Genitourinary Tract Infections

GENITOURINARY TRACT INFECTIONS Bautista, Raene Hyacinth Olis, Cristina Ruchti, Stephany Villaluz, Maureen

What is UTI? • It is the result from the presence of microorganisms in urine (not related to contamination) that has the potential to invade the urinary tract and adjacent tissues • It is one of the most common bacterial infections (~ 8M visits/year) • Prevalence: – Women> men while young – Women= men at age of 65 • Localized vs. systematic – Localized infection is normally seen when the skin is broken and a wound or cut becomes infected. If the infection is carried throughout the body in the bloodstream, it is systematic.

Types of UTI • Uncomplicated Infection present in individuals with normal UTI anatomy and no alterations in urine flow or voiding mechanisms.

• Complicated Infection resulting from predisposing lesion such as congenital abnormalities, distortion of UT, stone, indwelling catheter, prostatic hypertrophy and neurogenic deficits. Affect both genders similarly, and can involve the upper and lower UT. Men UTI’s are considered complicated.

Anatomy of the Male Urogenital (Reproductive) System

Anatomy of the Female Urogenital (Reproductive) System

Urinary Tract

Kidney

Bacterial Prostatitis • Acute Bacterial Prostatitis – Type 1 (most rare type) – Well-defined infectious disease of the Lower Urinary Tract – Bacterial cause is Escherichia coli – Frequently presents with bacteremia

Clinical Presentations • • • • • • • •

Dysuria (painful urination) Urinary Frequency Intense suprapubic pain Urinary obstruction Fever Arthralgia (joint pain) Myalgia (muscle pain) Malaise (feeling of general discomfort or uneasiness)

Epidemiology • 6% incidence, prevalence rate is 8%. • Occurs in 0.02%of all patients of prostatitis • 3rd most common diagnosis in men older than 50 years, after BPH (Benign Prostatic Hyperplasia) or BEP (Benign Enlargement of the Prostate) and prostate cancer

Pathogens or Etiologic Agents • • • • • • •

Escherichia coli Proteus mirabilis Klebsiella sp. Enterobacter sp. Pseudomonas aeruginosa Serratia sp. Staphylococcus aureus

Pathogens or Etiologic Agents • Escherichia coli is the most common of all the possible pathogens of ABP Escherichia coli •Gram negative, facultative anaerobic, non-sporulating •37 °C, but some laboratory strains can multiply at temperatures up to 49 °C

E. coli in MCA

E. coli in EMBA

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

Duration of Therapy or Laboratory Diagnosis • Gentle rectal examination • Prostatic massage – Unadvisable because it could precipitate bacteremia • Prostate-specific antigen • CT scan • Careful Transrectal Ultrasound • Bladder Scanning

Antibiotics, 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

Clinical Presentations • 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

Pathogens or Etiologic Agents • same as in acute bacterial prostatitis. • Most infections are caused by a single pathogen • Obligate anaerobic bacteria rarely cause prostatic infection.

Pathogens or Etiologic Agents • Escherichia coli (80%) • • • • •

Klebsiella sp. Enterobacter sp. Proteus enterococci sp. Pseudomonas sp. Staphylococcus sp.

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

Duration of Therapy or laboratory Diagnosis • expressed prostatic secretions or EPS • Prostate specific antigen • Prostatic massage

Antibiotics, 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

Antibiotics, 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

Clinical Presentations • • • • • • •

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

Pathogens or Etiologic Agents • Mycobacterium tuberculosis – aerobic, non-sporeforming, nonmotile bacillus – 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

Duration of Therapy or 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

Antibiotics, 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

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.

• There are many types of cystitis but the only significant kind of this disease is the Emphysemtous cystitis which is caused by gasforming 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.

Pathogens or 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.

Clinical Presentations • • • • • •

Pressure in the lower pelvis Dysuria urgency Nocturia Hematuria Foul odor of Urine

Duration of Therapy or 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.

Antibiotics, 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.

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

Clinical Presentations • dysuria • haematuria • pneumaturia • Glycosuria

Pathogens or Etiologic Agents Escherichia coli and Aerobacter aerogenes are the most commonly isolated organisms from the infected part.

Pathogenesis • poorly understood • Elevated tissue glucose levels in diabetic patients may provide a more favorable microenvironment for gas-forming microbes

Diagnosis • Radiographs Conventional radiographs humps in the bladder wall.

demonstrate

irregular

• 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.

Antibiotics, 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

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

Clinical Presentations • 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

Pathogens or Etiologic Agents • Non-gonococcal urethritis - Chlamydia trachomatis - Ureaplasma urealyticum

Pathogenesis • Attachment of Escherichia coli fimbrae on urethral epithelium

Diagnosis • • • • •

Personal history Symptoms noted Endourethral swabs Gram stain Urine examination

Antibiotics, Treatments and Prevention • 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

Pathogens or Etiologic Agents • • • • •

Escherichia coli (Primary) Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa Enterobacter spp.

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

Clinical Presentations • • • • •

shaking chills high fever flank tenderness /back pain dysuria Hematuria

irritative voiding symptoms: • dysuria • a sense of urgency • increased frequency of urination

Chronic Pyelonephritis • or 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

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

• 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

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

Pathogens or Etiologic Agents 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

Clinical Presentations • severe and rapid loss of kidney function •

proteinuria

•

cola- colored urine (hematuria)

•

hypertension

•

edema

•

decreased urine volume

Diagnosis • physical exam •

kidney biopsy

Antibiotics, Treatment and Prevention • APGN - antibiotic treatment (Penicillin) - peritoneal dialysis •

RPGN - treatment with streroids and or cyclophosphamide