UTI and incontinence

Urinary Tract Infections (UTI)Prevalence

• Most common bacterial infection

male female

First year of life 1.5% 1%

1 to 8 2% 8%

20 to 40 1% 30%

Over 60 40% 50%

UTI

• Upper UTI

pyelonephritis, pyonephrosis, kidney abscess

• Lower UTI

cystitis, prostatitis, epididymo-orchitis

UTIPathogenesis

• Ascending

• Hemotogenous to kidney

• Host immunity – age, DM

• Microorganism virulence

• Prostate with antibacterial secretion

• Colonisation of vagina with uropathogens

• Bladder emptying

• Abnormal urinary tract – reflux, obstruction

• Short urethra and sexual activity in female

UTIMicro-organism

• Gram negative bacteria

Commonest E. Coli 70 – 90%

• Gram positive

• Yeast and fungus

• Viral

• Specific infection - mycobacteria

UTIUncomplicated and Complicated

• Uncomplicated UTI

No structural or functional disease

• Complicated UTI

With structural or functional disease

reflux, obstruction, neurological, DM

higher chance of getting renal damage, septicaemia

UTISymptoms

• Acute cystitis

suprapubic pain, frequency, dysuria, urgency

• Acute pyelonephritis

loin pain, fever, frequency, dysuria

• Acute prostatitis

suprapubic/perineal pain, frequency, fever, dysuria, slow streeam

• Acute epididymo-orchitis

scrotal swelling and pain, fever

UTIDiagnosis

• History & Physical Examination

• Mid-stream urine

microscopy for pyuria

male 5WBC/HPF, female 10WBC/HPF

(cell counter method

dip-stick leukocyte esterase test)

pyuria can be due to other inflammatory conditions

bladder stone, radiation, chemotherapy, autoimmune disease, interstitial cystitis

UTIDiagnosis

• MSU

culture for bacteria

culture plate method

dip-slide method

>105/ml sensitivity of 50% and specificity of 99%

(most Urology centres reported to 103/ml)

suprapubic aspiration, urethral catheterisation - invasive

dip-stick test for nitrite for screening of bacteriuria

UTIDiagnosis

• Abacterial pyuria

partially treated UTI

virus

other inflammatory conditions

TB

UTITreatment

• Cystitisuncomplicated - 3 days oral drugscomplicated – 7 to 10 days drugs

• Pyelonephritis2 weeks drugsif bacteraemia – parenteral then to oral

• Prostatitis6 weeks drugs

• Epididymo-orchitis10 – 14 days drugs

UTIInvestigations

• Uncomplicated cystitiscost-effective, most would treat patients on clinical diagnosis

• Complicated infectionto check for structural or functional abnormalitiesrenal functional testurine for asymptomatic bacteriuriaultrasound / intravenous urography /radiological

teststreatment of underlying problems

DM, obstructive causes, reflux

Acute Pyelonephritis Vs Pyonephrosis

• Acute pyelonephritisInfection of renal parenchymaMedical infection

• Acute pyonephrosisInfection of stagnant urineSurgical infection

• Differentiation by ultrasonographymoderate to severe hydronephrosis in acute

pyonephrosis and effectively drained by percutaneous drainage

Acute Epididymo-orchitis Vs Acute Torsion of Testis

• Testes can stand ischaemia for 6 hours

• All testes would be dead after ischaemia for 24 hour

• Acute surgical condition

• Differentiation by Doppler ultrasound

decrease vascular blood supply to torsion

emergency surgical correction

Urinary IncontinencePrevalence

• UK

male female

15 – 44 5-7%

45 – 64 8-15%

15 – 64 3%

>65 7-10% 10-20%

Urinary IncontinenceClassification

• Genuine stress incontinence

• Urge incontinence

• Mixed stress and urge incontinence

• Overflow incontinence

• Continuous incontinence

• (terminal dribble vs post-micturition dribble)

Genuine Stress Incontinence

• Involuntary loss of urine during coughing, exertion

• Most common cause of incontinence in female

• Due to weakness of pelvic floor and could not support the proximal urethra inside the pelvic cavity

pregnancy, vaginal delivery, pelvic surgery, congenital

• Some may be due to weakness of external urethral sphincter

TURP, radical prostatectomy

Urge Incontinence

• Involuntary loss of urine after sudden urge feeling

• Second commonest cause of incontinence in female

• Due to detrusor instability

idiopathic – aging, BPH

if neurological causes found, called detrusor hyperreflexia

Overflow Incontinence

• Sporadic involuntary loss of urine

• Slow stream, frequency, palpable bladder

• Due to bladder underactivity

hypotonia, DM, drugs, pelvic mass, chronic obstruction

Continuous Incontinence

• Continuous loss of urine

• Due to fistula

congenital ureteric fistula

after surgery or trauma

vesico-vagina fistula, uretero-vaginal fistula

Post-micturition Dribble

• Leaking of small amount of urine up to few minutes after micturition

• Due to storing of some urine in the proximal bulbous urethra after micturition

Terminal dribble• Slow dribble at the end of micturition

• Due to bladder outflow obstruction

History & Examination

• Micturition pattern

• Obstetrical history

• Neurological problems

• Surgery

• Drugs

• Abdominal masses, palbable bladder

• Vaginal prolapse

• Marshall test for stress incontinence

Investigations

• MSU

• Bladder diary

• Pad test – verify and quantify leakage

• Uroflowmetry – obstructed flow

• Cystometry – detrusor instability, detrusor contraction pressure

• Urethral pressure profile

• Radiological tests

Treatment of Genuine Stress Incontinence

• Pelvic floor exercise to strengthen the pelvic floor muscle

• Surgery to suspend the bladder neck

Due to sphincter weakness

• Sling procedure

• Injection of material at sphincter level

• Sphincter prostheses implantation

Treatment of Urge Incontinence

• Bladder training

• Anticholinergic drugs

• Correction of underlying problems e.g. BOO

Treatment of Overflow Incontinence

• Correction of underlying cause eg BOO

• Intermittent catheterisation

• Catheter drainage

Treatment of Urinary Fistula

• Surgical repair of corresponding abnormalities