Surgery part 1 pdf - د.أحمد

Lec:1

Surgery

History, Physical exam and Specialized

methods of urological diagnosis

History:



Pain: Location (CVA, genitals, suprapubic) Onset, Quality ( colicky, burning ) Severity,
Radiation .



Associated symptoms: Fever, Chills, Weight loss, Nausea, Vomiting .



Irritative symptoms: Frequency, Nocturia, Dysuria, Urgency .



Obstructive Symptoms: Hesitancy, Straining, Intermittency, decreased force or caliber
of stream, Prolonged voiding, post-void dribble, Incomplete emptying .



Incontinence: Stress incontinence, Urge inco., Overflow inco., history of neurological
problems, past pregnancies and method of delivery, past abdominal-pelvic operations



Urine: Hematuria, Pneumaturia, foul smell, Colour (cloudy, white, orange)



Urethral discharge: ( colour, amount, smell ), Sexual history, UTIs, external skin
lesions, lymphadenopathy .



Others: Renal calculi, Infertility, Erectile dysfunction, Congenital disorders, family
history of urological disease.

Physical Exam:

Inspection



Abdomen : masses, Scars from previous operations, Suprapubic distention, hair
distribution .



Penis : Circumcision, Phymosis/Paraphymosis, Epispadias, Hypospadias, Urethral
discharge, Superficial ulcers or vesicles, Venereal warts, Meatal stenosis, Balanitis .



Scrotum : Testicular atrophy, Testicular asymmetry, Dilated veins (varicocele ) on
Standing, Scrotal erythema/edema/cysts/hemangiomas .

Palpation



Kidneys, Bladder, Penis, Testes, Vas deference, Epididymis, Prostate .



Abdomen : Masses, CVA tenderness, Suprapubic distention/ tenderness (examine for
dullness on percussion), lymphadenopathy.



Penis : Peyronie’s plaques, Penile masses, Penile tenderness .



Scrotum : Scrotal tenderness/masses (size, consistency, location, mobility, shape),
hernia, hydrocele, spermatocele.



Spermatic cord : ( varicocele, fusiform enlargement, thickening of the cord ), absence
of vas deference .



Epididymal : size/induration/tenderness .



Prostate : on DRE ( Digital Rectal Exam )



Size, Consistency ( rubbery, hard, boggy, indurated ), Nodularity ( size, location ),
Tenderness, Warmth .

SPECIALISED METHODS OF UROLOGICAL DIAGNOSIS

Clinical examination
Fig. bimanual palpation of the kidney

Laboratory investigation

Urine analysis



This is best performed on a mid-stream specimen of urine. After cleansing the

external urethral meatus, the first 20 ml or so of urine (containing bacteria and cells
from urethra) are discharged before collecting the next part of the voided urine in a
sterile container.

Chemical tests



"Dipstick" = a strip coated with chemicals for measuring the urine pH and for
detecting the presence of glucose, protein or blood; bilirubin, urobilinogen, ketones
and nitrites can also be detected.

The urine pH



Varies between 4.5 and 8.0 Persistently alkaline urine (pH > 8.0) suggest infection
with urea-splitting organism such as Proteus mirabilis

Protein



The amount of protein in the urine is normally less than 100 mg/24 h. Dipstick will
only detect levels greater than 300 mg/l Transient proteinuria (e.g. UTI) or persistent
(glomerulopathia)

Glycosuria



Usually diabetes mellitus, rarely renal glycosuria

Microscopy
Microscopical examination of urine directly of the urinary sediment studied after
centrifugation



Red blood cells



White blood cells



Epithelial cells



Casts - from glomerular disorders (hyaline or cellular)



Crystals - related to stone disease



Bacteria - Gram stain should be performed; if tuberculosis is suspected, the urinary
sediment should be stained using the Ziehl-Nielsen methods



Ova - schistosomiasis

Culture



The specimen should be plated out promptly or refrigerated until processing to
prevent multiplication of bacteria after voiding.



Significant infection is present if there are more than 100 000 (= 10 5 ) organism/ml ,
whilst counts less than 10 000 (=10 3 )/ml suggest contamination.



