Urinary tract infection

Tbilisi referral hospital, Tbilisi, Georgia

Nephrologist
Nino Maglakelidze
 Urinary tract
infection

Upper urinary tract infection: Lower urinary tract infection:

Acute peylonphirits Cystitis,

Chronic pyelonephritis Urethritis
Renal abscess Protatitis
Perirenal abscess

Both of them can be complicated

and uncomplicated;
UTI terminology

Uncomplicated: UTI without underling renal or neurologic disease;

Complicated: UTI with underling structural, medical and neurologic

disease;

Recurrent: >3 symptomatic UTIs within 12 months following clinical

therapy;

Reinfection: recurrent UTI caused by a different pathogen at any

time

Relapse: recurrent UTI caused by same species causing original UTI

within 2 weeks after therapy.
 Urinary tract infection

Cystitis

Definition:

Cystitis is inflammation of urinary bladder, caused by infection,

which can be alone or in combination with pyelonephritis.

Cystitis: Complicated and uncomplicated;

 Cystitis

Classification of cystitis

Uncomplicated cystitis is limited lower urinary tract and the patient

has no underling medical problems or anatomic or physiologic
abnormalities;

Complicated cystitis is defined by coexisting upper UTI,

multiple drug resistant uropathogens, or host with special
considerations;
 Cystitis
Risk factors of cystitis:

•Female sex
•Lack of circumcision is risk factor for UTI in males
•Sexual activity
•Abnormalities of the urinary system:
•Bladder stones
•Bowel and bladder dysfunction
•Neurogenic bladder
•Indwelling bladder catheter
•Diabetes mellitus
•Immunodeficiency
 Cystitis
Clinical presentation

Lower urinary tract symptoms:

Dysuria

Frequency

Urgency

New onset incontinence

Hematuria (microscopic hematuria or gross hematuria with cloth

formation)

Fever very rare

 Cystitis
Laboratory evaluation

Urinalysis: dipstick

Urinary sediment microscopic examination

Urine culture

Ultrasound or CT scan
 Cystitis

Bacterial infections in children and adolescence

may be caused by:

E. Coli; Klebsiella spp; Enterobacter spp and

Pseudomonas aeruginosa

Viral culture
Adenovirus, cytomegalovirus, polyomaviruses (BK
and JC);
Method: polymerase chain reaction;

Fungal culture:
Vast majority are caused by Candida spp;
 Cystitis
Treatment:

Antibiotics: Trimethoprime-sulfamethoxasole; amoxicilline-

clavunate, second or third generation cephalosporines,
nitrofurantoin;

Duration of therapy:
3 days with antibiotics uncomplicated
7-14 days with antibiotics complecated;
 Prostatitis

Risk factors: Acute prostatitis can occur in the setting of cystitis,

urethritis, or other urogenital tract infections.

The pathogens associated with acute prostatitis reflect the spectrum

of organisms causing cystitis, urethritis, and deeper genital tract
infections.
 Protatitis

Prostatitis most frequently is caused by:

•E. coli – 58 to 88 percent

•Proteus species – 3 to 6 percent

•Other Enterobacteriaceae (Klebsiella, Enterobacter, and
Serratia species) – 3 to 11 percent
•Pseudomonas aeruginosa – 3 to 7 percent
•gram-positive cocci including Staphylococcus aureus, streptococci
and enterococci
 Prostatitis:

Clinical signs:

fever, chills,
malaise,
myalgia,
dysuria,
irritative urinary symptoms (frequency, urgency, urge incontinence),
pelvic or perineal pain,
and cloudy urine.
Swelling of the acutely inflamed prostate can cause voiding symptoms.
 Prostatitis

Complications:

Bacteremia

Epididymitis

Chronic bacterial prostatitis

Prostatic abscesses

and metastatic infection (eg, spinal or sacroiliac infection)

 Prostatitis:
Treatment:

Patients with gram negative rods levofloxacin or ciprofloxacin may be

given with or without an aminoglycoside (gentamicin or tobramycin
5 mg/kg daily, if the creatinine clearance is normal).

Gram-positive cocci treatment with amoxicillin or ampicillin .

Of note, these regimens are not active against most Enterococcus
faecium or other ampicillin-resistant strains.

Gram-positive cocci - due to Staphylococcus

aureus or coagulase-negative staphylococci
effective oral antibiotics are cephalosporins cephalexin or
penicillinase-resistant penicillins dicloxacillin; cefazolin or nafcillin.
If there are risk factors of methicillin-resistant S. aureus, vancomycin
can be used.
 Pyelonephritis
Clinical signs

•Fever

•Chills

•Flank pain

•Nausea/vomiting

•Costovertebral angle tenderness

 Pyelonephritis
Complications:

•Bacteriemia

•Sepsis

•Multiple organ system dysfunction

•Shock

•Acute renal failure

•Abscesses

•Emphysematous pyelonephritis,
 Pyelonephritis
Diagnosis:

•Urinalysis

•Urine culuture

Imaging :
Renal ultrasound;
MRI imaging
CT scanning
 Pyelonephritis
Management :

Empiric antibacterial treatment promptly taking into account

risk factors, including previous antimicrobial use and results of
recent culture results, with antimicrobial susceptibility data.

