Non-specific urinary tract infections - Surgery

Question 1

Causes of sterile pyuria? (A++)

Answer 1

A. Infectious causes:
1. UTI with antibiotic therapy
2. T.B.
3. Mycoplasma or Chlamydia infection
B. Noninfectious causes:
1. Urolithiasis
2. Tumors

Question 2

Definition of Acute cystitis (B)

Answer 2

Acute cystitis is an acute inflammation of the urinary bladder; it is more common in female due to short urethra and ascending infection is easy to occur.
Honeymoon cystitis: it means cystitis occurs after sexual activity in the early marriage or when a woman has sex after a long period of time without sexual activity.

Question 3

What are the symptoms of Acute cystitis? (B)

Answer 3

• Irritative voiding symptoms: (Remember: FUN)
  1. Frequency
  2. Urgency
  3. Nocturia
• Dysuria and supra-pubic pain
• Hematuria.

Simple cystitis does not require a urine culture.
Urine culture/ sensitivity test should be done in the following situations:
- Suspected acute pyelonephritis;
- Symptoms that do not resolve or recur within four weeks
- Pregnant women.

Question 4

treatment of Acute cystitis (B)

Answer 4

Most of cases resolve spontaneously or with short course of antibiotic.
a. Plenty of water intake
b. Antibiotics: Nitrofurantoin 100mg bid or Fluoroquinolones.
You have to exclude presence of pregnancy or lactation before prescribe Fluoroquinolones for females in childbearing period.
c. Antispasmodics (antimuscarinics) and analgesics to relieve symptoms

Question 5

Definition of ACUTE PYELONEPHRITIS (C)

Answer 5

Acute pyelonephritis is an acute inflammatory condition of the kidney and renal pelvis caused by bacterial infection invading the renal pelvis and kidney parenchyma.
Routes of infection: Most probably ascending infection from the lower urinary tract with gram negative organisms. Hematogenous route of infection is less common and caused by staphylococcus infections.

Question 6

Clinical picture of Acute pyelonephritis ? (A++)

Answer 6

• High grade fever,
• Chills and rigors
• Flank pain and dysuria

(Absent in children, so if they present with high grade fever exclude UTI)

Question 7

Investigations of pyelonephritis (A++)

Answer 7

• Urine analysis and urine culture /sensitivity test should be done for every suspected case of pyelonephritis.
• CBC will reveal leukocytosis
• Abdominal ultrasonography.
• CT scan of the abdomen is indicated if there is no improvement within 72 hours.

Question 8

Complications of Acute pyelonephritis (B)

Answer 8

• Renal and perirenal abscesses
• Papillary necrosis
• Chronic pyelonephritis

Question 9

Treatment of Acute pyelonephritis (A++)

Answer 9

• Hospitalization and bed rest.
• Intravenous fluids.
• Analgesic antipyretic
• Start with parenteral, broad spectrum, empirical antibiotics like third generation cephalosporin then shift to suitable antibiotic according to culture/ sensitivity results.

Question 10

Clinical picture of Acute bacterial prostatitis (A++)

Answer 10

• Fever and chills in severe cases.
• Dysuria, frequency, urgency, or acute urine retention
• Low back pain, perineal pain
• History of recurrent UTI.
  DRE: The prostate is extremely tender and DRE should be avoided.

Question 11

Investigations used in acute bacterial prostatitis (A++)

Answer 11

Laboratory:
- Urine analysis and urine culture/sensitivity test.
- CBC: Leukocytosis
- Do not perform prostatic massage in acute bacterial prostatitis (ABP).

Imaging:
-Imaging studies are usually unnecessary during the initial evaluation, but may help when the diagnosis remains unclear or when patients do not respond to adequate antibiotic therapy.
-US: A diffusely enlarged, edematous gland and increased blood flow with predilection for peripheral zone involvement.
-CT: Demonstrates a diffusely enlarged, edematous gland with predilection for peripheral zone involvement.

Question 12

Treatment of acute bacterial prostatitis (b)

Answer 12

1. Hospitalization in severe cases or urine retention.
2. Parenteral empirical antibiotic therapy e.g. Fluoroquinolones then shift to appropriate antibiotic according to culture/sensitivity results.
3. Analgesics, antipyretics.

Question 13

Clinical picture of chronic bacterial prostatitis (A++)

Answer 13

1. Symptoms related to urination: Dysuria, urgency and Increased frequency of urination
2. Symptoms related sex: premature or painful ejaculation.
3. Pain: Deep pelvic pain, perineal pain, and/ or low back pain.

Question 14

Investigations used in chronic bacterial prostatitis (A++)

Answer 14

• Urine analysis and culture/sensitivity test (WBCs >10 /HPF).
• Expressed prostatic secretion (EPS): collected after prostatic massage for microscopic exam and culture/sensitivity test (+ve).