Antibiotic sensitiveness is determined using culture plates with antibiotic discs that
inhibit the growth of susceptible organisms.



If tuberculosis is suspected, three early morning samples of urine (EMU) are taken
and cultured on Lowenstein-Jensen medium .

Blood tests
Renal function studies



the plasma urea (normal range 2,3-6,9 mmol/l) and creatinine (normal range 50-120
µmol/l)



creatinine clearance (normally 100-140 ml/min) - closely approximates to the
glomerular filtration rate (GFR)

Haematology



Anaemia - tumours, renal impairment



White blood cell count - may raised in infections



ESR - elevated in certain disorders, tumors, retroperitoneal fibrosis

Other tests



PSA - see BPH and prostate cancer

Diagnostic imaging

Plain abdominal X-ray (KUB)

The KUB (a plain X-ray to include the kidneys, ureters and bladder) is useful to detect:



Radio-opaque urinary calculi (90% of calculi) unless they overlie areas of the bony
skeleton



Soft tissue masses in the renal areas and pelvis



Gallstones (10%)



Pelvic phleboliths



Calcified lymph nodes



Sclerotic deposits in prostate cancer (osteoplastic metastases



for other tumours are more typical osteolythic metastases)

Intravenous urography (IVU)



After a plain film, iodine-containing contrast medium is injected intravenously and
serial films are taken to follow its excretion by the kidneys



The nephrogram phase - on the initial film 1-3 minutes after injection, contrast
medium is in the glomeruli and proximal tubules so that a clear image of the renal
outline is obtained



The pyelogram phase - subsequent excretion of contrast medium outlines the
collecting systems, renal pelvis, ureter and bladder, showing any structural
abnormalities or filling defects



The procedure may be complicated by allergic reaction to the contrast medium,
ranging in severity from a mild urticarial rash to anaphylactic shock .

Ultrasound



The most frequently used radiological techniques in urological disorders



Almost all urological out-patient department are able to perform ultrasound
immediately after physical examination



Colour-flow Doppler techniques - measuring blood flow

CT scanning (computed tomography)



Multidetector Spiral CT



It enables reconstructions in different planes and biphasic CT angiography

PET/CT



Combination of positive emission tomography and CT.



It allows precise localisation of tumours.

MRI (magnetic resonance imaging)
Arteriography



Renal arteriography is used in diagnosis of renal vascular disorders, renal tumours and
renal trauma; therapeutic embolisation of the renal artery can be performed at the
same time to control bleeding from the kidney.



Iliac arteriography is useful for assessing the pelvic tumours or trauma, and
therapeutic embolisation of the internal iliac artery is occasionally used for
uncontrollable bladder haemorrhage, pelvic trauma, and priapism.

Other radiological techniques

Antegrade pyelogram - contrast medium is injected via a small-bore needle passed into the
collecting system under local anaesthetic or via a percutaneous nephrostomy
Ascending ureterogram - using a catheter inserted into the ureteric orifice at cystoscopy
Urethrography (ascending and descending) - contrast medium is instilled directly into
urethra (ascending urethrography), contrast medium is passed out and is performed with
micturition
cystogram (it can demonstrate vesicourethral reflux) and descending urethrography.
Urethrography is useful for diagnosis of urethral stricture mainly.
Lymphography - following injection of contrast medium into a lymphatic in the foot is used
to demonstrate the iliac and para-aortic nodes in pelvic malignancy; nowadays, it has been
replaced by CT scanning

Radionuclide studies



Renal scintigraphy

It is useful mainly for dynamic diagnosis - upper urinary tract obstruction, assessing of renal
function of both kidneys.



Bones scintigraphy

It is most widely used in the detection of bony metastases from prostatic, bladder and renal
carcinoma.

Lec:2

Surgery

Specialized methods of Urological Treatment

CATHETERISATION

Catheters are used mainly therapeutically to relieve urinary retention.

