Genitourinary System

GENITOURINARY TRACT INFECTIONS Apolinario, Ma. Jesusa De Sotto, Ryan Edora, Jessica Laraine

ANATOMY MALE

FEMALE

KIDNEY

BACTERIAL PROSTATITIS • ACUTE BACTERIAL PROSTATITIS • most rare type • Type 1 • Well-defined infectious disease of the LUT • Bacterial cause is E. coli • Frequently presents with bacteremia

SIGNS AND SYMPTOMS • • • • • • • •

Dysuria Urinary frequency Intense suprapubic pain Urinary obstruction Fever Arthralgia Myalgia Malaise

EPIDEMIOLOGY • 6% incidence, prevalence rate is 8% • Occurs in 0.02% of all patients of prostatitis • It is the third most common diagnosis in men older than 50 years, after BPH and prostate cancer

ETIOLOGIC AGENTS • Escherichia coli • Proteus mirabilis • Klebsiella species • Enterobacter species • Pseudomonas aeruginosa • Serratia species • Staphylococcus aureus

ETIOLOGIC AGENTS • Of all the possible pathogens of ABP, Escherichia coli is the most common Escherichia coli • Gram-negative, facultative anaerobic and nonsporulating • 37°C, but some laboratory strains can multiply at temperatures of up to 49°C

E. coli growth in MacConkey agar

E. coli growth on EMB

PATHOGENESIS • Uropathogenic E. coli (UPEC) is responsible for approximately 90% of urinary tract infections (UTI) • Uropathogenic E. coli utilize P fimbriae • Uropathogenic E. coli produce alpha- and beta-hemolysins, which cause lysis of urinary tract cells • UPEC can evade the body's innate immune defenses • They also have the ability to form K antigen, capsular polysaccharides that contribute to biofilm formation

LABORATORY DIAGNOSIS • Gentle rectal examination • Prostatic massage • Unadvisable because it could precipitate bacteremia

• Prostate-specific antigen • CT scan • Careful Transrectal Ultrasound • Bladder Scanning

TREATMENT and PREVENTION • rapid initiation of broad-spectrum parenteral antibiotics • Penicillin or Penicillin-derivatives with addition of Aminoglycoside • Fluoroquinones after initial therapy • Healthy way of living • Increase fluid intake

BACTERIAL PROSTATITIS • CHRONIC BACTERIAL PROSTATITIS • diagnosed with recurrent UTI • most common cause of relapsing urinary tract infection in males. • Asymptomatic periods are interspersed between episodes of recurrent bacteriuria. • condition is characterized by bacterial growth in culture of the expressed prostatic fluid, semen, or post massage urine specimen

SIGNS and SYMPTOMS • Genitourinary pain • Dysuria • hematospermia • Clear urethral discharge • perineal, scrotal, and low back discomfort • Vague discomfort in pelvis, perineum, lower abdomen, back and testis

EPIDEMIOLOGY • Affects 5%-10% of all patients have this type of prostatitis • occurs in less than 5% of patients with prostatitis

ETIOLOGIC AGENTS • same as in acute bacterial prostatitis. • Most infections are caused by a single pathogen • Obligate anaerobic bacteria rarely cause prostatic infection.

ETIOLOGIC AGENTS • Escherichia coli (80%) • Klebsiella species • Enterobacter species • Proteus enterococci species • Pseudomonas species • Staphylococcus species

ETIOLOGIC AGENTS • The role of the gram-positive organisms Staphylococcus epidermidis and Staphylococcus saprophyticus is controversial

PATHOGENESIS • Biofilm-producing E. coli are resistant to immune factors and antibiotic therapy • The actual routes of prostatic infection are unknown in most cases • Routes of infection include the following: • Ascending urethral infection • Reflux of infected urine into prostatic ducts • Migration of rectal bacteria via direct extension or lymphogenous spread • Hematogenous infection

LABORATORY DIAGNOSIS • expressed prostatic secretions or EPS • Prostate specific antigen • Prostatic massage

