Infections of GenitoUrinary System

1
Infections of Genito-Urinary System

• Dr.Song Yongsheng
• Urological Department of the 2nd Hospital,CMU

2
Susceptibility factors and defense mechanisms

• 1.Bacterial virulence factors
• The"nonspecific"infections of the genitourinary
  tract are a gruop of diseases with similar
  manifestations that are caused mainly by aerobic
  gram-negative rods (eg.E.coli) and gram-positive
  cocci (eg.staphylococci).E coli accounts for
  about 90of urinary tract infections.

3
2.Extrinsic factors

• In wonem, there are two factors. One is introital
  factors. Bacteria are known to adhere selectively
  to various mucosal surfaces by means of tiny
  hairlike projections(pili or fimbriae).Some
  E.coli adhere readily to urinary tract mucosal
  surface cells. Another is urethral factors,
  including periurethral glands, and the nature and
  turbulence of urinary flow.
• In men, the main route of infection is ascent
  from urethral colonization. But chronic bacterial
  infectoin of the prostate appears to be main
  cause of recurrent urinary infection

4
3.Intrinsic susceptibility factors

• Efficient voiding may serve as a defense
  mechanism against bladder infection.
• Other factors may concern the ease with which
  bacteria abhere to bladder surface cellssurface
  mucin, surface glycosaminoglycan, urinary
  antibody, and the antimicrobial properties of
  urine (eg.high osmolality and extremes of pH).
• Genetic factor may also prove important(DM,etc).

5
Pathogenesis of Urinary Tract Infection.

• There are 4 major pathways for the entry of
  bacteria into the genitourinary tract
• 1.Ascending infection from the urethra is the
  most common cause of genitourinary tract
  infections. The tendency for rectal bacteria to
  colonize the perineum and vaginal vestibule, the
  sexual intercourse and the childrenbearing
  enhance the susceptibility of women to urinary
  tract infection.

6

• 2.Hematogenous spread
• This mode is uncommon.
• 3.Lymphatogenous spread
• The bacterial pathogens travel through the rectal
  and colonic lymphatics to the prostate and
  bladder and through the periuterine lymphatics to
  the female genitourinary tract, but this is rare.
• 4.Direct extension from another organ
• Intraperitoneal abscess, fulminant pelvic
  inflammatory disease, paravesical absccsses, and
  genitourinary tract fistulas can infect the
  urinary tract by means of direct extension.

7
CLINICAL DEFINITION OF GENITOURRARY TRACT
INFECTION

• The genitiourinary infections can be classified
  into upper urinary tract infection, lower urinary
  tract infection and genital system infection
  according to the pathogenesis and the infection
  portion. The upper tract infection refers to the
  infections of kidney and ureters. And the bladder
  and the urethra comprise the lowe urinary tract.
  Prostatitis and epididymitis are the most common
  genital infections.

8
OUTLINE OF DIAGNOSIS AND TREATMENT

• 1.Identify diagnosis of urinary tract infection.
• Quantitative urine culture106colonies/ml.
• 2.Location of urinary tract infection.
• Symptoms and signs
• Laboratory findings
• X-Ray findings
• Radionuclide imaging
• MRI findings
• All those will be disscussed in detail in the
  following part.

9
3.Treatment strategy.

• Antimicrobial drug should be given according to
  sensitivity test. Medication should be given for
  pain, fever, and nausea. It is important to give
  fluids intravenously and orally to ensure
  adequate hydration and maintenance of adequate
  urinary output. Complicating factors,
  eg.obstructive urography or infected stones, must
  be recognized early and dealt with effectively.

10
TUBERCULOSIS(TB) OF THE GENITO-URINARY SYSTEM

• Dr. Song yongsheng
• Urological Department of the 2nd Hospital, CMU

11
PATHOGENESIS AND PATHOLOGY

• 1.Kidney and rueter
• When a shower of tubercle bacilli hits the renal
  cortex(glomerulus)the organisms may be destroyed
  by normal tissue resistance and only scars are
  found in the kidney(pathological kidney
  TB).However, if enough bacteria of sufficient
  virulence become lodged in the kidney and are not
  overcome, a clinical infection is established. TB
  of the kidney prgresses slowly, there is no renal
  pain and little or no clinical disturbance of any
  type until the lesion has involved the calices or
  the pelvis, at which time pus and organisms may
  be discharged into the urine.

12
PATHOGENESIS AND PATHOLOGY

• It is only at this stage the smptoms of cystitis
  are manifested(clinical kidney TB). Usually,
  there is a soft. yellowish localized bulge
  surrounded by marked perinephritis. On section,
  the involved area is seen to be filled with
  cheesy material(caseation).Widespread destruction
  of parenchyma is evident. Small abscesses may
  down in the reparative rocess. The ureter
  undergoes fibrosis and tends to be shortened and
  straingtened. Ureteral stenosis may be complete,
  causing"autonephrectomy".

13
2.Bladder

• In early stages, the mucosa may be inflamed as
  the bladder is bathed by infected material.
  Later, tubercles form and can be easily seen
  through the cystoscope, as white or yellow raised
  nodules surrounded by a halo of hyperemia. With
  severe involvement, the bladde becomes fibrosed
  and contracted, this leads to marked frequency.
  Ureteral reflux or stenosis and , there fore,
  contralateral hydronephrosis may develop.

14
3. Prostate, seminal vesicles, epididymis and
testis

• The passage of infected urine through the
  prostatic urethra will ultimately lead to
  invasion of the prostate and or both seminal
  vesicles. Prostatic infection can ascend to the
  bladder and descend to the epididymis. If the
  epididymal infection is etensie and an abscess
  forms, it may rupture through the scrotal skin,
  thus establishing a permanent sinus, or it may
  extend into the testicle.