Types and sizes of catheters

Material :
- soft silicon coated latex (silicon is highly resistant to incrustation) , it can be introduced up
to 4 weeks
- 100% silicon - it can be introduced up to 8 weeks (it is better, but more expensive)
Types of catheters :
1. One way catheter : for dilatation of urethral stricture, to discover residual urine (better it
is performed by ultrasound), to introduce contrast medium into the bladder
2. Two way catheter : self-retaining balloon catheter = Foley catheter
3. Three way catheter : for irrigation (lavage) of bladder (by bleeding to bladder after
prostatectomy, due to bladder tumour)

Division by a tip of catheter :

Nelaton - straight round tip
Tiemann - curved pointed tip

Size of catheters :

French scale = Charrie scale = circumference in mm diameter is size in F (Ch) divided by
( = 3.14) e.g. catheter 18 F has diameter 6 mm

ENDOSCOPY
Two types of endoscopes:
1. rigid .
2. flexible .
Examination is more difficult, an endoscope is more expensive, through this
endoscope can be passed only flexible instruments, but for patient is this
flexible endoscopy more pleasant



Panendoscopy : Uretroscopy and cystoscopy = endoscopy of urethra and urinary
bladder



Ureteroscopy

: Endoscopy of ureter



Ureterorenoscopy : Endoscopy of ureter and renal pelvis too

Endoscopic operations



Lithotripsy : disintegration of stone in bladder and ureter



Transurethral resection of prostate (TURP = TUPE) and bladder tumour ( TURT )

Nephroscopy



It is used mainly for treatment of stones = nephrolitholapaxy

Nephrostomy

To the dilated renal pelvis is introduced under ultrasound and/or radiological control
catheter (= percutaneous nephrostomy).
Percutaneous nephrostomy step by step:



Needle puncture of dilated renal pelvis under X-ray or/and ultrasonography control



Guide wire passed down needle Dilatation of channel over guide wire



"pig-tail" catheter inserted over guide wire

BIOPSY

Prostate biopsy



Indication: suspicion on prostate cancer It is performed transrectal (or transperineal)
under mainly ultrasound control

Biopsy of kidney



It is done under ultrasonography or CT control. Mainly used in nephrology, biopsy for
kidney tumour is indicated rarely.

Lec:3

Surgery

Symptoms of urological diseases

Changes in urine volume



Anuria - diuresis < 100 ml/24h



Oliguria -diuresis < 500 ml/24h



Polyuria- diuresis > 1500 ml/24h

Chages in urine appearance



Haematuria-blood presence in urine



Pyuria : pus presence in urinae



Bacteriuria – bacteria in urine



Leukocyturia- leucocytes in urine



Proteinuria- proteins in urine



Pneumaturia – passage of gass



Stercoruria-stool presence in urine

Voiding disorders



Polakisuria or frequency – going to void too often



Urine retention- inability to void – subvesical obstruction



Overflow incontinence – bladder overdistension



Nocturia- frequet voiding on the night



Stranguria – painful voiding



Urinary incontinence :

o  Urgent- overactive detrussor
o  Stress – due to raised abdominal pressure
o  Reflex
o  Mixed
o  Overflow incontinece
o  Ureteric – ectopic ureteric orifice under the level of  sphincter
o  Enuresis nocturnal



Dysuria- difficult voiding

o  Voiding initiation delay
o  Interrupted voiding
o  Weak urine stream
o  Necessity of abdominal pressure during voiding

Renal pain



Nefralgia

o constant ache in lumbar area caused by distention of renal capsul
o inflamation, tumor, hydronephrosis



Renal colic

o colicky pain caused by spam and hyperperistalsis of smooth muscle organ.
o radiats from costovertebral angle, toward the lower anterior abdominal quadrant,

along the corse of the urether into the scrotum or vulva

o passage of blood clot or stone.

