Nephrology & Urology Urinary Tract Infections PDF

Nephrology & Urology Buffi - Urology - Lesson 01: Urinary Tract Infections 23/10/2024 - Group #33 (Stefania Pesaresi - Valeria Viti) Urinary tract infections are both a clin...

Nephrology & Urology Buffi - Urology - Lesson 01: Urinary Tract Infections 23/10/2024 - Group #33 (Stefania Pesaresi - Valeria Viti) Urinary tract infections are both a clinical and pathological condition. On one side we have signs and symptoms that we will explore, on the other we have inflammation. If we have signs and symptoms we can have a UTI, but it is very important to note that sometimes it is possible to have asymptomatic bacteriuria, meaning to have presence of bacteria in the urine without any sign and symptom typical of a UTI. Classification A way to classify a UTI is the anatomical district, the terminology is: Lower part of the UT → cistitis Prostate → prostatitis Pyelonephritis → kidneys Another way of classification is the pathological conditions associated with the UTIs, listed in the table below. 1 Risk factors Some main risk factors of UTIs are: - A previous UTI - Frequent sexual intercourse - A new sexual partner - Family history of UTI - Diabetes - Neurogenic disorders - Incontinence - Fimosis - BPH We can also divide the risk factors between females and males, obviously presenting some differences. Look at table on the right For example, especially at an older age, the main risk factors for women are estrogen deficiency and bladder prolapse, while for men it is prostatic enlargement. Epidemiology UTIs are a very big issue in the health system. They are more common in women. 2 Pathogenesis The pathogenesis of UTIs is simple: it is an ascending infection. Normally the bacteria colonize the perineal area, then they ascend in the urethra reaching the bladder, defined as cystitis. From the bladder, some kinds of bacteria will arrive in the ureters and then kidney, defined as pyelonephritis. Very rarely we can have a hematogenous pathway or lymphatic development. This is the reason why it is more frequent in women. In the perineal area, in the picture on the left, you can see a E. Coli colonization. From there, it moves to the vagina, then urethra (since it is not long in women, it is easier to reach), then ascending to the bladder. There, we have some mechanisms of the bacteria able to adhere to the superficial umbrella cells leading to the colonization of the epithelium. When we think of the pathogenesis of a UTI, there is an interaction between the host and the uropathogens: it is not only depending on the pathogen, since the host and the environment play a big role. This interaction between host and uropathogens plays a role in the initiation, development and sometimes the maintenance of UTI. By uropathogen virulence-associated factors we define all the characteristics of these pathogens linked to the possibility to adhere to the epithelium and cause inflammation. 3  Here are some examples of virulence-associated factors. Surely, one of the most important ones is the adhesion to the urothelium: some proteins of the membrane favor the binding of the Coli to the epithelial layer. The second mechanism is the immune evasion, the reason why there can be a development of antimicrobial resistance. The third mechanism is invasion: bacteria will bind the extracellular membrane, go inside the cells and rest there. That is at the base of recurrent infections. Host defense The host defense can be aspecific, like in the case of urinary flow or integrity of the urothelial barrier (typical of a non-pathological urinary tract). On the other hand, when we have the aggression of the bacteria, we have an immunity driven defense, activating signaling pathways that trigger the process of inflammation, responsible for the signs and symptoms of UTIs. Sometimes bacteria don't activate inflammation, for various reasons. In this case we have asymptomatic bacteriuria. 4 Etiology The main cause of UTI is E. Coli. E. coli accounts for 75–90% Staphylococcus saprophyticus for 5–15% Klebsiella, Proteus, Enterococcus, and Citrobacter species, along with other organisms, for 5–10%. Gram-positive bacteria (e.g., enterococci and Staphylococcus aureus) are important pathogens in complicated UTI (prostatitis) As doctors, we have to characterize and distinguish the clinical syndrome. Most frequently we will have to deal with uncomplicated cystitis, sometimes pyelonephritis and prostatitis and complicated UTI, while it is also very important to recognize an ASB (asymptomatic bacteriuria). ACUTE UNCOMPLICATED CYSTITIS The most common type of UTI. In AUC there is no fever, no chills, no rigors, no significant fatigue or malaise, no flank pain, no costovertebral angle tenderness. Normally it is harder to find in: men, pregnant women, people with an abnormal urinary tract, people wearing catheters, people suffering from renal diseases or those who are immunocompromised since in those cases the infection would be more severe. The clinical presentation of an AUC is: dysuria (painful or uncomfortable urination) urinary frequency (the need to urinate more often with a reduced volume) urinary urgency suprapubic pain sometimes hematuria, which can also be a sign of tumor of the urinary tract In older patients, the infection is subtler, with non specific symptoms. In that case, a urine sample is checked for alteration in urine color, clarity and odor, although it is quite an unreliable indicator. 