Urological Infections

Miss Rashmi Singh

June 2012

Overview

• UTI Simple Complicated High risk groups Recurrent

• Pyelonephritis

• Epididymo-orchitis

• Prostatitis

• Rarities

UTI’s

• 15% of all community prescribed abs

• 100,000 hospital admissions

• 40% of hospital acquired infections

• Distressing for patients

• Impact on quality of life

• Can be significant cause of morbidity in the elderly

Acute Uncomplicated Cystitis

• Acute cystitis in otherwise healthy individual

• Usually women with no underlying urinary tract abnormality

70-80% E coli 10-20% other coliforms (serratia, enterobacter,

klebsiella, morganella) 6-7% Enterococci 1% pseudomonas- suspect urological abnormality 1-2% others- group B Strep, staph aureus, staph

saprophyticus, Coag negative staph, Candida

Diagnosis

• Symptoms Exclude vaginal discharge/irritation

• Urine dipstick can be sufficient

• Urine cultures if: Suspect acute pyelonephritis

Atypical symptoms

Symptoms persist or recur 2-4 weeks after treatment

• >103 colony count microbiologically diagnostic

Urine dipstick

• Leucocytes- 75-95% sensitive False negative –concentrated urine,

glycosuria, ascorbic acid, urobilinogen False positive- contamination

• Nitrites- low sensitivity 35-85% False negative- very common if low

bacterial count False positive- contamination. Use in conjunction with urine

appearance

• MSU sensitivity affected by collection technique, time taken to reach lab, bacterial count etc

Antibiotic Therapy

• Clinical success significantly more likely with antibiotics compared to placebo

• Local resistance patterns

• Efficacy

• Tolerability

• Adverse effects

• Compliance

• Cost

• Availability.

Local sensitivity patterns

• “simple” Ecoli Trimethoprim 60-70% Amoxicillin 50-60% Co-amoxiclav/cephalexin 70-80%- beware C. diff in

>65yr Nitrofurantoin 90%- only for simple UTI. Poor renal

penetration

• Enterococci- most sensitive to amoxicillin. Resistant to cephalosporins

• Pseudomonas- cipro only oral option- risk of C.diff

• Others- d/w microbiology

Resistance patterns

• Increasing problem locally with multi resistant Ecoli and coliforms (ESBL producer and AMP-C producer)

• 15-20% incidence

• Always resistant to amox, ceph and co-amoxiclav

• 80-90% resistance to trimethoprim and cipro

• Can be sensitive to nitrofurantoin if simple UTI

• Usually need parenteral antibiotics to eradicate

Follow up

• No need for routine urinalysis/MSU

• MSU for culture If symptoms do not resolve or resolve and recur within 2 weeks

• Re-treat with alternative antibiotic for 7/7

Acute pyelonephritis

• Rigors, fever > 38 degrees, flank pain, N&V

• Absent cystitis symptoms

• Uss and KUB xray recommended to rule out obstruction or calculi

• Refer if vomiting, signs of sepsis or suspect complicating factors.

• 1-3 days parenteral antibiotics

• 14 days antibiotic treatment recommended

Who to Investigate?

• Recurrent episodes

• Atypical symptoms

• Haematuria with equivocal symptoms/msu results

• Persisting sterile pyuria

• Failure to respond to appropriate antibiotics

• Hx of urological disease/surgery

Terminology

• Isolated UTI- first UTI or one separated by 6 months from a previous infection

• Unresolved bacteriuria- urinary tract not sterilised Resistant to selected antibiotic Rapid development of resistant organism from previously

susceptible population Patient compliance problem

• Bacterial persistence-urine sterilised but repeat infection with same organism

Implies a persistent source of infection: stone, fistula

• Re-infection- new infection with new organism after a previous infection eradicated

Recurrent UTIs

• At least 3 UTI’s within 12/12 or 2 UTI’s within 6/12 confirmed by culture.

• Usually due to re-infection. Minority bacterial persistence

• Usually young healthy women

• Not necessary to routinely investigate

• Antibiotics- reduce recurrences by 90% cf placebo Post coital Self diagnosis and self start Continuous low dose 3-6/12

• Trimethoprim, nitrofurantoin, cephalexin

Other measures

• Lifestyle measures Avoid spermicides Fluids Regular bladder emptyng Local hygiene/avoidance of artificial products

• Oral pro-biotics- lactobacillus strain

• Topical yoghurt!

