Urinary Tract Infection and Urodynamics

1
Urinary Tract Infection and Urodynamics

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

2
Urinary Tract Infection

• Acute infection
• Chronic infection
• Non-specific UTI
• Granulomatous UTI- Tuberculosis
• Genital tract infection
• Complicated UTI- Surgery, Calculi

3
Acute Cystitis

• The most common form of Female UTI
• Annual incidence 0.5-0.7/person-year
• 25 of women have recurrent UTI
• 1/3 of women have recurrent cystitis within 3
  months, 75-80 recur within 2 years
• Sporadic or recurrent cystitis

4
Pathogenesis of recurrent UTI

• Bacterial factors Longer duration of
  colonization of vaginal introitus with pathogenic
  E. coli
• Host factors Women with recurrent UTI are 3-4
  times more likely to be nonsecretors of ABH
  blood-group antigen

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Pathogenesis of recurrent UTI

• Immune status local and systemic immune
  response are weak in women with recurrent UTI
• Estrogen depletion Increased susceptibility of
  UTI in post-menopause women, a lower glycogen
  content in vaginal epithelium, vaginal bacterial
  flora shift toward E. coli G(-) bacilli

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Pathogenesis of recurrent UTI

• Anatomical factors Distal urethral meatal
  stenosis, uterine prolapse, cystocele, increased
  postvoid residual urine
• Microbial ecology Lack of inhibitory effects of
  hydrogen peroxide producing lactobacilli against
  pathogenic micro-organisms including E. coli

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Treatment of Acute cystitis

• First line antibiotics for 7 days
• 90 self-treatment cure rate
• Routine culture before therapy is not necessary
• Prophylactic therapy (gt2 UTI / 6Mo) decreases
  recurrence rate by 95
• Nitrofurantoin or sulfamethoxazole once daily for
  6 to 12 months

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Acute pyelonephritis (APN)

• Uncomplicated or complicated APN
• Ampicillin or broad-spectrum cephalosporin
  combined with aminoglycoside for 2 weeks
• For relapsed APN a 6 weeks therapy according to
  culture is necessary

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Asymptomatic bacteriuria

• Treatment for asymptomatic pyuria with positive
  culture is not mandatory
• Should be treated in diabetic, preganant women as
  well as women undergoing invasive GU procedures
• 70-80 pregnant women cured after therapy for
  7-10 days

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Management of recurrent UTI

• Intermittent self-start therapy 92 responded
  clinically
• Estrogen therapy oral or topical estriol
• Behavioral therapy increased E coli bacteriuria
  after sexual intercourse certain contraceptives
  alter vaginal flora
• Anal sex, masturbation, sex during menstruation
  increase risk for UTI

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Prophylaxis of recurrent UTI

• Cranberry contains fructose which interferes
  adhesion of type I fimbriated E. coli to
  uroepithelium
• Acupuncture 85 vs 58 sham 36 control group
  during 6 months
• Intravesical heparin therapy prevent bacterial
  adhesion to urothelium

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Urodynamics and Recurrent UTI in Women

• Detrusor instability pseudo-dyssynergia
  (Dysfunctional voiding)
• Pelvic floor hypertonicity
• Detrusor external sphincter dyssynergia
• Poor compliant bladder
• Detrusor underactivity residual urine
• Bladder outlet obstruction

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Detrusor Overactivity

• Idiopathic or neuropathic
• Involuntary contraction of external sphincter at
  initiation of voiding
• Increased intravesical pressure at bladder
  capacity
• Combined with inadequate contractility in elderly
  and CVA patients

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Idiopathic Detrusor Overactivity
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Increased Sphincter activity during Detrusor
overactivity
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Detrusor instability Inadequate contractility
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Low bladder compliance and low contractility
after surgery
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Pelvic floor hypertonicity

• Poor relaxation of pelvic floor
• Low detrusor contractility and low efficient
  voiding
• Moderate to large residual urine developed
• Associated with constipation and increased
  vaginal colonization of E.coli

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Spastic urethral sphincter High voiding pressure
20
Detrusor underactivity and Low efficient voiding
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Detrusor external sphincter dyssynergia (DESD)

• Neuropathy in origin
• High voiding pressure and low bladder compliance
• Large residual urine
• Upper tract deterioration

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Detrusor external sphincter dyssynergia in an SCI
woman
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Poor Bladder Compliance

• Increased intravesical pressure at bladder
  capacity
• Urothelium damage
• Increased bacterial adherance to urothelium
• Diminished detrusor contractility
• Large residual urine

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Bladder Outlet Obstruction

• Bladder neck dysfunction
• Urethral stricture
• Spastic urethral sphincter
• Cystocele
• Urethral meatal stenosis

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Dysfunctional voiding in woman with UTI,
incontinence
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Cystocele with Bladder outlet obstruction
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Nocturnal polyuria and Recurrent UTI

• Women may have large nocturnal urine volume
  (gt900mL or gt33 total volume) and small bladder
  capacity or lower compliance
• UTI develops during night time
• Treatment with antidiuretics (DDAVP) or CISC
  before bed time

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Recurrent UTI in Children

• In neonates UTI occurs more commonly in boys
  (2.7) than girls (0.7)
• In children gt1 y/o UTI is 9 times more frequent
  in girls than boys
• In asymptomatic children reflux is 1
• Reflux is diagnosed in 50 of infants lt 1 years,
  25 of children gt 4 years