TREATMENT and PREVENTION • Treatment requires prolonged courses (4-8 weeks) of antibiotics • These include quinolones (ciprofloxacin, levofloxacin), sulfas (Bactrim, Septra) and macrolides (erythromycin, clarithromycin)

• Radical transurethral prostatectomy • Healthy diet

TREATMENT and PREVENTION • Antimicrobial agents that most effectively penetrate into the prostatic fluid fluoroquinolones and TMP-SMZ • Treatment should be guided by urine culture results

GENITOURINARY TUBERCULOSIS • associated with pulmonary infection or occurs during reactivation many years later from infection previously seeded in the kidneys • second most common form of the disease after pulmonary tuberculosis

Signs and Symptoms • fever • weight loss • Urgency • Frequency • flank pain • suprapubic pain • hematuria

Epidemiology • affects between 3.5 and 4 million people per year worldwide • 4% to 9% of people with active pulmonary tuberculosis develop genitourinary involvement • often occurs in older people and in immigrants from places with high prevalence rates • predominantly a disease of young adults, with roughly half of the patients between 20 to 40 years, and 75 percent under 50

Etiologic agent • caused by Mycobacterium tuberculosis • Mycobacterium tuberculosis is an aerobic, non-sporeforming, nonmotile bacillus

Pathogenesis • Mycobacterium tuberculosis bacilli are inhaled through the lungs to the alveoli • some are carried to the region's lymph nodes • thoracic duct may deliver mycobacteria to the venous blood • may result in seeding of different organs, including the kidneys

• the bacteria lodge within the tissues of the genitourinary tract • form caseating granulomas • damage may obstruct the drainage system and impair the blood supply, causing hypertension

Infected kidney

Laboratory Diagnosis • Routine urinalysis • Early morning urine specimens 3 days in a row • Urine culture • Skin test (Intradermal Mantoux) • Intravenous urogram • Kidney-ureter-bladder (KUB) x-ray

Treatment and Prevention • early diagnosis is important • contact with people with active pulmonary tuberculosis should be avoided • GENERAL MANAGEMENT: -Bed rest -ensure adequate nutrition • DRUG THERAPY: -rifampin -ethambutol -isoniazid • SURGERY: -may be necessary to remove a nonfunctioning kidney

EPIDIDYMITIS • is an inflammation or infection of the epididymis • common cause of intrascrotal inflammation • most often caused by a bacterial infection or by a sexually transmitted disease (STD) such as gonorrhea or chlamydia • non-infectious cause of epididymitis is the use of anti-arrhythmic medication, amiodarone

Signs andSymptoms • • • • • • • • • • • • •

Painful scrotal swelling(testes enlarged) Testicular lump Tender, swollen testicle on affected side Tender, swollen groin area on affected side Testicle pain aggravated by bowel movement Chills and fever Discharge from urethra (the opening at the end of the penis) Blood in the semen Groinpain Painful intercourse Enlarged lymph nodes in the groin Pain or discomfort in the lower abdomen or pelvic area Pain in urination

Epidemiology • most common in men between the ages of 19 and 35 • incidence is approximately 600,000 cases per year • Men who have recently had surgery or have a history of structural problems involving the genitourinary tract

Etiologic Agent • gram-negative aerobic rods caused more than two thirds of the cases of bacterial epididymitis • coliform organisms: - Escherichia coli - Pseudomonas sp. • Mycobacterium tuberculosis (TB) can manifest also as epididymitis

Complications • Infertility • Scrotal abscess formation • Shrinkage of the affected testicle • Epididymo-orchitis

Diagnosis • • • • • • • •

Urinalysis and culture CBC Gram stain physical exam rectal examination STD screening Ultrasound imaging Nuclear scan of the testicles

Treatment and Prevention • Antibiotic therapy: - trimethoprim sulfamethoxazole, ceftriaxone, doxycycline or azithromycin, fluoroquinolone and trimethoprim sulfamethoxazole

• Analgesics for pain control • Supportive care • Bed rest • Scrotal elevation • Wear an athletic supporter

• Apply cold packs to your scrotum • Surgery is sometimes necessary • a follow-up visit with your health care provider

CYSTITIS • Cystitis is an inflammation of the bladder, sometimes involving the tube that drains urine from the bladder, called the urethra. • Cystitis is the most common form of urinary tract infection and occurs mainly in women. But men and children also can experience cystitis. • Bacterial infection causes most bouts of cystitis. This bacterial growth causes the inside walls of the bladder to become inflamed.