Vesical pain



Cystalgia:

o persistant pain localised behinde pubic



Painful contraction

o spasmodic bladder contraction



Urethralgia

o Several pain along the urethra
o Inflammation, tumor, foreign body



Prostatic pain - prostatodynia

o sharp pain promoting to the perineum



Orchalgia

o pain localised it the testes, often propagating along the spermatic cord
o inflammation, tumor, torsion

Haematuria

Presence of blood in the urine

Danger signal, that cannot be ignored

Macrohematuria:



Total



Initial- prostate, urethra



Terminal- urinary bladder

Microhemturia:



Noticeable just with microscope



4 erytrocytes/fields of view



Dismorphic erytrocytes detected by phase-contrast indicative of glomerular disease

Diferential diagnosis



Trauma



Urolithiasis



Tumor



Inflammation



Glomerulonephritis



BPH



Malformation



Sports



Coagulophaty

Examination



Chemical and microscopic examination



Bacterial culturs



PCR for TBC



Urine cytology

Ultrasonography



Pyelolithiasis



Trauma



Dilatation of KPS



Renal tumor, cysts



Tumor of urinary bladder



Anomalies



Cystolithiasis



BHP



Trauma



Tumor of urinary tract



Urolithiasis



Abcess

Cystocopy



Tumor of urinary bladder



Varix in urinary bladder



Cystolithiasis



Fisstula

Lec:4

Surgery

Urinary tract stone (calculi)

urinary calculi: composition ,frequency, and characteristics

Type of stone frequency (%) effect of ph on solubility radiographic density (bone=1.0)
Calcium stones 80

▪

   ▫ Oxalate                      35                          little effect                                          0.50
       (monohydrate
        and dihydrate)
   ▫   Phosphate               10                      increased at ph <5.5                               0.1
▫  Oxalate and             35                             variable                                         variable
       phosphate
Struvite                         10                      increased at ph <5.5                             0.20

▪

Uric acid 8 increased at ph >6.8 0.05

▪

Cystine 1

increased at ph >7.5 0.15

▪

Other types 1

▪

▫ triamterene
▫  xanthine                                            increased at ph >6.8                               0.05
▫  Matrix
     (noncrystalline)

Factors associated with urolithiasis

Factor conditions of increased incidence
Genetics /heredity         cystinuria – autosomal recessive
                                           renal tubular acidosis  type I
                                           medullary sponge kindney
Geography                       high temperature/humidity
Diet                                   increased intake of calcium or oxalate
Occupation                      sedentary

Type of stone eticologic factos

▪  Calcium oxalate                                            supersaturation of urine with calcium
▪  Calcium phosphate                                      from (1) renal leak ,(2) intestinal absorption,
▪  Calcium carbonate                                       (3) bone resorption ; hyperoxalueia
▪  Uric acid                                                         hyperuricosuria , low uriea ph
▪  Cystine                                                           cystinuria
▪  Magnesium ammonium                             alkaline urine produced by urea-splitting

phosphate (struvite) organisms

▪ Matrix alkaling urine produced by urea-splitting

organisms

Epidemiology of stones

o USA---- 400.000 hospitalization annually
o Men: Women 3:1

Etiology and Pathogenesis :

o  Multifactorial process
o  Supersaturation
o  Nucleation and aggregation of crystals

- exmp. : Uric acid , cystine , xanthine

o  Inhibitors Pyrophosphete , Citrrate , mngnesium , zine
o  Matrix : non crystalline mucoprotein – proteus-infection
o  Exogenenous sutstances
o  Indinavir – antiviral
o  Triamterene  } rudolucent stones
o  Stone of the upper urinary tract

clinical presentation :

o  obstration  :  pain – Hematuria
o  nausea , vomiting -- urine infection
o  silent stones

Diagnosis :

o  urine A.
o  KUB , ULS
o  IVP
o  Axinlor spirel CT.

Treatment :

o Conservative Treatment – Hydation

  Low grade obstruction
  Stone 4mm --- 90 % passage
  Stone  6mm --- 20 % passage
  intervention  :

▫ infection
▫ high grad obstruction

o Expectant treatment

  narrowing  sides
  PUJ ( ureteropelvic  Junction)
  Pelvic brim
  Ureterovesical Junction

o Stone extraction

 Nepheroscopy ( PCNL

(

 Uretoroscopy

o Shock wave hithotripsy
o ureterolithotomy .