Question 15

Treatment of chronic bacterial prostatitis (b)

Answer 15

1- Fluoroquinolones for 4-6 weeks are the mainstay in the treatment.
2- Macrolide (e.g. Azithromycin) or a tetracycline (e.g. Doxycycline) if intracellular bacteria have been identified as the causative agent of CBP.
3- Metronidazole in patients with Trichomonas vaginalis CBP.

Question 16

Treatment of chronic non-bacterial prostatitis (b)

Answer 16

• Alpha blockers
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Certain plant extracts.
• Antibiotic: Tetracycline (anti-inflammatory properties)

Question 17

Etiology of epididymo-orchitis (b)

Answer 17

• Bacterial causes as a complication of UTI or sexual transmitted infection e.g. E-coli, N. gonorrhea or Chlamydia trachomatis. Infection spreads from prostate, bladder or urethra through the vas to epididymis. Also, hematogenous route of infection is considerable.
• Viral causes e.g. mumps.

Question 18

Clinical picture of Epididymo-orchitis (c)

Answer 18

Gradual onset of scrotal pain and swelling, fever, malaise, and parotiditis may precede the onset of mumps orchitis by about one week.
Should be differentiated from testicular torsion which is a true surgical emergency and immediate referral is warranted.

Question 19

Treatment of Epididymo-orchitis (c)

Answer 19

• Rest and scrotal support and elevation
• Anti-inflammatory, analgesic, antipyretics and chymotrypsin.
• Antibiotics for bacterial epididymo-orchitis. Antibiotic course treatment should continue for two weeks.

Question 20

Fournier’s gangrene ( Risk factors, Causes, Clinically, Treatment) (A++)

Answer 20

Fournier’s gangrene is a life threatening, necrotizing infection of the soft tissue of the perineum.

Risk factors: Include diabetes mellitus, obesity, immunosuppression (e.g. HIV infection), malignancy, alcoholism, smoking, adrenal failure.

Causes: The infection is typically polymicrobial, with mixed aerobic and anaerobic bacteria (E. coli, Klebsiella, enterococci, Bacteroides, Fusobacterium, and Clostridium) and rarely fungi.

Clinically: Patients may simply have localized tenderness without other outward findings; later in the disease there may be changes in the skin and soft tissue overlying the infection (e.g. edema, bullae, blisters, crepitus, and local anesthesia).
Severely ill patients may have abnormal vital signs such as tachycardia, tachypnea, hypotension, and hyper- or hypothermia, in some cases presenting in florid septic shock.

Treatment:
1. Broad-spectrum intravenous antibiotics.
2. Aggressive surgical debridement.

Question 21

Causes of Acute Scrotal Pain and Swelling (B)

Answer 21

Ischemia
-Torsion of the testis
-Testis or epididymis appendiceal torsion.

Trauma
-Intratesticular hematoma,
-testicular contusion, or
-Hematocele.

Infectious
- Acute epididymo-orchitis.
- Abscess; intratesticular, intravaginal, scrotal skin, or cutaneous cysts).
- Gangrenous infections (Fournier’s gangrene).

Inflammatory
-Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall or Fat necrosis.

Hernia
-Strangulated inguinal hernia, with or without associated testicular ischemia

Acute on top of chronic events
- Hydrocele: rupture, hemorrhage, or infection.
- Testicular tumor: rupture, hemorrhage, infarction or infection.

Question 22

Urosepsis short note (C/P abd ttt) (A++)

Answer 22

Sometimes, organisms causing UTI invade the blood stream. The response of immune system to infection may be exaggerated and leads to multiple organs damage and this condition named urosepsis.
Sepsis is a life-threatening organ dysfunction with high mortality rates up to 40% of cases. Pyelonephritis is the most frequent cause of urosepsis.

Clinical picture:
Urosepsis leads to organs dysfunction which can be identified by:
1. Hypotension: systolic blood pressure ≤100 mm Hg.
2. Altered mental state
3. Tachypnea: respiratory rate ≥ 22/min

Urosepsis is considered an emergency condition and time factor to start treatment is crucial. It needs a urologist and an intensive care specialist to care the patient.
If you clinically suspect urosepsis case in emergency department, what should
you do?
1. Oxygen mask and intravenous fluid.
2. Urine and blood sampling for culture/sensitivity.
3. Start empirical antibiotics, broad spectrum, parenteral, and in high dose, as soon as possible.
4. Request urologist and intensive care specialist for help.

Septic shock is a subset of sepsis, when a patient with sepsis requires
vasopressors to maintain systolic blood pressure ≥ 60 mm Hg.