Treatment:

•Ceftriaxone
•Piperacillin –tazobactam
•Vancomycin , Linesolid - MRSA
•Ciprofloxacin, levofloxacin
•Imepenem, meropenem and doripenem
 Urinary tract obstruction

Etiology :

The causes of urinary tract obstruction vary in part based upon the
location of the obstruction

Kidney:

•Stones
• Renal cell carcinoma
 Urinary tract obstruction

Ureter:

•Stones
•Renal cell carcinoma
•Extrinsic tumors
•Retroperitoneal fibrosis
•Infection
•Obstructed stent
•Blood cloth
•Trauma
•Ectopia
 Urinary tract obstruction

Bladder:

•Blood cloth
•Edema/inflammation
•Bladder dysfunction
•Posterior urethral valve

Urethra:

•Prostatic enlargement
•Stones
•Stricture
 Urinary tract obstruction

Clinical signs:
•Pain
•Change in urine output
•Hypertension
•Hematuria and pyuria
•Increased serum creatinine
•Hyperkalemic renal tubular acidosis

Diagnosis:
•Ultrasound
•CT – computed tomography
•MRI – Magnetic Resonance Imaging
 Urinary incontinence

Definition:

It is defined as involuntary or uncontrolled urination from the bladder

sufficient to cause a social or hygienic problem.

Classification of urinary incontinence:

•Stress urinary incontinence-increased Intra abdominal pressure

•Urgency incontinence – overactive bladder
•Overflow incontinence – detrusor muscle under activity
•Overflow incontinence – urinary outlet obstruction
 Urinary incontinence

Stress incontinence

1. Urethral hypermobility – is thought to stem from insufficient support

of the pelvic floor musculature and vaginal connective tissue to the
urethra and bladder neck. This causes the urethra and bladder neck to
lose the ability to completely close against the anterior vaginal wall.
Which increases in intra-abdominal pressure, coughing or sneezing ,the
Musculature of the urethra fails to close, leading to incontinence;
 Urinary incontinence
Stress incontinence

2. Intrinsic sphincteric deficiency – Intrinsic sphincteric deficiency (ISD)

is a form of stress urinary incontinence that results from a loss of
intrinsic urethral mucosal and muscular tone that normally keeps the
urethra closed. In general, ISD results from neuromuscular damage and
can be seen in women who have had multiple pelvic or incontinence
surgeries. ISD can occur in the presence or absence of urethral
hypermobility and typically results in severe urinary leakage even with
minimal increases in abdominal pressure. Treatment is aimed at
improving urethral blood flow with vaginal estrogen and with pelvic
muscle exercise or surgery.
 Urinary incontinence

Urgency incontinence:

1. Women with urgency incontinence experience the urge to void

immediately preceding or accompanied by involuntary leakage of
urine. "Overactive bladder" is a term that describes a syndrome of
urinary urgency with or without incontinence, which is often
accompanied by nocturia and urinary frequency.

2. Urgency incontinence is more common in older women and may be

associated with comorbide conditions that occur with age. It is believed
to result from detrusor overactivity, leading to uninhibited (involuntary)
detrusor muscle contractions during bladder filling. This may be
secondary to neurologic disorders (eg, spinal cord injury), bladder
abnormalities, or may be idiopathic.
 Urinary incontinence

Overflow incontinence — Overflow incontinence typically presents

with continuous urinary leakage or dribbling in the setting of incomplete
bladder emptying. Associated symptoms can include weak or
intermittent urinary stream, hesitancy, frequency, and nocturia.
When the bladder is very full, stress leakage can occur or low-amplitude
bladder contractions can be triggered resulting in symptoms similar to
stress or urgency incontinence.
 Urinary incontinence

Overflow incontinence is caused by detrusor underactivity or

bladder outlet obstruction.

●Detrusor underactivity – Detrusor underactivity may be caused by

impaired contractility of the detrusor muscle. Impaired urothelial
sensory function may also contribute. Studies suggest that detrusor
contractility and efficiency decrease with age. Severe detrusor
underactivity occurs in about 5 to 10 percent of older adults. Other
etiologies of detrusor underactivity include smooth muscle damage,
fibrosis, low estrogen state, peripheral neuropathy (due to diabetes
mellitus, vitamin B12 deficiency, alcoholism), and damage to the spinal
detrusor efferent nerves by pathologies affecting the spinal cord .
 Urinary incontinence

A subset of women with this condition can have detrusor hyperactivity

with impaired contractility (DHIC). The bladder does not
effectively contract to empty and also has low-amplitude hyperactivity,
resulting in urgency as well as overflow incontinence. DHIC is
particularly difficult to treat as any therapy for over activity results in
increased urinary retention and overflow incontinence.