5 Diagnosis: Symptoms are usually enough for a diagnosis. A dipstick and urinalysis can be done. Only in case we suspect a complicated UTI, a urine culture can be done to confirm a prior diagnosis. The dipstick is normally an emergency tool, since it’s cheap and fast. The urinalysis is slower and more expensive, better at evaluating the contamination. Urine culture Normally urine is not sterile, there is presence of a urinary microbiota (bacteria that in the standard urine culture are not detected). Sometimes there can still be contamination, especially from the urethral and periurethral bacteria. It is advised to analyze the midstream clean catch. This consists in eliminating the fist part of the urine, taking the second part of the flow for the culture. Depending on the bacteria we have a different count. For Enterobacteriaceae: >105 CFU/mL in asymptomatic (to confirm with second specimen) >102 CFU/mL in symptomatic Steps: 1. Wash your hands before you collect the urine 2. If the collection container has a lid remove it carefully (without touching the inside of the cup with your fingers) 3. Clean the area around your genitals (pulling back the foreskin for men, spreading open the folds of skin around the vagina for women) 4. Start to urinate into the toilet or urinal, and after several seconds, place the collection cup into the stream collecting about 60mL of the "midstream" urine without stopping the flow 5. Do not touch the rim of the container to your genital area 6. Finish urinating into the toilet or urinal 7. Carefully replace the lid on the cup 6 This table sums up the EU guidelines regarding the diagnosis of AUC in women. Where there is a low risk factor, a history of lower urinary tract infection (dysuria, frequency and urgency) is enough. A urine culture is performed in case we suspect an acute pyelonephritis, a complicated UTI, in pregnant women, in the presence of atypical symptoms or recurrent UTIs.. Treatment: In order to choose the most appropriate antimicrobial agent, we consider: Spectrum and susceptibility patterns Tolerability and adverse reactions Costs Availability Usually we opt for: Fosfomycin Nitrofurantoin Co-trimoxazole (TMP/SMX) (only if Escherichia coli resistance rate 20%) Quinolones are usually not suggested, since: High prevalence of resistance and negative ecological impact High frequency of disabling and long-lasting side effects They are still used in some particular scenarios. The spectrum of resistance to these antimicrobials has changed in the past years. Spectrum of resistance to quinolone Spectrum of resistance to cephalosporins 7 Acute cystitis in men Some people consider it an uncomplicated UTIs. It is much less common than in women because of the longer urethral length, so the ascending mechanism is more difficult. Also there is a less frequent colonization around the urethra, since the perineal area is not near the urethral meatus in men. Lastly because the prostatic fluid contains some antibacterial substances. The clinical manifestations are similar. If we have cystitis in men we expect prostatitis as well, if pelvic or perineal pain. The diagnostic approach is the same as in women, while the treatment, in this case, may require the use of quinolones (or co-trimoxazole) because of the prostate involvement. RECURRENT CYSTITIS Recurrent cystitis is defined as >2 UTIs in 6 months or >3 UTIs in 1 year There are 2 possibilities, from the pathogenic point of view: Reinfection (UTI due to a different pathogen or different strain of same pathogen) Relapse (UTI due to the same pathogen), in this case we may suppose an abnormality of the urinary tract since the infection shows up again, even after treatment Epidemiology Up to 50% with a recurrent episode within 6 months Incidence around 100 per 100,000 in the US Risk factors They vary depending on age and sex. Read the following table 8 Pathogenesis The pathogenesis is always the same: in this case, besides the ascending pathway we have a colonization of the vaginal and periurethral area. In these kinds of patients we can often find Coli in the vagina, along with the alteration of the normal flora (loss of H2O2-producing lactobacilli) and the colonization of the epithelium of the bladder. In this case we find bacteria not on the surface of the bladder, but inside the cells, making them difficult to eradicate. Treatment Recurrent UTIs need long term management. Behavioural modifications avoiding diaphragm or spermicides adequate fluid intake post-coital urination wiping from front to back after evacuation - in order to lower the risk of fecal contamination Antimicrobial prophylaxis low-dose continuous prophylaxis → taking a low-dose antimicrobial for 3 months, continuously everyday post coital prophylaxis as a single dose → especially in case of sexual related UTIs (not transmitted through sexual activity but that start after the intercourse) self-treatment → the patient starts the treatment independently Non Antimicrobial approaches Vaginal oestrogen replacement (especially in older women) Vaccine Probiotics (Lactobacillus spp) Cranberry D-mannose - Hyaluronic acid (not a lot of evidence on the effectiveness, but D-mannose is thought to inhibit E. Coli binding to urothelial receptors) 9 ACUTE PYELONEPHRITIS Acute pyelonephritis is a complicated, dangerosu syndrome. It is important to identify its main characteristics. Sometimes it starts as an acute cystitis, symptomatic, other times no cystitis-like symptoms are felt. Symptoms There is always the presence of fever and flank pain. Sometimes these are accompanied by chills, rigors, significant fatigue or malaise and costovertebral angle tenderness. We can sometimes have uncomplicated pyelonephritis, in case of non-pregnant, pre-menopausal women, with no known urological abnormalities or comorbidities. It is important to pay attention to complicated pyelonephritis, since it is what starts a condition of urosepsis, in case of no treatment in the first week/10 days. The uropathogens are similar, there are some differences between outpatients and inpatients and in the case of complicated and uncomplicated UTIs. Diagnosis: Laboratory tests (Urinalysis, and blood tests to check CBC (complete blood count), creatinine, urea, Na, K, CRP) Microbiology tests (Urine culture, Blood cultures (at least 2 sets, before starting the treatment especially if there is fever)) Imaging Diagnosis relies a lot on imaging assisting in this case. It can detect structural or functional abnormalities and evaluate patients at risk of complications (diabetic, elderly, or immunocompromised) and also the extent of organ damage. 10 There are 2 main kinds of imaging: Ultrasonography: Fast, cheap, available No ionizing radiations (only possible method in pregnant women) Operator-dependent Contrast-enhanced CT scan Higher cost, reduced availability Higher sensitivity Better characterization of complications Ionizing radiation Preferred method in non-pregnant patients Treatment: The main treatment in this case is the use of III generation cephalosporins: Beta-lactams (Ceftriaxone, Ceftazidime/Cefepime) Alternatively: Beta-lactam/beta-lactamase inhibitor (Piperacillin-tazobactam) If these are not effective, the third line treatment is: Carbapenems (Meropenem, Imipenem, fighting against a particular, very dangerous type of E. Coli → ESBL-producing, or Ertapenem) → Fluoroquinolones (Levofloxacin, Ciprofloxacin) are possible to administer but not advised for long periods) → Fosfomycin and nitrofurantoin are not used in this case because they are present inside the bladder, so not useful in case of pyelonephritis Complications: Not recognising and treating pyelonephritis can lead to complications. Sepsis, septic shock Acute renal failure (pre-renal like sepsis-related, intrinsic or post-renal) Local complications (like a renal corticomedullary or perinephric abscess, emphysematous pyelonephritis, papillary necrosis) Pathogenesis: From the ureters pathogens reach the kidney. If you don't treat the infection, they will get in the blood leading to bacteremia and sepsis. Only some agents can pass to the blood, but it’s still very important to act fast in this case. 11 RENAL AND PERINEPHRIC ABSCESSES If you don’t treat pyelonephritis you have a lot of complications, one of the most frequent complications of renal infections are abscesses. We classify abscess in function of the position: perinephric abscess – perinephric area cortical renal abscess - inside the kidney paranephric abscess – outside of the Gerota fascia. Usually, pathogenesis is a local complication of a urological infection. So, we always start with a urinary tract infection, which ascends up the kidney, or sometimes we start with sepsis due to other reasons and we have abscess as a secondary event. More frequently, these abscesses are due to local spread. A lot of times, renal abscesses are a complication of a bacteraemia and lots of times we can see a Staphylococcus Aureus inside the infected blood. Instead, perinephric abscesses always diffuse after renal infection, sometimes due to a rupture of renal abscess. Clinical picture: The clinical representation is similar to pyelonephritis since it is its complication. Therefore, we find fever, pain, fatigue, lumbo-abdominal pain, sweats and weight loss. In this case the symptoms do not derive from an inflammation at the level of the bladder, but bacteria go in the ureters and kidneys and cause pyelonephritis or renal abscesses. Sometimes they involve adjacent structures, like spleen, liver, and colon, depending on the position of the abscess. Diagnosis: Note that the clinical presentation of the abscess is insidious: meaning that it is not clear, it is suspected. If you suspect it, it