Urinary tract infection

Introduction
• UTI is term to describe acute urethritis and cystitis
• Accounts about 1-3% visit in general medicine practice
• In women, prevalence about 3% at age of 20 years, increasing by 1%
in subsequent decade
• In men, uncommon except in first year of life and over 60 years
 Spectrum of presentation of urinary tract
infection
• Asymptomatic bacteriuria
• Symptomatic acute urethritis and cystitis
• Pyelonephritis
• Acute prostatitis
• Septicaemia (usually gram –ve bacteria)
Common Organisms
• E. coli (as it is predominant periurethral flora)
• Klebsiella, Enterobacter, Staphylococci epidermidis
• Proteus and Pseudomonas (obstruction, instrumentation)
• Candida (immunocompromised, prolonged antimicrobial therapy)
Pathophysiology
• Urine is excellent culture media for bacteria
• Urothelium of susceptible persons may have more receptors to
adhere virulent strains of E. coli
• Organisms easily ascent into bladder in female (the urethra is shorter
and the absence of bactericidal prostatic secretions)
• Organisms may also be introduced by
• Minor urethral trauma during sexual intercourse
• Instrumentation of bladder
Asymptomatic bacteriuria
• Defined as more than 105 organisms/mL in the urine of apparently
healthy asymptomatic patients
• 3% of non-pregnant adult women
• 5% of pregnant women have asymptomatic bacteriuria
• Increasingly common in those aged over 65
• Up to 30% will develop symptomatic infection within 1 year
• Treatment is required in infants, pregnant women and those with
urinary tract abnormalities
Features of cystitis and urethritis
• Abrupt onset of frequency of micturition and urgency
• Burning pain in the urethra during micturition (dysuria)
• Suprapubic pain during and after voiding
• Intense desire to pass more urine after micturition, due to spasm of
the inflamed bladder wall (strangury)
• Urine - may appear cloudy and have an unpleasant odour
• Non-visible or visible haematuria
ACUTE PYELONEPHRITIS
• ‘Pyelonephritis’ means inflammation of the kidney and renal pelvis

Pathogenesis
Ascending Infection
• Develops from infection in the bladder through the mechanism of
vesicoureteral reflux
Hematogenous Infection
• Element of obstruction is of importance
Clinical features
• Constant ache over one or both kidneys
• Pain may radiate to the lower abdomen or to the groin
• Children often complain of vague abdominal discomfort instead of
localized renal pain
• Complaints due to cystitis - Increased frequency of micturition,
urgency, nocturia and burning sensation on urination
• Prodromal symptoms e.g. headache, lassitude, nausea, vomiting and
prostration
• Rigor along with high temperature is quite common
PHYSICAL SIGNS
• General signs - increased temperature, increased pulse rate
• Local examination - tenderness at the renal angle
• Anterior tenderness might not be easily palpable due to muscle
spasm
• Percussion over the renal angle may be painful
• Abdominal distension with quiet intestine revealed by auscultation (in
acute cases)
• Rebound tenderness may also be elicited if there is intraperitoneal
infection
Investigations
• Blood Examination - high neutrophil count, increased E.S.R, culture -
bacteremia is not uncommon
• Urine - scanty and highly concentrated, usually cloudy, protein
content high, contains large amounts of pus and bacteria, few red
cells may be noted
• Renal function slightly affected unless there is overwhelming sepsis

X-RAY - some obliteration of the renal shadow due to edema of the

kidney and perinephric fat (may not be decisive)
Intravenous pyelogram
• Pelvis and calyces on the affected side
may be smaller
• Presence of obstruction or
vesicoureteral reflux should be noted
• When infection is severe, it shows less
concentration of dye on the affected
side
Complications
• May turn to be chronic

Chronic form may gradually lead to

• Renal insufficiency
• Renal ischemia
• Hypertension
Treatment
• Antibiotic should be started immediately even when the culture and
sensitivity reports
• Antibiotics should be continued for 7-14 days. Seriously ill patients
may require intravenous therapy with gentamicin for a few days later
switching to an oral agent
Failure of Response
• If no clinical improvement occurs in 2 to 3 days of treatment
excretory urograms should be advised to detect any obstruction or
vesicoureteral reflux
• Obstruction may necessitate surgical treatment e.g. removal of a
ureteral stone
Chronic Pyelonephritis
• Characterized by chronic tubulointerstitial inflammation and deep
segmental cortical renal scarring and clubbing of the pelvic calyces as
the papillae retract into the scars

Pathogenesis
Ascending Infection
Hematogenous Infection
Clinical features
• More common in females (3:1)
• May remain asymptomatic until renal insufficiency takes place
• Mild discomfort or dull pain over the kidney
• Vesical irritability - increased frequency, urgency and dysuria
• Hypertension (seen in half the cases)
• Vague gastro-intestinal complaints
• Constitutional symptoms - lassitude, headache, malaise, nausea and anorexia
• Anaemia
• Pyrexia (about 10 to 20% of cases)
Physical Signs
• Hypertension is discovered in half the cases
• Some degree of localized renal tenderness may be elicited
Investigations
• Blood Examination - slight leukocytosis, low Hb
• Urine Examination - decreased protein content
• RME - may or may not contain numerous white cells, some bacteria are
always present
• Renal function tests should always be performed
• X-RAY - may show small atrophic kidney
• IVU may be either normal or show
changes suggesting scarring e.g.
indentations of the lateral borders,
roughening and deformity of the calyces.
It may show dilatation of the ureter or
vesicoureteral reflux.
• Voiding cystourethrography -
demonstrates vesicoureteral reflux
• Cystoscopy may reveal evidence of
chronic infection in the bladder. Reflux at
the ureteric orifices may be detected. Voiding cystourethrogram (VCUG)
Medical Treatment
• Drug should be given for 2 to 3 weeks
Surgical Treatment
• If any obstruction is detected this should be removed surgically.
• If vesicoureteral reflux has been demonstrated and is considered to
be the cause of chronicity, repair of the ureterovesical junction should
be considered
• If one kidney is badly damaged, nephrectomy should be considered
• When the hypertension has become malignant type and the cause is
chronic pyelonephritis, if the other kidney is normal, nephrectomy of
the affected kidney is curative
• Partial nephrectomy of a badly damaged portion of the kidney may be
necessary
• When this condition affects both the kidneys badly with uncontrolled
hypertension, transplantation of kidney or recurrent dialysis should be
considered
References
• Davidson's Principles And Practice Of Medicine, 23rd Ed
• A Concise Textbook of Surgery, 6th Ed - S. Das
Thank You