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The Urinary System
Lower Urinary Tract Infections (Lower UTIs) Clinical features, Diagnosis, Management, Prognosis, According
to pathogenesis, these infections may be: 1. Uncomplicated
Anatomically
and physiologically normal urinary tract, normal renal function and no
associated disorder which impairs defence mechanism 2. Complicated
Abnormal
urinary tract, e.g., obstruction (by cysts, tumours, fibrous strictures),
calculi, vesico-ureteric reflux
Impaired
renal function when it leads to oliguria (e.g., late stage chronic renal
failure, chronic heart failure)
Associated
disorder which impairs defence mechanisms or favours bacterial multiplication
in some other way (e.g., immunosuppressive/corticosteroid therapy, glycosuria
in diabetes mellitus)
Medical
procedures (e.g., indwelling urinary catheter, repeated cystoscopy) Most
infections, especially uncomplicated, are due to a single strain of organism,
usually E. coli (80% of all
infections), which belongs to normal gut flora. Therefore UTIs caused by
E.coli are autogenous infections.
Other bacteria that may occasionally be implicated, especially in complicated
infections, are Proteus, Klebsiella, Enterobacter, Staphylococcus
saprophyticus. Urethritis can also be caused by sexually transmitted pathogens
such as Chlamydia and Ureaplasma (so called nonspecific urethritis), Neisseria
gonorrhoeae also known as gonococcus (gonorrhoea, ‘specific urethritis?. Clinical features: < BACK TO TOP >
There
is often a sudden onset of frequency of micturition and dysuria (burning,
scalding pain is felt in the urethra during micturition).
Men
with urethritis usually present with urethral discharge (not common in women),
which is purulent due to N. gonorrhoeae and whitish mucoid when nonspecific.
Cystitis
may give rise to dull and boring suprapubic pain that intensifies during and
for a few moments after voiding.
Intense
desire to pass more urine after the bladder has been emptied is reported in
many patients and is caused by contractions of inflamed bladder.
Systemic
symptoms are usually slight and body temperature is usually normal.
Urine
may be turbid (cloudy) and have an unpleasant odour dur to the presence of pus
(pyuria).
Gross
haematuria (reddish urine) occasionally occurs especially in acute cystitis,
but microscopic haematuria is almost always found. In acute prostatitis there is urinary frequency and urgency, perineal discomfort sometimes described as fullness or heaviness and considerable systemic disturbance (chills, fever, sweating, pain in muscles and joints). Diagnosis: < BACK TO TOP >
Characteristic clinical
features may help in diagnosis of UTI, although clinical differentiation
between lower and upper UTI is very difficult.
Suprapubic tenderness may be
elicited on palpation of the lower abdomen.
Culture of a midstream urine
(MSU) sample usually demonstrates more than 105/mL organisms (significant bacteriuria).
Urine analysis for blood and
protein reveals minor haematuria and proteinuria.
Microscopic examination of
urine for red and white blood cells detects leukocytes, pus cells-deformed dead
leukocytes, and erythrocytes which are morphologically normal (not crenated).
Intravenous urography,
micturating cystoureterography and ultrasound can be carried out to identify
physiological and anatomical abnormalities of the urinary tract, especially in
patients suffering from recurrent UTIs. Management < BACK TO TOP >
Ideally a causative organism
should be identified before starting specific antibiotic therapy, which is not
always feasible (it is time consuming).
Since infection is usually
due to E.coli initial use of trimethoprim [Triprim, Alprim], co-trimoxazole
[Bactrim, Resprim] or fluoroquinolone antibiotic (norfloxacin [Noroxin]) is
rational and the antibiotic can be changed if a resistant organism is
identified or the response is unsatisfactory.
Symptomatic relief usually
occurs within 48 hours and the course need not exceed 5 days.
Alkalisation of urine with
preparations such as Sodibic, Citralite, Ural and Dexsal is useful for
symptomatic relief of burning pain which is largely caused by acid urine;
furthermore E. coli bacteria do not multiply well at higher pH.
A fluid intake of at least 2
L/day ensures regular voiding and thus removal of bacteria.
Urine culture should be
repeated on the 7th day after the end of the antibiotic course; failure to eradicate an
organism or re-appearance of the same organism in the urine suggest that some
complication is present and investigations should be undertaken to diagnose the
problem.
In women with recurrent
infections the defences of the lower urinary tract may be inadequate and simple
measures may prevent recurrence: - Fluid intake
of at least 2 L/day; cranberry juice appears to be helpful due to its
antiadherent properties - Regular
emptying of bladder (3h intervals by day and before going to sleep) - Ensure
complete emptying of bladder (double micturition) - Emptying
bladder before and especially after intercourse Prognosis < BACK TO TOP >
(source :
Dr Zoran Pletikosa) |
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