is important that you perform a CT scan or ultrasonography. You have to perform lab tests, that will always result in leukocytosis and increased CRP. Urinalysis is performed if possible, showing pyuria and bacteriuria in the case of the renal abscess; if the abscess is outside the kidney (perinephric abscess) you will have a normal urinalysis. You also perform a blood culture and urine culture. Remember, in case of: uncomplicated UTI → no urine culture complicated UTI → urine culture complication of complicated UTI (abscess and pyelonephritis) → blood culture 12 Treatment: Obviously, we have to start a long-term antimicrobial treatment, since we cannot treat an abscess with short-term therapy. It is a therapy against Staphylococcus and not only Escherichia Coli. Drainage of the abscess is possible: in the case of renal abscess, we will drain it only if it is bigger than 5cm; if it is less than 5 cm we treat it only with an antimicrobial treatment in the case of a perinephric abscess, it is drained since there is no risk for the kidney, and it can be useful for diagnostic purposes, to understand which bacterium is causing it (since you do not find the bacterium in the urine in this case). CATHETER-ASSOCIATED UTI (CA-UTI) Particular kind of UTIs in which the patient has a urinary catheter. Normally, a urinary catheter is the kind of catheter shown in the picture, called Foley catheter, a latex catheter. The catheter-associated UTIs are obviously infections of the urinary tract that affect patients with a urethral catheter, or patients that have the catheter directly inserted inside the bladder, which is called suprapubic catheter (used when the urethra is not available), or even in the case of an intermittent catheter, which is used for some neurologic patients (with a neurological disorder that affects the bladder) that are catheterized only when they have to void the bladder, 3/5 times each day. Diagnosis: Urine culture, obviously, is performed. Symptoms: We can have the classical fever, suprapubic pain and costo-vertebral angle tenderness. We can also have some systemic symptoms, because often these kinds of patients are hospitalized, in a geriatric area, and so they can present some other conditions, such as hypotension, altered mental status and sepsis. 13 Pathogenesis: The pathogenesis is always the same ascending process but is facilitated because the catheter is colonized by the bacteria. They create biofilms on the catheter and so is the catheter the way of the proliferation of bacteria. After the colonization of the bladder, an inflammatory response is activated. Then the bacteria ascend causing the infection with the symptoms. Epidemiology and microbiology: 3-8% of patients each day of catheterization display catheter-associated bacteriuria. In general, 10-25% of patients with catheter develop a CA-UTI and 20% of hospital-acquired bacteraemias are due to the catheter of the patient. Normally the microbiology is very similar to cUTIs and more than once we can find Candida in urine. Therefore, we can also start with the treatment for candida if we find this kind of infection. Risk factors and prevention: If we want to prevent UTIs linked to the catheter, we have to avoid unnecessary catheterization and remove the catheter as soon as possible. This is very important for all the doctors. When is it permitted to put the catheter in our practice? if we have a clinically significant urinary retention, in which the bladder is not able to void, so that we can give to the patients a temporary relief; then the patients start a medical therapy, which, if is not adequate, it will be followed by surgical correction of the cause of urinary retention. in case of urinary incontinence, only to give comfort to terminally ill patients way of monitoring accurately the output of the urine, frequent in critical patients. But it is very important to remember that this critical patient is at risk of infection linked to the catheter. So, we give him a problem in order to accurately monitor the urine. 14  if the patient is unable or unwilling to collect urine, for example because he is completely blocked after a spinal trauma or something similar, or with the patients during some surgical procedures, for example in urologic surgery. Normally we remove the catheter after one, two, three days, not more. Other risk factors for CA-UTIs: Female sex, older age, diabetes Bacterial colonization of drainage bag, inadequate catheter care Diagnosis: Clinical and laboratory findings are similar to that of complicated UTIs. It is a syndrome, with frequently nonspecific symptoms. Odorous or cloudy urine are present but not diagnostic. We don’t always see clear symptoms of infection, meaning that we need urine cultures and blood cultures. It is difficult to have the urine culture, because often in the catheter, we have a colonization: either outside the catheter, in the point of the catheter or in the bag of the catheter. To take urine for urine culture we could: Use a midstream specimen after catheter removal Replace the catheter before sample collection Obtain the sample directly from the catheter, obviously not from the bag, because the bag is the first place where biofilms are formed. Treatment: The treatment is similar to complicated UTIs, so we could have a short-course therapy, which would be better, but sometimes we could need a long-course therapy. The treatment is the removal of the catheter if it is possible. So as soon as possible, we have to remove the catheter. If it is not possible to remove the catheter, when we have a clear infection, it is better to change the catheter and treat the patient, in order to avoid the colonization of the whole catheter, that is a risk factor of relapse of the infection. 