Infections of urinary tract and male reproductive system

URINARY TRACT INFECTIONS

Urinary tract infections (UTIs) are among the most common infectious diseases encountered in urological practice. According to EAU terminology, UTIs are classified as lower urinary tract infections (lUTIs) or upper urinary tract infections (uUTIs). Lower urinary tract infections primarily involve the bladder and urethra, with cystitis being the most frequent clinical entity. Typical symptoms of lUTIs include dysuria, urinary frequency, urgency, and suprapubic pain. Upper urinary tract infections affect the kidneys and renal pelvis and are most commonly referred to as acute pyelonephritis. Upper UTIs are usually associated with systemic symptoms such as fever, flank pain, chills, and malaise. UTIs are further categorized as uncomplicated or complicated based on patient-related and anatomical factors. Uncomplicated UTIs occur in healthy, non-pregnant individuals with a structurally and functionally normal urinary tract. Complicated UTIs are associated with factors such as urinary tract obstruction, indwelling catheters, renal impairment, or immunosuppression. Escherichia coli remains the most common causative pathogen in both uncomplicated lUTIs and uUTIs. Diagnosis of UTIs is based on clinical presentation supported by urinalysis and urine culture. Imaging of the urinary tract is not routinely required in uncomplicated lUTIs. In suspected uUTIs or complicated infections, imaging is recommended to exclude obstruction or other complications. Antimicrobial therapy should be guided by local resistance patterns and culture results whenever possible. EAU guidelines emphasize antimicrobial stewardship to reduce the development of antibiotic resistance. Asymptomatic bacteriuria should not be treated except in specific clinical situations, such as pregnancy or prior to urological procedures. Recurrent UTIs require careful evaluation to identify modifiable risk factors. Prevention strategies include behavioral measures and, in selected cases, prophylactic antimicrobial or non-antimicrobial approaches. Prompt recognition and appropriate management of uUTIs are essential to prevent sepsis and renal damage. Urinary tract infection (UTI) is a significant health problem in community and hospital based settings. The majority of community-aquired UTIs manifest as uncomplicated bacterial cystitis and occur mainly in females. In hospitals approximately 40 % of all nosocomial infections are UTIs, mostly associated with urinary catheters. Contamination is introducing of organisms during collection of urine, asymptomatic bacteriuria is presence of organisms in the urine without symptoms. UTI is combination of pathogens within urinary tract and symptoms and/or inflammatory response. Uncomplicated UTI is infection in healthy non-pregnant, premenopausal female with normal urinary tract. Complicated UTI is infection associated with factors increasing colonisation and decreasing efficacy of therapy. Reccurent UTI: ≥ 2 infections in 6 months or ≥ 3 in 12 months. Persistent UTI: the same bacteria from focus of infection. Most comon way of UTIs is ascensus of bacterias through the urethra into the bladder. There are known risk factors for UTI: - bladder outlet obstruction (benign prostatic hyperplasia, prostate cancer, urethral stricture, pelvic organ prolapse) - voiding dysfunction (neurogenic bladder) with residual urine - sexual activity in female - estrogen depletion in female - catheterization - urinary and/or fecal incontinence - endourological surgical procedures - diabetes mellitus (DM)- glycosuria may contribute to severity of infections due to immune compromise. - pregnancy – bacteriuria is in 4-7 % of pregnant women leading to acute pyelonephritis in ¼ of them.

Diagnosis
Clinical symptoms: Colonisation may be asymptomatic. Cystitis has irritative symptoms (urinary urgency, frequency and dysuria), suprapubic pain and sometimes hematuria. Similar symptoms are in urethritis and cystoprostatitis. Pyelonephritis can include symptoms of cystitis as well as fever, rigors, flank or abdominal pain, nausea and vomiting. Analysis of the urine is most important. Most common way of collection is clean catch midstream voided urine, but often in women contamination of urine by vaginal or perineal organisms is common and catheterized urine should be used. A chemical analysis (dipstick) is suggestive for UTI if leukocyte esterase and/or nitrite are positive. Urine microscopy or urine flow cytometry are more important, the finding of elevated white blood cells in the urine (pyuria) means infection as well as finding of bacteria or yeast. Common causative pathogens in adult UTIs: Escherichia coli (80%), Staphylococcus saprophyticus, Klebsiella pneumoniae and Proteus mirabilis. In general, more than 100 000 colonies/ml is concidered diagnostic for UTI. In men is sometimes used 4-glass culture test: 1.glass – initial voided urine reflects bacterial activity within urethra. 2.glass – mid-stream urine evaluate bacteria within the bladder. 3.glass – prostatic secretions captured while massaging the prostate. 4.glass – post-massage voided urine. Note: 3. and 4.glass reflect prostatic bacteria. Imaging in UTI. Patient with uncomplicated cystitis does not need imaging, pytient with pyelonephritis need kidney ultrasound to be performed (to exclude obstructive pyelonephritis), in patients with complicated or recurrent UTIs ultrasound or non-contrast CT scan of the abdomen and pelvis or cystoscopy should be performed. Differential diagnosis include STDs - sexually transmitted diseases (herpes, gonorrhea, chlamydia, trichomoniasis, HIV, syphilis), vaginal infection, candida infection, tuberculosis, bladder cancer, bladder outlet obstruction, urinary fistula, ureteral or bladder stone, vesicoureteral reflux, foreign body or overactive bladder.

Management of UTI
Each symptomatic episode of acute cystitis should be evaluated with urinalysis and urine culture. Treatment is based upon pathogen identification, type and degree of inflammation. Preferred are Fosfomycin 3g single p.o. dose or Nitrofurantoin 100 mg p.o. bid x 5 days or Trimethoprim-sulfamethoxazole 960 mg p.o. bid x 3 days. Alternative when bacteria are resistant to preferred antibiotics is Ciprofloxacin 250 mg bid x 3 days. In complicated cystitis and uncomplicated pyelonephritis can be used: Ciprofloxacin 500 mg bid x 7 days, Levofloxacin 750 mg x 5 days, Trimethoprim-sulfamethoxazole 960 mg p.o. bid x 14 days. Complicated pyelonephritis requires hospital admission and initialy i.v. antibiotics: fluoroquinolone, aminoglycoside +/- ampicilin, 3rd generation cephalosporin or carbapenem. Antibiotic prophylaxis regimens for recurrent cystitis: long-term fosfomycin 3g every 10 days, Nitrofurantoin 50 – 100 mg daily (evening dose), Cephalexin 125-250 mg daily, postcoital profylaxis 50-100 mg nitrofurantoin single dose (best 1 hour prior to sexual intercourse). Treatment of asymptomatic bacteriuria is recommended in pregnant women and before planned urological procedures. Infections of the male reproductive system represent a significant cause of morbidity in urological practice. These infections may involve the prostate, epididymis, testes, seminal vesicles, or urethra. Acute and chronic prostatitis are among the most common inflammatory conditions affecting the male reproductive organs. Epididymitis and orchitis frequently present with scrotal pain, swelling, and systemic symptoms of infection. Sexually transmitted pathogens play an important role in infections of the male reproductive system, particularly in younger patients. Ascending infection from the lower urinary tract is a common pathogenic mechanism, especially in older patients. Laboratory evaluation includes urinalysis, microbiological cultures, and inflammatory markers. Imaging modalities such as ultrasonography are useful in assessing complications, including abscess formation. Early diagnosis and appropriate antimicrobial therapy are essential to prevent long-term sequelae. Untreated or recurrent infections may result in infertility, chronic pain, or structural damage to the reproductive organs.

Courses

• Surgery 4 (Trauma Surgery, Urology) [ChK/CH-V4/09]