TYPES • There are many types of cystitis but the only significant kind of this disease is the Emphysemtous cystitis which is caused by gas-forming organisms such as E. coli and Aerobacter aerogenes. • Other types include hemmorhagic and ulcerative cystitis which are under acute simple infection and cystitis follicularis which belongs to the chronic infection.

ETIOLOGIC AGENTS • Organisms inhabiting the perineal area, especially Esherichia coli, Proteus and Klebsiella, are the common infectious agents. • Other causative agents include; pseudomonas and Corynebacterium.

PATHOGENESIS • Uropathogenic E. coli frequently produce the extracellular protein hemolysin • Adherence properties of gram-negative organisms of the vaginal mucous membrane • Ascending of the bacteria from the vaginal reservoir to the bladder mucosal surface and invasion of the vesical wall

EPIDEMIOLOGY • This disease can occur to 2 out of 100 people and most cases are found in women.

SIGNS AND SYMPTOMS • Pressure in the lower pelvis • Dysuria • urgency • Nocturia • Hematuria • Foul odor of Urine

LABORATORY DIAGNOSIS • Urine analysis is done if the doctor suspects infection of the bladder • Cystoscopy is done with a cytoscope and used remove a sample tissue for further analysis and inspection • Imaging tests like X-ray or ultrasound is quite important to help rule out other potential causes of bladder inflammation, such as a tumor or structural abnormality.

TREATMENT AND PREVENTION • Cystitis caused by bacterial infection is generally treated with antibiotics which serves as the first line of treatment for cystitis caused by bacteria. • Keeping the genital area clean and remembering to wipe from front to back may reduce the chance of introducing bacteria from the rectal area to the urethra. • Increasing the intake of fluids may allow frequent urination to flush the bacteria from the bladder.

TREATMENT AND PREVENTION • Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during intercourse.

EMPHYSEMATOUS CYSTITIS • A rare form of infectious cystitis characterized by the presence of gas in the bladder wall. • Emphysematous cystitis is nearly always associated with diabetes mellitus, because gas in the bladder wall is the result of fermentation of urinary glucose to carbon dioxide

SIGNS AND SYMPTOMS • dysuria, • haematuria • pneumaturia • Glycosuria

ETIOLOGIC AGENTS • Escherichia coli and Aerobacter aerogenes are the most commonly isolated organisms from the infected part.

PATHOGENESIS •

The pathogenesis of emphysematous cystitis is poorly understood •Elevated tissue glucose levels in diabetic patients may provide a more favorable microenvironment for gas-forming microbes

DIAGNOSIS • Radiographs Conventional radiographs demonstrate irregular humps in the bladder wall. • Intravenous urography Intravenous urography confirms the presence of gas in the bladder, as a horizontal air contrast level on erect films. • Ultrasound Ultrasound may detect bladder wall air as intramural echogenic foci with "dirty" shadowing.

TREATMENT AND PREVENTION • Antibiotics are used to control bacterial infection. It is vital that one finish an entire course of prescribed antibiotics.

• Commonly used antibiotics include: • • • • •

Nitrofurantoin Trimethoprim-sulfamethoxazole Amoxicillin Cephalosporins Ciprofloxacin or levofloxacin

URETHRITIS • Inflammation of urethra • Very common condition that is also associated with both nonspecific genital infections and specific STD’s

2 Divisions: • Gonococcal urethritis - infection with Neisseria gonorrhoeae • Non-gonococcal urethritis - urethritis is present but gonococci are not detected

EPIDEMIOLOGY • Occurs both in men and women • Condition generally diagnosed only in men • When in women and is not associated with a urinary bladder infection(cystitis) it is called urethral syndrome