15 ASYMPTOMATIC BACTERIURIA Definition and epidemiology: In asymptomatic bacteriuria, there is the presence of one or more species of bacteria in urine culture. We have to confirm it and it's clear that it is not a clinical condition but it is a pathological condition, because we have absence of signs and symptoms of UTI, we have only the bacteria inside the urine. There are some bacteria that are typical of this kind of situation, of the asymptomatic bacteriuria: it is mainly caused by Escherichia coli. It is a prototype of coli (ABU E.coli) that does not ascend, does not adhere to the surface and stays in the bladder without virulence, and sometimes gives some biofilm formation without triggering host response. There are instead some coli that are uropathogenic coli (UPEC), and they start to adhere to the bladder, and travel in the ureters, reaching the kidneys and causing pyelonephritis, abscesses and sepsis. So, one kind of bacterium does not trigger a host response, and the other kind triggers it. If we have a host response, we will have a symptomatic infection. If we don't have a host response, we will have an asymptomatic infection. But sometimes if we have a host with a lot of comorbidities, diabetes, neurology, also some kind of non-typical uropathogenic agents can give us asymptomatic infection. So, our way to consider it is always the kind of virulence, the power of the bacteria and the power of the host to defend from the bacteria. 16 Student’s question: If you have your urinary tract colonized by an asymptomatic kind of bacteria does that predispose you to get colonized then by a pathogenic pathogen? Answer: Yes, it is possible, but what is important is if there are symptoms or if there are no symptoms. Management: Don’t treat asymptomatic bacteriuria and don’t ask for a urine culture if you don’t need a urine culture. Indeed, if we give antimicrobials, in this case, we select the coli that will be more and more virulent. This means that we are giving the patients’ coli, a strategy to obtain the virulence with our treatment. This is the real problem. The patients that you should screen and treat are pregnant woman, and patients undergoing endourological procedures, this is because we have a big risk factor during pregnancy in the woman, and during surgery and so we can start rapidly from an asymptomatic bacteriuria to bacteraemia, sepsis, pyelonephritis and so on. Urinary tract infections need to be treated as a continuum that starts from the absence of urinary symptoms, and absence detectable bacteriuria, to asymptomatic bacteriuria, to subclinical UTIs, to symptomatic UTI. 17 PROSTATITIS Prostatitis is an infection of the prostate, so it is not specifically a urinary tract infection, but even if the prostate is part of the genital tract, it is attached to the urinary tract, because the urethra passes inside the prostate. So, we decided to put the prostatitis in this big field of urinary tract infection. We can classify prostatitis syndrome in Acute bacterial prostatitis Chronic bacterial prostatitis Chronic prostatitis/chronic pelvic pain syndrome Asymptomatic inflammatory prostatitis In the first two cases, we have bacteriuria and sometimes we have bacteria also in the seminal liquid. In acute prostatitis we have bacteriuria, infection localized to prostate, inflammatory response, abnormal rectal examination and we have a systemic illness, so fever, sore, rigor, something similar to the pyelonephritis, obviously, with another localization of the pain at the level of the bladder. In chronic bacterial prostatitis, we have bacteriuria, infection localized to the prostate, inflammatory response, but normally in chronic prostatitis we don't have nor an abnormal rectal examination nor a systemic illness. Prostatitis is an important part of the chronic pelvic pain syndrome, which can be divided into an inflammatory and a non-inflammatory kind. So, we have bacterial acute and chronic prostatitis, and a non bacterial, inflammatory and non-inflammatory prostatitis. The main difference between the inflammatory and non-inflammatory types of prostatitis is the presence of leukocytes in the urine. But it's not so important because there are no big differences in the symptoms and in the therapy. It is important mainly because if you think about inflammatory prostatitis, you will treat it with anti-inflammatory drugs, whilst if you have non-inflammatory prostatitis, you will treat the patients with other methods. 