Urinary Tract Infection PDF

Prepared by ABDO BREK BATYOUR Fournier Gangrene; Fournier gangrene (FG) is a potentially life threatening progressive infection of the perineum and genitalia. Risk factors for developing FG include alcoholism,...

Prepared by ABDO BREK BATYOUR Fournier Gangrene; Fournier gangrene (FG) is a potentially life threatening progressive infection of the perineum and genitalia. Risk factors for developing FG include alcoholism, diabetes, recent urogenital or colorectal instrumentation or trauma, and preexisting peripheral vascular disease. Infection may spread along FASCIAL planes. The diagnosis of FG is a surgical emergency as the soft tissue infection can spread very rapidly. Treatment involves a combination of broad-spectrum antibiotics and extensive surgical debridement to margins of healthy bleeding tissue. GONOCOCCAL URETHRITIS Symptoms in men may include urethritis, epididymitis, prostatitis, and PROCTITIS. Women are usually asymptomatic and may present with sequelae of the disease (e.g., pelvic inflammatory disease, tubal scarring, infertility, ectopic pregnancy, and chronic pelvic pain). Nucleic-acid amplification tests (NAATs) are the preferred method for detecting both N. gonorrhoeae and C. trachomatis. In symptomatic men, a positive Gram stain of a male urethral specimen that demonstrates polymorphonuclear leukocytes with intracellular gram-negative diplococci can also be considered di- agnostic. Because of its low sensitivity, a negative Gram stain does not rule out N. gonorrhoeae infection. Treatment involves a single dose of both ceftriaxone 250 mg intramuscularly and azithromycin 1 g orally. Alternative regimens are single oral doses of cefixime 500 mg plus azithromycin 1 g. NONGONOCOCCAL URETHRITIS. Chlamydial Urethritis Chlamydia, caused by C. trachomatis, is the most frequently re- ported infectious disease in the United States. Ascending chlamydial infections in women can lead to scarring of the fallopian tubes, pelvic inflammatory disease, pelvic pain, and infertility. NAAT using first-catch urine is the most sensitive test for detecting C. trachomatis infections in men. The recommended treatment is single-dose, oral azithromycin 1 g or oral doxycycline 100 mg twice daily for 7 days. Concurrent testing for gonorrhea, human immunodeficiency virus (HIV), and syphilis should be performed. As with gonorrhea, all sex partners within the 60 days preceding the onset of symptoms should be referred for evaluation. Trichomonas vaginalis T. vaginalis is a flagellated parasite that preferentially infects the urethra in men and the urethra, vagina, and vulva in women. NAATs or wet mounts of cultures are used for diagnosis. The low prevalence of T. vaginalis in NGU does not warrant using these tests in the initial workup, although they should be considered for male sexual partners of women with trichomoniasis and for other male populations in high-prevalence areas. The recommended treatment is a single dose of oral metronidazole 2 g or tinidazole 2 g. CANDIDIASIS Candida albicans is a yeastlike fungus that is a normal inhabitant of the respiratory and gastrointestinal tracts and the vagina. The intensive use of potent modern antibiotics is apt to disturb the normal balance between normal and abnormal organisms, thus allowing fungi such as Candida to overwhelm an otherwise healthy organ. The bladder and, to a lesser extent, the kidneys have proved vulnerable; candi- demia has been observed The patient may present with vesical irritability or symp- toms and signs of pyelonephritis. Fungus balls may be passed spontaneously. The diagnosis is made by observing mycelial GENITOURINARY TUBERCULOSIS  Gram positive Obligate aerobe Non-spore-forming Non-motile rod Mesophile 0.2 to 0.6 x 2-4um1 Slow generation time: 15-20 hours May contribute to virulence1 Lipid rich cell wall contains mycolic acid—50% of cell wall dry weight1 Responsible for many of this bacterium’s characteristic properties Acid fast—retains acidic stains Confers resistance to detergents, antibacterials  Urinary TB A disease of young adults. 