Bladder Stones

o  outlet obstruction
o  Foreign Bodies
o  Passed Ureter stones

Clinical Presentation

o  Pain – Hypogastrim
o  Referred to penis
o  Intermittent Stream
o  Dysuria , Hematuria

Treatment

o  Lithotrities (cystolitholapaxy)
o  (Mechanical crushing devices)
o  Electrolaydraulic Lithotripsy
o  uslithotripsy
o  pneumatic lithotripsy
o  cystolithotomy
o  Recurrent stone Disease
o  predisposing factors can be identified in 80%

Hypercalciuria

o  Resorptive  Hypercalciuria
o  Hyperparathyroidism >> 50% - Ca-oxlaete
o  Metastatic bone
o  Multiple myeloma
o  Immobilization ( Spinal cord injury

(

o  Cushings disease
o  Hyperthyroidism
o  Absorptive Hypercalciuria  >> 50% Ca – Stones
o  Exaggerated intestinal response to Dvit
o  Renal Hypercalciuria >> 10% of Hypercalciuria
o  Treatment  : Hydrochlorothiazide  50 mg  1x2 potassium supplementation !

Treatment

o  Hydration Fluid intake > 3 L .
o  Alkalinization  - sodium Bicarbonate
o  Potassium citrate
o  Reduction of uric acid load
o  90 gr. Protien
o  Allopurinol ( 200 – 600mg )

Hyperoxalueria

o primary Hyperoxaluria → Rare autosomnl recessive disorder



Treatment : 100 – 400 mg Phyricoxine

o Enteric Hyperoxaluria



inflammatory bowel disease



Small bowel bypass surgery



Fatty acid → bind calcim

o Exogenous Hyperoxaluria



ascprbic acid → 5 gr/ day .



Struvite stones

o Triple – Phosphete stones



Composed of Mg- ammonium – Pho



sphat – Carbonate a patite



PH markedly elerated



Ammomin + bicarbonate in urine – Due to urea splitting organisms .



Protius species 75%



Klebsialla , pseudomonal , providencia Staphylococeus , and ureaplasma
urealyticum

Lec:5

Surgery

UTI in adults and children

Urinary Tract Infection in Adults

Incidence



UTI (urinary tract infection) - common, affecting all ages and both sexes.



The most common but one infections (the first - breath infections) .

Clinical syndromes associated with UTI:



Septicaemia (urosepsis)



Renal infection

o  Pyelonephritis
o  Pyonephrosis
o  Renal abscess
o  Peri- ET paranephric abscess
o  Cystitis - bacterial, abacterial
o  Prostatitis
o  Urethritis
o  Epididymitis, epididymo-orchitis

Methods of introducing UTI



Ascending infection - via urethra to bladder, reflux of infected urine up to ureter and/or

spread of organisms along peri-ureteric lymphatics



Infection via a fistula (e.g. vesico-colic)



heamatogenous infection (via renal artery)

Aetiology and pathogenesis



The urinary tract is normally sterile above the distal urethra



The chiefly defence mechanisms:

Hydrokinetic = the dilution of bacteria by the flow of urine

Mucosal = mainly secretion of immunoglobulin A (Ig A) and phagocytic capability of
the urothelium itself

Factors predisposing to infection



UTI - commoner in women:

1. Due to shorter urethra
2. Opening of urethra at the vaginal vestibule, which is readily contaminated with

faecal organism

3. In many young women, infection are precipitated by sexual intercourse, bacteria-

laden secretion from the perineum entering the urethra during sexual activity (so
called honey- moon cystitis)



In either sex UTI may develop:

1. Incomplete bladder emptying (residual urine) due to outflow obstruction (BPH,

urethral stricture …)

2.  Bladder diverticula
3.  Neuropathic bladder
4.  Upper urinary tract stasis due to obstruction of ureter, mega ureter, stones



Vesico-ureteric reflux interferes with both ureteric and bladder emptying and is

commonly accompanied by infection



Calculi, bladder tumors and foreign bodies (e. g. catheters) are predispose to infection,

as may instrumentation of the urinary tract



Factors that suppress the immune response (diabetes mellitus, cytotoxic or

immunosuppressive agents)

Common urinary pathogens

1- Ascending infection Bacteria



Gram-negative - Escherichia coli - klebsiella spp, proteus spp, pseudomonas spp.



