending cystogram: vesico-ureteral reflux Cystoscopy: tubercles (confirmed by biopsy), bladder ulcers, widely dilated (golf-hole) ureteric orifice, contracted bladder
28. 28. UROGENITAL TUBERCULOSIS TREATMENT Anti-tuberculous treatment For 6 months Surgical reconstruction Ureteral stricture (resection of the strictured segment and re- anastomosis of the 2 healthy ends of the ureter) Vesico-ureteral reflux (ureteral re-implantation in the bladder by an anti-reflux) Contracted bladder (ileocystoplasty or colocystoplasty) Nephrectomy if there is autonephrectomy