URINARY TRACT INFECTION Dr Kulwant Singh Principal: S H Medical College Jamshedpur
URINARY TRACT INFECTION • Second most common infection following respiratory infections • UTI occur when bacteria (E. coli) from the digestive tract get into the opening of the urinary tract and multiply • Bacteria first infect the urethra, then move to the bladder and finally to the kidneys • UTI tend to occur more in women than men
Urinary tract is normally sterile due to the fact that bacteria moving upwards are regularly washed out by urination Normal flora found in the urethra consist of lactobacillus and staphylococcus to name a few URINARY TRACT INFECTION
Importance of Urinary Tract Infections is demonstrated by the fact that 20% of women between ages 20-65 suffer one attack per year Approximately 50% of women develop a UTI during their lives and there is a prevalence rate of 5% per year of asymptomatic or covert bacteriuria in non-pregnant women between ages 21 and 65 URINARY TRACT INFECTION
URINARY TRACT INFECTION TYPES LOWER TRACT INFECTION UPPER TRACT INFECTION URETHRITIS PROSTATITIS CYSTITIS PYELONEPHRITIS PERI NEPHRIC ABSCESS
URINARY TRACT INFECTION AETIOLOGY Background 1. Bacterial infections of urinary tract are a very common reason to seek health services 2. Common in young females and uncommon in males under age 50 3. Common causative organisms • Escherichia coli (gram-negative enteral bacteria) causes most community acquired infections • Staphylococcus saprophyticus, gram-positive organism causes 10 – 15% • Catheter-associated UTI’s caused by gram-negative bacteria: Proteus, Klebsiella, Seratia, Pseudomonas
URINARY TRACT INFECTION PATHOGENESIS BACTERIA GET ACCESS FROM URETHRA AND ASCENDS • FEMALES ARE MORE PRONE DUE TO: • SMALL URETHRA • GRAM NEGATIVE ORGANISM RADIATE FROM PERI ANAL AREA TO URETHRA • SEXUAL INTERCOURSE • SUSCEPTIBILITY OF EPITHELIUM
URINARY TRACT INFECTION PATHOGENESIS • WHETHER BLADDER INFECTION ENSURES IT, DEPENDS ON THE FOLLOWING: • FLUSHING AND DILUTING OF MICURITION AND VOIDING • ANTIBACTERIAL PROPERTIES OF BLADDER MUCOSA AND URINE • SIZE OF INOCULUM
URINARY TRACT INFECTION PATHOGENESIS • FEMALE SEX AND INTERCOURSE PREDISPOSES • PREGNANCY: URETERAL TONE AND URETHRAL PERISTALSIS DECREASES • OBSTRUCTION IN FREE FLOW OF URINE: TUMOR, STRICTURE, CALCULI AND BPH ETC. • CATHETERISATION, URETHRAL DILATATION, CYSTOSCOPY
URINARY TRACT INFECTION PATHOGENESIS The normal bladder is capable of clearing itself of organisms within 2 to 3 days of their introduction. Defense mechanisms (1)the elimination of bacteria by voiding (2) the antibacterial properties of urine and its constituents (3) the intrinsic mucosal bladder defense mechanisms (4) an acid vaginal environment (female) (5) prostatic secretions (male)
URINARY TRACT INFECTION PATHOGENESIS Two potential routes: (1) the hematogenous route, with seeding of the kidney during the course of bacteremia (2) the ascending route, from the urethra to the bladder, then from the bladder to the kidneys via the ureters.
URINARY TRACT INFECTION PATHOGENESIS Hematogenous Infection Because the kidneys receive 20% to 25% of the cardiac output, any microorganism that reaches the bloodstream can be delivered to the kidneys. The major causes of hematogenous infection are S. aureus, Salmonella species, P. aeruginosa, and Candida species.
URINARY TRACT INFECTION PATHOGENESIS Hematogenous Infection Chronic infections (skin, respiratory tract) blood circulation kidney (cortex) small abscess renal tubular renal pelvis renal papillary
URINARY TRACT INFECTION PATHOGENESIS ASCENDING INFECTION The ability of host defense Urinary tract mucosal cells damaged The power of bacterial adhesions(toxicity) organisms urethra,periurethral tissues bladder ureters renal pelvis renal medulla
URINARY TRACT INFECTION PATHOGENESIS Voiding dysfunction is characterized by some or all of the following: urgency frequency dysuria hesitancy dribbling of urine overt incontinence secondary to a UTI or to local irritants such as pinworm infestation
URINARY TRACT INFECTION PATHOGENESIS • The normal bladder is capable of clearing itself of organisms within 2 to 3 days of their introduction. • Defense mechanisms • (1) the elimination of bacteria by voiding • (2) the antibacterial properties of urine and its constituents • (3)the intrinsic mucosal bladder defense mechanisms • (4) an acid vaginal environment (female) • (5) prostatic secretions (male)
URINARY TRACT INFECTION PATHOGENESIS • CONTINITUATION OF UTI DEPENDS : • Female sex and intercourse predisposes • Pregnancy: ureteral tone decreased, ureteral peristalsis decreased • Obstruction in free flow of urine • Catheterisation , urethral dilatation, cystoscopy • Vesico-ureteric reflux: it occurs during voiding -- pressure increase in bladder, flow from bladder to kidney • Impaired defence • Neurogenic: spinal injury, sclerosis
URINARY TRACT INFECTION HISTORY AND PHYSICAL EXAMINATION Age-related Risk Factors for UTI • Advanced Age • Fecal incontinence/impaction • Incomplete bladder emptying or neurogenic bladder • Vaginal atrophy/estrogen deficiency • Pelvic prolapse/cystocele • Insufficient fluid intake/dehydration • Indwelling foley catheter or urinary catheterization or instrumentation procedures
URINARY TRACT INFECTION CLINICAL PRESENTATION • Cystitis • dysuria (burning or discomfort on urination) • frequency • nocturia • suprapubic discomfort
URINARY TRACT INFECTION CLINICAL PRESENTATION • Fever with chill & rigor • Haematuria • Strangury • Ineffectual desire • Cloudy urine • Offensive urine • Pain lower abdomen
URINARY TRACT INFECTION CLINICAL PRESENTATION • Uncomplicated • Cystitis • Urethritis • Female >>> male • Sequel rare
URINARY TRACT INFECTION CLINICAL PRESENTATION • Complicated • Pyelonephritis • Prostate obstruction • Relapse +++
URINARY TRACT INFECTION INVESTIGATIONS • WBC ++++ • Urine: C & S • Cystoscopy • Ultra Sound • IVU • P/R • PID
URINARY TRACT INFECTION TREATMENT • FLUID ++ • ALKALI • EMPTYING OF BLADDER • HYGIENE
Recurrent U.T.I.s that are reinfection. Unresolved infection Isolated infections Classification of U.T.I. Recurrent infections resulting from bacterial persistence.