60% between 20~40y. Infecting organism — Mycobacterium tuberculosis Tubercle bacilli Transmission  Risk factors close contact with sputum positive individuals vagrancy, social deprivation, neglect, immunosuppression, HIV infection, diabetes mellitus renal failure elderly patients with TB elsewhere Caseation & Fibrosis  Starts around orifice (descending infection) Inflammatory bullous edema Foll by granulation “Golf-hole orifice” Withdrawn, fibrotic, dilated Ulcers rare  Epididymal TB Young, sexually active males (infertile) 70% have previous TB history Infertility Hematospermia Painless epididymal nodule or thickening Painful swelling of scrotum Acutely usually epididymorchitis Nodular enlgment head, tail epididymis Caseous granulomas Heterogeneously hypoechoic lesions in testis  Culture  Gold standard  positive in 80% to 90% of cases  Decontamination of sediment.  main problems: -COST -AVAILABILITY -DELAYS  Diagnosis: X-ray Findings Chest film; found in 50 % Plain film: Enlargement of 1 kidney Obliteration of the renal & psoas shadow Renal stones 10%  IVU “Moth-eaten” appearance of ulcerated calyces. Obliteration of 1/more calyces. Dilation of calyces. Abscess cavities connecting with calyces. Ureteral stricture with secondary dilatation. Absence of function of the kidney. Papillary necrosis Fuzzy irregular calices, truncated calix, phantom calix – features of papillary necrosis. Lobster claw Papillary (forniceal) excavation. The necrotic papillary tip may remain within the excavated calix, producing a signet ring sign when the calix is filled with contrast material. Moth eaten appearance Fuzzy & irregular calices due to papillary necrosis. Infundibular stenosis causing phantom calix Phantom calix Infundibular stenosis Golf ball on a tee On IVP : Collecting system shows contrast material in a large papillary cavity, the “golf ball” (∗). Blunted calyx, the “tee,” is adjacent (arrow). Kerr kink Cortical scarring with dilatation & distortion of adjoining calices coupled with strictures of the pelvicaliceal system. Cause luminal narrowing either directly or by causing kinking of the renal pelvis at the UPJ. Saw tooth appearance Ulcerations causing mucosal irregularity of ureter. Putty kidney Autonephrectomy. Diffuse, uniform, extensive parenchymal calcifications forming a cast of the kidney with autonephrectomy. End stage of GuTB. Beaded / Corkscrew ureter Mucosal irregularity and erosions resulting in chronic fibrotic strictures of ureter. Pipe stem ureter Rigid ureter: irregular and lacks normal peristaltic movement, fibrotic strictures noted. Note the distortion, amputation and irregularity of the upper pole calices. Thimble bladder Diminutive and irregular urinary bladder – simulating a thimble.  Differential Diagnosis Chronic pyelonephritis Papillary necrosis Medullary sponge kidney Xanthogranulomatous pyelonephritis  Treatment TB must be treated as a generalized disease!  Treatment: Renal TB Combination of drugs(1st line): 1. Isoniazid (INH) 200~300mg/d 2. Rifapin (RFP) 450~600mg/d 3. Ethambutol (EMB) 15mg/kg/d 4. Streptomycin (STM) 1g/d im 5. Pyrazinamide (PZA) 1.5~2g/d  Treatment: Renal TB Nephrectomy : 1. After 3 m, urine culture still (+) and gross involvement radiologically evident. Indications 1.Extensive disease in whole kidney, with 1HTN and UPJO 2. Coexisting renal carcinoma 3. Non-functioning kidney +/- calcification 2. Severe sepsis, pain or bleeding from 1 kidney.  Partial Nephrectomy Indications; 1. Localized polar lesion with calcification which fails to respond after 6 wks intensive chemotx 2. Area of calcification slowly increasing in size and threatening to destroy whole kidney Not justified in absence of calcification - can treat effectively with chemotx