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Evaluation of UTI in Children

• All children regardless of sex and age be
  examined by ultrasound and VCUG after first UTI
• Radionuclide cystograpgy is more sensitive to
  detect VUR in younger child
• Renal scarring can be detected by ultrasound,
  IVP, DMSA scintigraphy

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Voiding cystourethrography in Vesicoureteral
reflux
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Recurrent UTI or VUR

• In girls with UTI, 40-60 have symptoms of
  urgency, frequency, squatting behaviour, and
  diurnal incontinence. In most girls with VUR,
  infrequent voids with large volume
• In boys, frequent small voids in more children
  with VUR (36) than healthy boys (15)

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Vesicoureteral Reflux

• Primary A short submucosal tunnel
• Secondary Increased bladder pressure due to
  neuropathic bladder, anatomical abnormality,
  outlet obstruction
• At birth the majority of VUR is seen in boys, by
  age 1 the incidence of VUR is greater in girls
• Many girls have secondary VUR because of voiding
  dysfunction

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Dysfunctional voiding in a girl with incontinence
VUR
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Children Voiding dysfunction

• External sphincter as a role of UTI
• Close association of constipation with voiding
  dysfunction, recurrent UTI and vesicoureteral
  reflux (dysfunctional elimination syndromes)
• Non-invasive programs for pelvic floor
  hypertonicity can successfully treat
  incontinence, recurrent UTI, reducing surgical
  intervention for reflux

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Voiding dysfunction and Incontinence in children

• Detrusor overactivity and/or Pelvic floor
  dysfunction
• Anticholinergics and behavioral therapy
• Diurnal enuresis or nocturnal enuresis
• Increased fluid intake, time voiding, correction
  of constipation cured 15-20 of children with
  voiding dysfunction

36
Detrusor overactivity in a boy with urge
incontinence
37
Dysfunctional voiding UTI

• Breakthrough UTI occurs 43 with DV leading to
  surgery versus 11 without DV
• VUR resolved spontaneously in 61 of girls with
  normal voiding and in 45 with DV after receiving
  antimicrobials and oxybutynin

38
Bilateral VUR in a girl with Meningomyelocele
39
Resolution of VUR after antibiotics and oxybutynin
40
Detrusor instability and VUR

• 28 unilateral VUR and 78 bilateral VUR have
  detrusor instability
• In cases with bilateral VUR 26 failed antireflux
  surgery
• Failed surgery for reflux is often associated
  with voiding dysfunction
• 70 VUR resolved after anticholinergics

41
Detrusor instability Pelvic floor overactivity

• Pelvic floor contracts with an uninhibited
  detrusor contraction
• Chronic contraction of pelvic floor can cause
  uninhibited detrusor contractions through
  collateral innervation
• Voiding dysfunction associates with constipation
• Anticholinergics and alpha-adrenergic blocker are
  effective

42
Voiding dysfunction and Pseudodyssynergia

• Bilateral VUR is a positive predictor for voiding
  dysfunction
• In voiding dysfunction with VUR, detrusor
  instability 55, large bladder capacity 14,
  pseudodyssynergia 30
• Managing constipation and voiding dysfunction has
  the biggest impact on preventing recurrent UTI

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Pelvic Floor Therapy

• Individually adapted voiding drinking schedule
• Pelvic floor relaxation biofeedback
• Instruction on toilet behaviour
• Biofeedback uroflowmetry
• Prophylactic antimicrobials during treatment
• In 83 girls UTI was effectively treated, in 64
  incontinence cured, in 7/8 reflux cured

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Diagnosis of Dysfunctional voiding

• Uroflowmetry combined with EMG
• Pressure flow study high voiding pressure low
  flow rate and overactive external sphincter EMG
  during voiding
• Videourodynamic study- high voiding pressure low
  flow rate, and a spinning top urethrogram

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Voiding cystourethrographyof Dysfunctional
voiding
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Videourodynamic study forDysfunctional voiding
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Factors for Recurrent UTI

• Low bladder compliance
• Large residual urine
• High voiding pressure
• Pseudodyssynergia
• Constipation
• Large bladder capacity and infrequent voids

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Treatment of recurrent UTI in Children

• Treat constipation,recurrent UTI, voiding
  dysfunction together
• Increased fluid intake for constipation
• Trimethoprim- Sulfamethoxazole is the drug of
  choice
• Patients gt 4 years pelvic floor retraining
• Start prophylactic antimicrobial if breakthrough
  UTI develops

49
Genital Tract Infection

• Acute chronic prostatitis
• Acute chronic epididymitis
• Should search for urinary tract obstruction such
  as prostate obstruction, urethral stricture, poor
  relaxation of urethral sphincter

50
Poor relaxation of urethral sphincter

• In younger population men
• Severe hesitancy, poor stream, intermittency,
  residual urine sensation
• Combined with chronic prostatitis
• No frequency or nocturia
• Low voiding pressure low flow urodynamic tracing

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Uroflowmetry in Spastic urethral sphincter
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Low pressure low flow in young man with dysuria
53
Reflux Genital infection and Chronic prostatitis
54
Postprostatectomy UTI genital tract infection

• Residual prostatic obstruction
• Urethral stricture
• Poor relaxation of urethral sphincter
• Low detrusor contractility and large residual
  urine
• Presence of diverticulum or VUR