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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 INFECTION 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 nonpregnant women between ages 21 and 65 URINARY TRACT INFECTION TYPES LOWER TRACT INFECTION UPPER TRACT INFECTION URETHRITIS PYELONEPHRITIS PROSTATITIS CYSTITIS 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 small abscess renal pelvis kidney (cortex) renal tubular 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 Isolated infections infection 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 urinate Sensation as if the bladder is full Urethritis Urge incontinency Contains thick stringy mucus to 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.