Gram-positive cocci - streptococcus faecalis - staphylococcus aureus



Chlamydia trachomatis



L-organism - ureaplasma urealyticum, mycoplasma hominis



Fungi - candida spp

2- Haematogenous infection



Bacteria - mycobacterium tuberculosis



Fungi



Parasites - schistosoma spp



Viruses - cytomegalovirus, adenovirus type 11

Clinical manifestation

Symptoms



Lower UTI

o Voiding symptoms - frequency, urgency, micturition with discomfort, burning

sensation (= dysuria)

o Occasionally hematuria



Upper UTI

o  Loin pain
o  Systemic disturbance - fever, sweating, rigors
o  Some patients have lower UTI as well (often upper UTI follow lower UTI)

Physical signs



Fever and tachycardia



Tenderness in the loin and in the suprapubic region

Diagnosis



The presence of pus cells on microscopy



The presence of significant number (over 10 5 per ml) of organism in a mid-stream

specimen of urine (MSU)



Microbiology laboratories determines antibiotic sensitivities



Specialized microbiological techniques may be required in certain circumstances (e. g.

Tuberculosis, fungal infection, viral infection)

Further investigation



Cystitis in young sexually active women investigation is not required for the first attack

unless it is accompanied by haematuria or loin pain



investigation is indicated in this group of women for recurrent infections, in older

women, pregnant women, children, men, diabetes mellitus, neuropathy, known urinary
stones or urinary tract anomaly - urinary tract ultrasound, if indicated IVU, blood count,
the serum urea and creatinine

Treatment



Antibiotics commonly used to treat UTI:

o Nitrofurantoin
o Co-trimoxazol (sulfamethoxazol + trimethoprim) and trimethoprim alone

o  Ampicillin, amoxycillin, co-amoxycillin (clavulic acid + amoxicillin)
o  Gentamicin
o  Quinolones (norfloxacin, ciprofloxcin)
o  Cefalosporins



High fluid intake and regular emptying of the bladder to promote hydrostatic clearance

of bacteria



Attention to personal hygiene for women with recurrent infection



In patients with collections of infected urine or pus (e.g. pyonephrosis, perinephric

abscess) drainage is usually required

Upper Urinary Tract Infection

Acute renal infection



Most result from ascending infection (75% of patients have preceding lower-tract

symptoms)



Some they are result of haematogenous spread



There is important to distinguish between infection alone and infection combined with

upper-tract obstruction; the latter combination may lead to rapid obstruction of renal
tissue unless prompt drainage of the obstructed kidney is established

Acute pyelonephritis

Acute inflammation of the pelvic epithelium, with bacteria entering the collecting duct and
fornices to produce inflammation of the renal parenchyma

Renal carbuncle

An abscess in the renal parenchyma and is usually due to haematogenous spread of organisms
(typically staph. aureus from foil, infected infusion site, contaminated needles in drug addicts)

Pyonephrosis

Infection within an obstructed kidney rapid destruction of kidney

Perinephric abscess



It result from any of the above infective processes



Initially the infection is confined by Gerota’s fascia (= perinephric abscess), but may

rupture through this (= paranephric abscess) and to reach the skin (in Petit’s lumber
triangle) , the psoas muscle or the bowel; it may even rupture through the diaphragm to
reach the pleura and lungs

Clinical symptoms



Loin pain, fever, tachycardia, scoliosis in severe cases



Mass may be palpable in the loin



Septicaemia and shock

Investigation



Urine should be examined for pus cells and bacteria (urine culture), blood culture (all

patients with pyrexia or clinical suspicious of septicaemia)



Ultrasound (urinary tract, liver, spleen)



Plain abdominal X-ray, chest X-ray, IVU[

Management

 Septicaemic patient



Rapid intravenous fluid replacement



Intravenous hydrocortisone or methylprednisolone



Parenteral bactericid antibiotics



Subsequent management depend on the pattern of infection, basic treatment is are

antibiotics.

