Urology
Monday 27/11/2017
Lower Urinary Tract Infections
Bladder Infection (Cystitis):
Infection of the bladder gives rise to symptoms of frequency, urgency, suprapubic discomfort, dysuria and cloudy offensive urine. These symptoms are often known as ‘cystitis’. Lower UTIs are much more common in women than in men.
Isolated Infection:
A single episode of lower urinary tract infection and is usually uncomplicated
Recurrent Infection:
Is an infection that occurs after documented resolution of a previous attack. It may occur by the same or a different microorganism.
Persistent Infection:
It is an infection that is not completely eradicated and goes into remitting relapsing course. This is either because of associated underlying condition that prevents adequate eradication or because of improper treatment: i.e. using a wrong antibiotic or giving the treatment for a shorter period. It may also be due to bacterial resistance
Predisposing Factors for Lower UTI:
Incomplete bladder emptying: which may be due to:Bladder outlet obstruction
Bladder diverticulum
Neurogenic bladder
Decompensation of detrusor muscle.
A calculuis, a stone or a tumor.
Incomplete emptying of the upper system, dilated ureters as in pregnancy or vesico-ureteric reflux.
Estrogen deficiency which decreases local tissue resistance.
Perineal skin colonization by bacteria.
Diabetes mellitus
Immunosuppression.
Clinical Features:
These include frequency, pain, hematuria and pyuria. Fever and rigor are not usually features unless there is associated upper tract infection or sepsis.
Examination reveals tenderness over the bladder in the suprapubic region.
Mid-stream urine analysis will usually reveal the infection.
Investigations:
Investigations may be needed when there is recurrent infection or when it affects male. It will include search for bladder outlet obstruction, urinary tract imaging and possibly cystoscopy
Treatment:
Antibiotic therapy should be commenced immediately and may need to be changed later if culture was obtained.
Interstitial Cystitis (Bladder Pain Syndrome):
A chronic non-infective debilitating condition that is almost always found in females (Male:Female is >5:1). The condition is manifested as frequency, urgency, nocturia and pain that is relived by micturition and aggravated by bladder overdistension. Hematuria may be present but pyuria and bacteriuria are usually absent. With advancing disease, the bladder capacity will start to decrease. The condition may be associated with other systemic manifestations as irritable bowel syndrome and chronic fatigue syndrome.
Urethral Inflammation:
Gonococcal urethritis: is a sexually transmitted infection caused by gram-negative Neisseria gonorrhea (gonococcus). It affects both sexes.
Most men complain of urethral discomfort and urethral discharge. There may be scalding dysuria. In females the disease may be asymptomatic or may cause mild dysuria and urethral discharge. In severe cases it may lead to salpingitis which, if bilateral may lead to infertility.
The diagnosis is made by identifying pus cells and gonococcus in urine or, more recently by PCR-based techniques.
In men the disease may lead to prostatitis, epidydimo-orchitis, periurethral abscess and urethral stricture. Other complications may include arthritis, iritis and endocarditis.
Treatment is by antibiotics with ceftriaxone being the drug of choice. Contact tracing is important for adequate eradication.
Non-specific Urethritis: (Non-gonococcal Urethritis)
It is a sexually-transmitted infection caused most commonly by Chlamydia trachomatis or Ureaplasma urealyticum. Sometimes the microorganism is not known. The condition presents as dysuria and urethral discharge. In some cases epididymitis may occur. In females it is usually asymptomatic or it may give rise to pelvic inflammatory disease.
Exclusion of gonococcal infection is important and the diagnosis is made by urethral swab or urine analysis. Treatment is by doxycycline or azithromycin. It is important to treat both partners to prevent recurrence…
Emphysematous Pyelonephritis:
Emphysematous pyelonephritis is a severe, necrotizing form of pyelonephritis with extension of the infection through the renal capsule. This leads to the presence of gas within the kidney substance and in the perinephric space. Persons with diabetes (with or without obstruction) account for 85-100% of cases.
Patient presentation includes fever, chills, abdominal pain, nausea, vomiting, flank pain, flank mass (50%), crepitation (over thigh or flank), urinary symptoms, and pyuria.
Management should be prompt and urgent and consists of heavy sustemic antibacterial therapy together with surgical drainage of the purulent material and debridement of the necrotic tissue. The condition has a high mortality.