SIGNS AND SYMPTOMS • First symptoms usually appear after 1-3 weeks of initial infection: • More frequent need to urinate • Itch in the urethra • Burning sensation on urination

• Signs: • Men: urethral discharge - clear, white or yellow - varies from a few drops to large amounts • Women: urethral discharge - slightly clear, white or yellow - more noticeable during morning hours

ETIOLOGIC AGENTS • Gonococcal urethritis - Neisseria gonorrhoeae • Non-gonococcal urethritis - Chlamydia trachomatis - Ureaplasma urealyticum

PATHOGENESIS • spread of Neisseria gonorrhoeae gonorrhoeae to the urethra Duringsexual sexual intercourse to the urethra during intercourse • Attachment of Escherichia coli fimbrae on urethral epithelium

DIAGNOSIS • Personal history • Symptoms noted • Endourethral swabs • Gram stain • Urine examination

TREATMENT • Gonococcal urethritis: - ceftriaxone - ciprofloxacin • Non-gonococcal urethritis: - tetracycline - erythromycin

Pyelonephritis: Upper Urinary Tract Infection • infection of kidney (parenchyma) and pelvis (pyelum) • usually results from non-contagious bacterial infection of the bladder

Urethra: male vs. female

Female urethra Male urethra

Etiologic agents primary etiologic agent: •Escherichia coli

Growth on MAC

Growth on EMB

secondary etiologic agents: •Klebsiella pneumoniae •Proteus mirabilis •Pseudomonas aeruginosa •Enterobacter spp.

Pyelonephritis: Upper Urinary Tract Infection Pathogenesis •Ascending route of infection •Hematogenous spread •Vesicoureteral reflux •Kidney stones •Instrumentation •Urinary tract obstructions- chronic pyelonephritis

Acute Pyelonephritis •a sudden inflammation caused by bacteria •most frequently occurs as a result of ascending movement of bacteria •can be resolved without permanent damage to tubules

Signs and Symptoms •shaking chills •high fever •flank tenderness /back pain •dysuria •hematuria irritative voiding symptoms: •dysuria •a sense of urgency •increased frequency of urination

Chronic pyelonephritis •also called Chronic Infective Tubulointerstitial Nephritis •persistent or recurrent kidney inflammation •occurs almost exclusively in patients with major anatomic abnormalities

Diagnosis •results of physical examination •laboratory tests: •blood tests and blood cultures •urinalysis •urine culture

Treatment •antibiotic therapy (ciprofloxacin, ampicillin or trimethoprimsulfamethoxazole) •initial hospitalization •surgery •follow-up treatment

Prevention • increase fluid intake (cranberry juice, blueberry juice, and fermented milk products) •strict personal hygiene •frequent urination

Glomerulonephritis

•a range of immune-mediated disorders that cause inflammation within the glomerulus and other compartments of the kidney •In 1% of children and 10% of adults who have acute glomerulonephritis, it evolves into rapidly progressive glomerulonephritis

GLOMERULUS: NORMAL VS. INFECTED WITH GN

www.unckidneycenter.org

Acute Postreptococcal Glomerulonephritis • an

immune complex disease caused by group A Beta-hemolytic streptococcus types 12 and 49 • typically occurs 10 to 14 days following a streptococcal infection

Rapidly Progressive Glomerulonephritis results in a rapid decrease in glomerular filtration rate •

• presence of crescents in the majority of the glomeruli

Etiologic agent Streptococcus pyogenes

β-hemolytic acitivity of Streptococcus pyogenes on SBAP

Pathogenesis • formation of antibodies by S. pyogenes - hyaluronic acid capsule - M protein - protein F - DNase

Signs and Symptoms • severe and rapid loss of kidney function • proteinuria • cola- colored urine (hematuria) • hypertension • edema • decreased urine volume

Diagnosis • physical exam • kidney biopsy

Treatment • APGN - antibiotic treatment (Penicillin) - peritoneal dialysis • RPGN - treatment with streroids and or cyclophosphamide