 Acute pyelonephritis

Antibiotics for 7-14 days, guided by the result of urine culture and sensitivity

 Renal carbuncle



Drainage



By aspiration of the abscess under ultrasound or CT control



By open surgery

 Pyonephrosis



Drainage by percutaneous nephrostomy or with a ureteric catheter passed retrogradely

from the bladder at cystoscopy



After improvement ascendant pyelography or descendent pyelography (nephrostogram)

identification of obstruction



Renal scintigraphy determines remaining renal function



Treatment of obstruction (e. g. ureteroscopy for ureterolithiasis, nephrectomy if kidney

function is by scintigraphy under 10-15 %.

 Perinephric abscess

Surgical drainage or nephrectomy, if function in the affected kidney is very poor

Chronic pyelonephritis



Combination of renal scarring and urinary infection



It may follow vesico-ureteric reflux and infection



Repeated episodes of acute pyelonephritis



Differential diagnosis of other types of interstitial nephritis or hypoplasia of kidney is

difficult

Treatment

Eradication of infection to prevent further renal damage. Nephrectomy, if:



Renal function is under 10 (15) %.



Severe secondary hypertension.

Xantogranulomatous pyelonephritis

The result of granulomatous reaction within kidney to chronic infection

Treatment

Nephrectomy

Lower Urinary Tract Infection

Acute bacterial cystitis



Usually result of ascending bacterial infection from the perineum



Particularly common in women (due to short urethra)

Clinical features:



Frequency and urgency of micturition with dysuria



There may be suprapubic pain, urine often has a fishy smell or may be blood stained =

haemorrhagic cystitis)



Association of loin pain and fever suggest spread of infection to the kidney (acute

pyelonephritis)

Management



MSU (including urine culture) before treatment to confirm the diagnosis



Antibiotics for a 5 days period this can be changed, if necessary, on the basis of

antibiotics sensitivity tests



Analgetics and spasmolytics (the best in combination e.g. Algifen®)



Resolution of symptoms = MSU to repeat at 2 weeks and at 3 months to ensure

eradication of infection

Chronic and recurrent bacterial cystitis

Clinical symptoms



Similar to acute cystitis



Histologically cystic changes (cystitis cystica) and squamous metaplasia

Treatment



In women self-help advice



Increase fluid intake



Pass urine every 2 hours



Regular washing of the vulva and vaginal introitus



Wipe from front to back after bowel actions



Empty the bladder after sexual intercourse (if the symptoms are precipitated by sex)



Infection (antibiotics)



Long-term low dose antibiotics (6-12 months), e. g. furantoin 100 mg daily,

trimethoprim 100 mg twice daily, co-trimoxazol one tablet (480 mg) one or twice daily



Immunotherapy (e.g. Uro-Vaxom®)



In women, whose infections are precipitated by sexual intercourse, voiding and single

dose of antibiotics after intercourse may be prevent infection developing

Abacterial cystitis

Trauma, toxic drugs (e. g. severe haemorrhagic cystitis is caused by cyclofosfamid),
chemicals, irradiation, viruses and related organism such as chlamydia trachomatis

Interstitial cystitis



Special type of chronic abacterial cystitis. Well recognise syndrome of unknown

aetiology.



Diagnosis and treatment are very complicated.

Asymptomatic Bacteriuria

1-2 % schoolgirls, 3-5% of adult women, 0.5% schoolboy, 0.5% of adult male.

Management



Exclude some abnormalities of the urinary tract



Active treatment – pregnant woman due to 30% risk of developing acute pyelonephritis



Other treatment is doubtful

Urinary Tract Infection in Children

Two special problems:

1- Symptoms of urinary infection in small children may be non-specific
2- Collection of urine, particularly in small girls, may be difficult

By coincidence UTI anomalies of urinary tract - 3 groups of children with UTI:

1- Anomalies, which can be lead to rapid deterioration in renal function - reflux,

obstruction

2- Relatively harmless anomalies - duplication of upper tract, bladder anomalies
3- Normal urinary tract