18 Then we also have asymptomatic prostatitis. Lot of men have histologic prostatitis, a big inflammation with no symptoms. This happens in men with a larger prostate, with benign hyperplasia, and in these patients an acute prostatitis can start suddenly from inflammation. Epidemiology: Not a big problem, there is a prevalence up to 16%. We have two peaks of incidence between 20-40 years old patients and with over 60 years old men. 10% of these patients develop acute prostatitis, while the 90% of them present a chronic one. Pathogenesis: Pathogenesis is approximately always the same: ascending urinary infection from the urinary tract, or an intraprostatic reflux, direct introduction (e.g. cystoscopies, biopsies, instrumentation) or through hematogenous seeding (rarer). Risk factors: Risk factors are benign prostatic hypertrophy (BPH), genitourinary and other kinds of infection, high-risk sexual behaviour, history of sexually transmitted diseases, immunocompromised patients, patients that underwent prostate manipulation (cystoscopy, transrectal prostate biopsy, transurethral surgery, urethral catheterization, urodynamic studies) and also urethral structure (for example a urethral stenosis). The main pathogens causing acute prostatitis are: always the Escherichia coli (but less frequent than urethra contractions), Pseudomonas aeruginosa, Klebsiella, Enterococcus, Enterobacter, Proteus and Serratia. Less commonly also Chlamydia, Aspergillus, Candida, Mycoplasma, Neisseria, Salmonella etc.. It's very difficult to find the exact cause of prostatitis, which is also the main reason because we start from acute prostatitis and progress to chronic prostatitis. Clinical presentation: The acute bacterial prostatitis has symptoms similar to acute infection of a urinary tract: dysuria, frequency, urgency, with weak stream, dribbling and hesitancy (the weak stream is due to an edema, which reduces the flow of the urine in the urethra). There is possible urinary retention, with acute swelling of prostate and pain or spasm of the bladder neck. Fever is possible, there is painful ejaculation and there can be haematospermia. Haematospermia is very typical: a lot of patients, when they have haematospermia, are afraid to have cancer, but in 99.9% of cases it is a sign of inflammation. It is very rarely related to prostate 19 cancer but notice that if it is caused by prostate cancer, the rectal examination will surely confirm it. In chronic prostatitis the symptoms are not clear, but there is some pain, discomfort, but it is not clear as the acute one. Chronic pelvic pain is similar. Diagnosis of acute bacterial prostatitis: Digital rectal examination → you will find a tender and enlarged prostate. Notice that you need to avoid prostate massage and pushing too much because you may cause bacterial dissemination, with bacteraemia and sepsis. Urinalysis → leukocytes, nitrites and obviously, sometimes, also haematuria and proteinuria. Midstream urine culture → blood cultures are usually negative PSA (prostate-specific antigen) → not routinely recommended, usually elevated Imaging → only to see if we have the suspicion of a prostatic abscess, which is very rare. We have to consider that if a patient has a BPH and has post-coital residual urine, normally this residual urine gives the possibility to the patient to develop an infection, that is an infection of the bladder and of the prostate. So, in a patient with BPH, prostatitis is linked to the postcoital residual volume, which is simple to obtain, and if it is high, the problem is that it gives the patient the possibility to develop UTIs. Diagnosis of chronic bacterial prostatitis: When we are in front of a chronic bacterial prostatitis, it's very difficult to have a diagnosis. We have the same approach as acute prostatitis, so the rectal examination, but normally we do not have specific signs. As for what regards microbiological diagnosis there is the gold standard test, in which 4 samples are collected: You collect the patient’s first stream, and then you get another specimen midstream You perform a prostate massage with gentle digital pressure, which will produce a prostatic secretion that is collected Urine after the prostatic massage is also collected The 2 glass test, in which only the midstream specimen and the last specimen are collected, is also adequate. If we find bacteria in the second glass, which we don’t find in the first one, it means that the infection is at the level of the prostate. 20 You could also perform semen or ejaculate culture, but they have very low specificity since they are at high risk of contamination. Management: The antimicrobials employed are fluoroquinolones and co-trimoxazole, which are the best since they penetrate the prostate tissue. The treatment should last a minimum of 2 weeks, and lasts about 4-6 weeks. In case of urinary retention urinary tract decompression is performed. In the case of abscess we perform drainage. 21