• Cranberry juice- small number of weak clinical studies. No pharmacological data Useful in reducing the recurrence rate of cystitis 36mg/day proanthocyainidin A

UTI’s and pregnancy

• Common

• Asymptomatic bacteriuria before pregnancy

• 20-40% will get acute pyelonephritis

• Asssociated with increased risk of pre-term labour and LBW

• All should be screened in first trimester and treated if positive

• Regular urine cultures

• Consider low dose prophylaxis if history of recurrent UTI’s

UTI’s in post menopausal women

Risk Factors

• Catheters

• Institutionalised

• Atrophic vaginitis

• Incontinence/prolapse

• Post void residual urine

• History of premenopausal UTI’s

Treatment

• As for pre-menopausal

• Asymptomatic bacteriuria common- should not be treated

• Topical oestrogens to re-colonize with lactobacilli

• Rule out obstruction/neurogenic bladder/malignancy

Catheter associated UTI’s

• Commonest non-socomial infection

• Risk increases with longer catheter time (>30 days)

• Use closed systems. Change promptly

• Keep drainage bag below bladder level

• Hand hygiene/sterile gloves/aseptic technique

• Routine ab prophylaxis not recommended

• Do not treat asymptomatic bacteriuria

• Consider alternatives e.gsuprapubic, conveen, CISC

• Beware bladder cancer

UTI and Diabetes

• Females prone to asymptomatic bacteriuria

• More likely to progress to acute pyelonephritis

• Abscess formation

• Emphysematous pyelonephritis

• Interstitial nephropathy

• Papillary necrosis

• Autonomic neuropathy- voiding dyfunction

Complicated UTI

• Infection associated with underlying condition or structural/functional abnormality of urinary tract

• Altered host defence mechanisms

• Increased susceptibility to infection

• Increased chance of therapy failure

• Broader range of pathogens

• More virulent/resistant e.g ESBL, pseudomonas, proteus

• Usually require hospitalisation

• Need to treat underlying condition

Factors suggesting complicated UTI

UTI’s in males

• Uncommon in men aged 15-50

• 7 days minimum treatment

• If febrile, usually concomitant prostate infection Need 2/52 quinolone

• Do not check PSA- elevated for up to 3/12

• Investigate if Febrile UTI Pyelonephritis Recurrent infections Suspect complicating factors

Epididymo-Orchitis

• Post Mumps- 30% post pubertal boys . Haematogenous spread

• <35 associated with STD organisms

• Older men- common urinary pathogens. BPH

• TB causes chronic epididymitis

• Complications Abscess formation Chronic epididymitis in 15% Testicular atrophy/infarction Infertility

Clinical picture

• Acute onset over few days

• Usually unilateral

• Pain and swelling in tail and body of epididymis +/- testis

• Swollen tender cord

• Can mimic acute torsion Consider age Onset Hx of urethritis/STD

Investigation and management• Urethral swab

• MSU

• Uss with doppler

• Urology opinion if ? Torsion

• <35 usually chlamydia- ofloxacin/doxycycline. Treat partner

• >35 as for UTI- ciprofloxacin

• NSAIDS/Scrotal support

• Beware abscess in Diabetics, Hx scrotal surgery

• Pain settles but up to 6-8 weeks for swelling to fully resolve

Classification of Prostatitis

Acute Bacterial Prostatitis

• Serious condition

• 1% after TRUS biopsy

• Fevers/rigors

• Pain in perineum,testes, penis,lower back, painful LUTS

• DRE- swollen boggy tender prostate

• May require hospitalisation

• Usually E coli

• Prostate abscesses need surgical drainage

• PSA elevated for up to 3/12

Chronic AbacterialProstatitis

• Multifactorial/unclear origin

• Negative cultures

• 2 weeks antibiotics (up to 6 weeks if response)

• Alpha blockers/ 5 alpha reductase inhibitors

• NSAIDS/tricyclics

• Muscle relaxants

• Prostatic massage 2-3x week

• Transurethral microwave heat therapy

• Holistic approach- physio/pain team/psychologists

• 30% resolution of symptoms within 1 year

Fourniers Gangrene

• Aggressive necrotising fasciitis of perineum and genitalia

• Rare. Can be fatal

• Diabetics

• Immunosuppressed

• malnourished

• Elderly males

• Nursing home

• Indwelling catheters

• Recent instrumentation/ perineal surgery

Presentation

• Severe sepsis

• Painful, swollen, erythematous skin

• Bullae/necrotic skin

• Crepitus

• Offensive smell

• Urgent debridement and parenteral antibiotics

Urogenital TB

• Common site of extra pulmonary TB

• Kidney- calyceal deformities, scarring, auto nephrectomy

• Ureters- strictures and obstruction

• Bladder- ulceration and fibrosis. “thimble” bladder

• Prostate- calcification. hard woody prostate

• Epididymis- beaded cord. Abscesses. Infertility.

• 6/12 Anti TB therapy/surgery

Schistosomiasis (Bilharzia)

• Second commonest parasite

• Parasite- schistosomahaematobium

• Africa/Egypt. Swimming in Nile

• Life cycle complex.

• Flu like illness

• Haematuria, frequency, terminal dysuria

• Chronic renal failure/bladder contraction/ carcinoma

• 2 doses praziquantel