15
CLINICAL FINDINGS

• Tuberculosis of the genitourinary tract should be
  considered in the presence of any of the
  following situations
• (1)chronice cystitis that refuses to respond to
  adequate therapy
• (2)the finding of pus without bacteria in culture
  of the urinary sediment
• (3)a nontender, enlarged epididymis with a beaded
  or thickened vas
• (4)a chronic draining scrotal sinus or induration
  or nodulation of the prostate and thickening of
  one or both seminal vesicles.

16
1.Symptoms and signs

• (1)The affected kidney is usually completely
  asymptomatic. On occasion. there may be a dull
  ache in the flank. The renal and ureteral colic
  may caused by passage of a blood clot, secondary
  calculi, or a mass of debris. Rarely, the
  presenting symptom may be a painless mass in the
  abdomen.
• (2)The earliest symptoms of renal TB may arise
  from secondary vesical involvement. These include
  burning, frequeney and noctruia. Ina a late stage
  of the disease. the vesical irritability may
  become extreme. If ulceration occurs, suprapubic
  pain may be noted.

17
1.Symptoms and signs

• (3)Hematuria or pyuria is occasionally found and
  is of either renal or vesical origin.
• (4)A thickened, nontender or only slightly tender
  epididymis may be discovered. The vas deferens
  often is thickened and beaded. A chronic draining
  sinus through the scrothal skin is almost
  pathognomonic of tuberculous epididymis. The
  tuberculous prostate shows areas of induration,
  even nodulation. The involved vesicle is usually
  indurated, enlarged and fixed.

18
2.Laboratory findings

• (1) Persistent pyuria without organisms on
  culture(sterile pyuria) means TB until proved
  otherwise. Acid-fast stains done on the
  concentrated sediment from a 24-hour specimen are
  positie in at least 60 of cases.
• (2)Culture or PCR detection for tubercle bacilli
  from the first morning urine are positive in a
  very high percentage of cases of TB infcction.
  But the negative results should be repeated three
  times.

19
2.Laboratory findings

• (3) The ESR is usually accelerated. The
  tuberculin test should be performed, negative
  test in an otherwise healthy patient speaks
  against a diagnosis of TB.
• (4)Renal function will be nomel unless there is
  bilateral damage. The kidneys can be infected
  with tubercle bacilli, or there is one TB and the
  other hydronephrotic (ureterovesical stenosis or
  reflux).

20
3.Imaging finding

• IVU can be diagnosed if the lesion is moderately
  advanced. The typical changes include
• (1)a "moth-eaten" appearance of the involved
  ulcerated calices
• (2)obliteration of one or more calices
• (3)dilatation of the calices due to ureterl
  stenosis from fibrosis
• (4)abscess cavities that connect with calices
• (5) single or multiple ureteral strictures, with
  secondary dilatation, with shortenting and
  straightening of the ureter

21

• (6)Absence of function of the kidney due to
  complete ureteral occlusion and renal
  destruction.(Autonephrectomy). Retrograde
  urography may be carried out on the unsuspected
  side as a verification of its normality.
• Ultrasonic examination. CT, MRI, etc, may give
  the diagnos is more accurate. Cystoscopy may
  reveal the typical tubercles or ulcers of TB.
  Biopsy can be done if nesessary. Severe
  contracture of the bladder may be noted. A
  cystogram may reveal ureteral reflux. A clean
  specimen of urine should also be obtaimed for
  further study.

22
DIAGNOSIS DIFFERENTIAL

• Chroic nonspecific cystitis or pyelonephritis.
  Acute or chronic nonspecific epididymis.
  amicrobic cystitis, interstitial cystits,multiple
  small renal stones or nephrocalcinosis.
  netcrotizing papillitis, medullary sponge
  kidneys, etc, amy mimic TB perfectly or partly.
  But they may all be ruled out by IVU, urine TB
  culture or PCR and Cystoscopy Examinations.

23
COMPLICATIONS

• 1.Renal TB
• Perinephric abscess, renal stone, uremia
• 2.Ureteral TB
• Scarring stricture formation, juxtavesical reflux
  ,hydronephrosis.
• 3.Vesical TB
• Bladder contracture, hydronephrotic atrophy.
• 4.Genital TB
• Sterility (bilateral ducts occluded)

24
TREATMENT

• 1.Renal TB
• A strict medical regimen should be instituted.
  The following combinations of drugs can be
  utilized.(1)Streptomycin, PAS, Rimifon(2)Rifampin,
  INH, and Ethambutol. While most authorities
  advise apropriate medication for 2 years.
• Nonfunctioning kidneys should be removed after
  1-2 months of medical therapy. If, after 3
  months, the affected kidney is radiologically
  evident, nephrectomy should be considered. But
  the counterlateral kidney must be norma.

25
2.Vesical TB

• TB of bladder tends to heal promptly when
  definitive treatment for the "primary" GU
  infectionis given. Vesical ulcer that fail to
  drug treatment may require transurethral
  electrocoagulation. For the extreme contracture
  of the bladder , it may be necessary to divert
  the urine from the bladder or perform subtotal
  cystectomy (ileocystoplasty ,sigmoidocystoplasty).
  

26
3.Genital TB

• If after months of treatment an abscess or a
  draining sinus exists, epididymectomy is
  indicated. For the prostate and the vesical TB,
  the majority opinion is that only medical therapy
  is indicatd.

27
4. Treatment of complications

• Perinephric abscess must be drained, and
  nephrectomy should be done either then or later
  to prevent development of a chronic draining
  sinus. For the ureteral stricture, ureteral
  dilatations offer a better that 50 chance of
  cure. The severe incompetence of the
  ureteovesical junction need some form of urinary
  diversion