URINARY TRACT INFECTION

dr Sidharta Darsoyono Sp.B Sp.U

Urinary Tract Infection
(UTI) is common disorder that may affect any
portion of the urinary tract
A Colony count >105/ml was considered the criterion
for urinary tract infection

Now recognized that up to 50% of women with

symptopmatic infection have lower count
Classification and Pathogenesis
First Infection
First documented infection

Unresolved Bacteriuria
Occurs when the urinary tract is never sterilized
during therapy
Persistent Bacteriuria
Occurs when urinary tract is initially sterilized during
therapy bur a persistent source of infection in contact with
urinaty tract remains result from
Infected stone
Chronic pyelonephritis
Chronic prostatitis
Vesicoenteric / vesicovaginal fistula
Obstructif uropathies
Foreign bodies
Urethral diverticula
Reinfection
Occur when new infection with new pathogens occur
following succesful treatment

Ascending infection

From urethra is the most common route.

Female are particulary at risk for UTI because the female
urethra is short and the vagina becomes colonized with
bacteria
Hematogenous Spread
Is uncommon exceptions being tuberculosis and cortical
renal abscess

Direct extension
From other organs may occur, especially from
intraperitoneal abscess in inflammatory bowel disease or
pelvic inflammatory dissease
UTI: Inflammatory response at the urothelium to
bacterial invasion
Bacteriuria: Presence of bacteria in the urine
Pyuria: Presence of white blood cell (WBCS) in the
urine indicates an inflammatory response of the
urothelium to bacterial invasion
 Bacteriuria without pyuria suggest bacterial colonisation
without active infection
Pyuria without bacteriuria suggest presence of
gentiourinary TB, stone chlamydia or cancer

Funguria: presence of fungus in the urine

Acute pyelonephritis
An acute inflammatory process in the kidney present if
as clinical syndrome of chills, fever, and flank pain
associated

Chronic pyelonephritis
Chronic inflammation at the kidney
Cystitis: Inflammation at the bladder

Uncomplicated UTI
Infection in an other healthy patient with a
structurrally and functionally normal urinary tract

Complicated UTI
Infection In a patient with substantial a
structurally or functionally abnormal urinary tract
Reccurent infections
Due the either reinfection or bacterial
persistence

Reinfection
Each infection is a new event, with negative
cultures between episode and bacteria
entering from outside the urinary tract
Bacterial persistence
Multiple infection with same bacterial type,
bacteria come from within urinary tract
Pathogenesis
Bacterial entry
- Host susceptibility factor
-Bacterial pathogenic factor
4 Possible modes of bacterial entry In to genitourinary
tract
1. Periurethral bacteria ascending to urinary tract causes
most UTI
Short nature of the female urethra combined with (?) to the
vaginal vestibule and rectum
2. Hematogenous spread
Can occure in immunocompromised patient and in neonatus
(Staphyllococcus aureus candida species and mycobacterium
tb)
3. Lymphatogenous spread
Through rectal, colonic and (?)
4. Direct extension
From adjacent organ in to urinary tract
-Intraperitoneal abscess
-Vesicavaginal pistulas
-Relapsing infection from in adequat treated visc (?)
in the prostate or kidney
Host defenses
1. Unobstructed urinary flow
-Wash out ascending bacteria
2. Urine has specific characteristic
-Osmolarity
-Urea concentration
-Organic acid concentration pH
3. Factor Inhibit bacterial adherence
- (?) glycoprotein
Any anatomic or functional abnormality at the urinary
tract that increase urinary flow can increase the hosts
succeptibility to UTI
Obstructive conditions
Neurologic disorder
Diabetes
Pregnancy
Similary: Foreign boies (stone, catheter, stent)
Diagnosis
Urinalisis, urine culture
Urine from voided specimen
Suprapubic aspiration fro urine
catheter
Urinalysis
Urinary nitrite
Reduction at diet nitrates by many fram (-) bacteria
Microscopic
Bacteria >100.000CFU/ml (colony forming unit)
Breakdown at the white cell in the urine
>3WBCs per high power field suggest possible infection
(table 13/2)
Urine Culture (table13.B)
Localisation Studies
A specimen collected at beginning at the void represents
possible infection in the urethra
A mid stream specimen possible infection in bladder
Prostate (?) -> Void -> Speciment represent possible
infectio (?)
Cystitis
Women > Men
Primary mode of infection is ascending from
periurethral / vaginal and fecal flora

Prestation and Findings

Irritative voiding symptoms
Dysuria

Frequency

Urgency

Low Back Pain

Hematuria

Claudy / Foul Smelling urine

Fever amd systemic symptom

Urinalisis
WBCs in the urine may be hematuria
Organism
Coli (80%)
Staphyllococcus saphrophyticus (10% in young women)
Gram (-) Klebsiella, proteus spp
Gram (+) Staphyllococcus saphrophyticus enterococci
Risk Factor
Female gender
Altered vaginal flora
Coitus and spermicide
Instrumentaton and catheter
Menopause (rise of vaginal pH)
Epithelial repceptivity (may be genetic)
Antibiotic especcially beta lactam
Voiding dysfunction
Immunosupression
DM
Management
Trimethoprim / Sulfa methoxazole
Trimethoprim
nitrofusantoin
fluoroquinolone
Duration 3-5 days
Reccurent cystitis
is caused either by bacterial persistence as reinfection
with another organism
Identification of the cause is important
If bacterial persistence is the cause of recureent cystitis
the removal of the infected source is open curative
Reinfection is effective therapy with preventative
Treatment
- Change contraception and avoid spermicide
- Post coital antibiotics
-Vaginal cream in past menopausal women
-Supressive antibiotics to prevent vaginal colonisation
-Intermittent self start therapy: 3 days antibiotics when
symptom arise and advice visit if symptoms persist
Epididymitis
Result from an ascending infection from the lower
urinary tract <35% due to STD
Children and older men are due to urinary pathogens
such as E Coli
May spread to testis
Presentation and findings
Severe scrotum pain radiate to groin or flank
Scrotal enlargement
(due to inflammation at the epidydimis or reactive hydrocel
Symptoms of urethritis, prostatitis, cystitis may be
present before or concurrent with the onset of scrotal
pain
Enlarged red scrotum is present
Often dificult to distiguish the epididymis from the
testis
 Thickening of the spermatic cord
WBCs and bacteria in the urine or urethral discharge
Leucocystosis

Radiologic Imaging
Scrotal doppler USG
Management
Oral antibiotic
Bed rest
Scrotal elevation
Non steroidal anti inflammation
Treatment of sexual partner
Severe and sepsis hospitalization