●Bladder outlet obstruction – Bladder outlet obstruction in women is

generally caused by external compression of the urethra. This can occur
with fibroids that obstruct the urethra, advanced pelvic organ prolapse
(ie, beyond the hymen), or overcorrection of the urethra from prior
pelvic floor surgery. Less common causes include external masses or
tumors at the level of the bladder outlet, urethral stricture, or uterine
incarceration of a retroverted uterus
 Urinary incontinence

Risk factors:

•Age

•Obesity

•Mode of delivery

•Family history

•Ethnicity/race

•Others – smoking, diabetes, depression, radiation, hormone

replacement therapy, cognitive impairment;
 Urinary incontinence

Evaluation
•History
•Urinalysis and urine culture
•Clinical tests
Bladder stress test – In patients with suspected stress incontinence, we
perform the bladder stress test to confirm the diagnosis. This test is
performed with the patient in the standing position with a full bladder.
While the examiner visualizes the urethra by separating the
labia, the patient is asked to Valsalva and/or cough vigorously. The
clinician observes directly whether or not there is leakage from the
urethra.
Postvoid residual – measuring the PVR can be helpful when diagnosis is
uncertain, initial therapy is ineffective, or in patients where there is
concern for urinary retention and/or overflow incontinence.
Urodynamic testing ;
 Urinary incontinence

Management:

Behavioral

Pharmacological

Surgical
 Urinary incontinence

Behavioral:

• Bladder training
• Schedule voiding

•Pelvic floor exercises – Kegel Exercises

•Biofeedback – placement of vaginal pressure sensor within the

vagina that masseurs pressure and provides an audible and visual
feedback of strength of pelvic floor contraction.
 Urinary incontinence

Pharmacological :

1. Oestrogen
Decrease obstruction of urine flow by restoring mucosal, vaginal
and muscular integrity – quinstrediol, estrol;

2. Anticholinergic agents
Decrease spasticity of bladder, inhibit bladder contraction –
Oxybutynine

3. Alpha adrenergic blocker

Decrease Spasticity of bladder neck – Prazocine
Urinary incontinence

Surgical:

1. Lifting and stabilizing the bladder or urethra to restore the

normal urethra vesicle angle
2. Periurethral bulking agents (periurethral injection of collagen,
silicon or fat)
3. Chronic catheterization
 Urinary incontinence

Strategies for managing UI:

•Increase our awareness of amount, timing of all fluid intake

•Reduce amount and timing of fluid intake
•Avoid blather stimulants (caffeine)
•Avoiding taking diuretics after 4pm
•Avoid constipation
•Void regularly 5-8 times
•Stop smoking
•Weight loss
 Nephrolithiasis

Structure of kidney stones :

80% of renal stones composed of

•Calcium oxalate
•Calcium phosphate

20% are composed of

•Struvite
•Uric acid
•Cystine
 Struvite stones

•Struvite stone compose of Magnesium amoniaphosphat and

calcium carbonate

•3-4 times more frequent in women

•Associated with urinary tract infection

 Uric acid stones

Gout

Increased serum uric acid level

Acid urine

Inherited condition
 Cystine stones

•Genetic autosomal recessive disease

•Urine acid

•Genetic defect of absorption of cystine in proximal tubules of kidney

Diagnosis:

•Genetic analysis SLC3A1 and SLC7A9

•To detect cystine in urine, cystine level in urine >400mg/day

•Screening for cianidpruside

 Calcium oxalate stones

Primary hyperoxaluria :

•Type I 80%
•Type II 10%
•Type III 5%

Primary hyperoxaluria is genetic autosomal recessive

Diagnosis:

Genetic test

Measure oxalates in 24 hour urine sample

 Pathogenesis of primary hyperoxaluria

High production of oxalates causes oxalate storage in different

organs – kidneys;

Kidney stone formation risk factor :

Hypercalciuria

Hyperoxaluria

Low level of citrate in urine

 Clinical signs of renal calculi

Pain

Hematuria

Nausea, vomiting

Hydronephrosis
 Clinical laboratory analysis

•Measurement of iPTH
•Microscopic analysis of renal stone if evaluable
•Urine pH
•Calcium in urine
•Oxalate in urine
•Uric acid
•Cytrite in urine
•Sodium in urine
•Potassium in urine
 Diagnosis of renal calculi

Ultrasound

CT scan

MRI

Intravenous pyelography
 Preventive measures

Avoid protein intake; usually preotein is restricted to 60 g; it

decreases urinary excretion of calcium and uric acid

A sodium intake of 3 to 4 g/day is recommended. High sodium

food should be reduced because sodium competes with calcium
reabsorption in the kidneys.

Avoid intake of oxalate – containing foods (Strawberries, spinach,

tea, peanuts and etc)

During the day drink fluid every 1 to 2 hours;

 Treatment of uric acid stones:

I. Alopurinol

II. Thiasides

III. Potassium citrate

 Management of renal calculi:

Pain killers:
NSAds
Analgetics
 Opioide analgetics

Surgical management:

Laser lithotripsy
Rigid and elastic uretheroscope (URS)
Thank you for
your attention