URINARY TRACT INFECTION TREATMENT • ROAD MAP OF TREATMENT • To limit the period of suffering. • To minimise the severity of suffering. • To arouse the immunity of the patient to prevent reinfection. • To avoid dialysis and kidney transplantation. • To reduce the cost of treatment.
URINARY TRACT INFECTION TREATMENT Eryngium aquaticum • Burning pain with frequent urge. • Prostatic fluid from slightest provocation • Tenesmus of bladder • Frequency / dysurea • Urine burns like fire
URINARY TRACT INFECTION TREATMENT Eupatorium purpereum • Strangury • BHP • Chill runs upward • Burning while urinating • Cystitis in pregnant women • Sweetish smell urine
URINARY TRACT INFECTION TREATMENT Chimaphila umbellata • Plethoric young women • BHP • Urine scanty loaded with ropy mucopurulent sediment • Burning and scalding pain Violent tenesmus • Urinate only when bends forward and with feel wide open
URINARY TRACT INFECTION TREATMENT Equisetum • Fullness of bladder not relieved by urination • Sharp cutting / burning pain • Right lumber region painful • Constant desire to urinate • Aggravation immediately after urination
URINARY TRACT INFECTION TREATMENT Epigea repens • Chronic cystitis / dysurea • Strangury • Urge in continency • Mucopus and uric acid deposition and renal calculi
URINARY TRACT INFECTION TREATMENT Petroselinum • Urge in continence • Burning and tingling in urethra • Dysurea with BHP • Ameliorate by rubbing the urethra
URINARY TRACT INFECTION TREATMENT PRUNUS SPINOSA • Forked urine – slow stream • Cramping pain in bladder < walking • Sudden urge • Violent pain Thinking of complaints ameliorates
URINARY TRACT INFECTION TREATMENT CANNABIS SATIVA • Burning in bladder while urinating • Stitches in urethra • Urethra sensitive • Urine scalding and spasmodic closure of sphincter • Fear of going to bed • Time passes slowly • Tickling sensation as of dropping water.
URINARY TRACT INFECTION TREATMENT • CANTHARIS • Inflammation are violent • Cystitis • Strangury • Haematuria with pain • Violent burning ,cutting ,stabbing pain • Urging for urination • Urine comes drop by drop with pain
URINARY TRACT INFECTION TREATMENT PARIERA BRAVA • Radiating pain to thigh during efforts to urinate • Sensation as if the bladder is full • Urethritis • Urge incontinency • Contains thick stringy mucus
TREATMENT THUJA OCC. • Fixed ideas • Anger from contradiction • Ill effects of vaccination • Urethra inflamed • Frequent urination with pain • Sudden urge • Left sided • Tickling in Urethra. • Must be used inter-currently to prevent reappearance
URINARY TRACT INFECTION TREATMENT TEREBINTHINA • Confusion of mind • Irritability • Concentration difficult • Bleeding mucous membrane • Strangury • Urethritis • Urine scanty with odor of violet • Urine smoky , coffee ground
URINARY TRACT INFECTION TREATMENT BERBERIS VULGARIS • Indifferent / anxiety • Changeability /wandering pain • Pain aggravate by pressure • Left sided • Sticking / cutting / burning • Bubbling sore sensation in kidney • Frequent maturation • Burns when non urinating • Associated with renal calculi
URINARY TRACT INFECTION TREATMENT ARSENIC ALBUM • Restlessness • Fear of death • Anxiety • Burning like fire > by heat • Putrid discharges • Thirst unquenchable for small quantity • Craves of acids / warm food • Burning urethra during urination • Dysuria • Urine is black
URINARY TRACT INFECTION TREATMENT APIS MEL • Fearfulness , can not help crying • Apathy • Sudden shrill piercing screams • Ailment from suppressed sexual desire • Burning / stinging pain with swelling • Thirstlessness • Craving for sour • Nephritis / cystitis / prostatitis • Strangury • Last drop burn and smart
URINARY TRACT INFECTION TREATMENT NITRIC ACID • Irritable/ Vindictive/ Headstrong • Sensitiveness to noise • Discontented • Pain appear suddenly and disappear suddenly • Discharges are offensive • Love fat and salt ,hate meat and milk aggravates • Urine cold on passing • Burning stinging after urination • Frequent urge at night
URINARY TRACT INFECTION TREATMENT POPULUS TREMULOIDS • Urethritis • Dysurea –Scalding during pregnancy • Severe tenesmus • Pain behind pubis at the end of Urination • B.H.P.