Surgery (Urinary tract infection)

Question 1

Causes of sterile pyuria?

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

What are the symptoms of Acute cystitis?

Answer 2

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

Question 3

When do we take do a urine culture in Acute cystitis?

Answer 3

• Suspected acute pyelonephritis;
• Symptoms that do not resolve or recur within four weeks
• Pregnant women.

Question 4

treatment of Acute cystitis

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

Clinical picture of Acute pyelonephritis ?

Answer 5

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

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

Question 6

Investigations

Answer 6

• 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 7

Complications of Acute pyelonephritis

Answer 7

• Renal and perirenal abscesses
• Papillary necrosis
• Chronic pyelonephritis

Question 8

Treatment of Acute pyelonephritis

Answer 8

• 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 9

Bilharzia Pathology (Genitourinary schistosomiasis)

Answer 9

Bilharzial eggs are deposited in smallest venules that can accommodate the female worm; the body responds and produces granulomas around the eggs. The granulomas are gradually replaced by collagen and resulting in fibrosis.

Question 10

Clinical manifestations of bilharzia

Answer 10

1- Initial stage: Swimmer’s itch, due to cercarial skin penetration.
2- Acute stage: Terminal hematuria and dysuria.
3- Stage of complications: signs and symptoms of complications.

Question 11

Urogenital complications of bilharziasis

Answer 11

o Urinary Bladder
- Atrophic lesions: ulcerations and contracted bladder
- Hypertrophic lesions: hyperplasia, metaplasia, dysplasia polyposis, and carcinoma.
o Ureters: Ureteral stricture leads to hydroureter and hydronephrosis.
o Genital organs: Hemospermia (blood in the ejaculate) due to involvement of seminal vesicles and the ejaculatory ducts.

Question 12

Investigations of Bilharziasis

Answer 12

Laboratory studies:
- Urine analysis: bilharzial eggs with characteristic terminal spine
- Serological tests: Antibody test is useful but cannot differentiate between active and past infection. Antigen test reflects the presence of active infection.
Imaging studies:
- Abdominal US: focal thickening of the bladder wall, polypoid lesions, hydroureter, and hydronephrosis.
- KUB: may show calcified bladder.
- CT or IVP: for evaluation of hydronephrosis.

Question 13

Treatment of Bilharziasis

Answer 13

• Early treatment, especially in childhood, is the most effective intervention to prevent the development of complications.
• Praziquantel is the drug of choice.
• Dose: 60 mg/kg in divided three doses 6 hours apart.
• As maturing worms are less susceptible to praziquantel than adult worms, a second course of treatment is necessary after several weeks.

Question 14

Clinical picture of Filariasis?

Answer 14

• Asymptomatic: in endemic areas.
• Lymphangitis-lymphadenitis, funiculo-epididymitis (inflammation of the
  spermatic cord and epididymis)
• Hydrocele
• Scrotal and Penile Elephantiasis
• Chyluria means leakage of lymph fluid into the urinary collecting system
  due to rupture of a lymphatic varix. The patient presents with milky urine
  after fatty meal. Protein & lipid loss, leading to hypoalbuminemia.

Question 15

Treatment of Filariasis ?

Answer 15

• Medical treatment: Diethylcarbamazine (DEC), and albendazole together for annual mass treatment in endemic area.
• Endoscopic sclerotherapy for cases of chyluria: Instillation of povidone iodine or glucose 25% into the renal pelvis.

Question 16

Clinical picture of Genitourinary TB?

Answer 16

• Microscopic hematuria in 50% of cases.
• LUTS in case of bladder involvement
• In epidydimal affection, a painful scrotal swelling, discharging sinus posteriorly and beaded vas.

Question 17

Lab studies and Imaging studies of Genitourinary TB?

Answer 17

Laboratory studies:
- Urine analysis: Sterile pyuria is the classic urinary finding.
- PCR test is essential for diagnosis.

Imaging studies:
- Ultrasonography: Hydronephrosis and/or renal cavities
- KUB: Calcification in the renal parenchyma and GU tract.
- Chest and spine X-ray: may show pulmonary or spinal disease.
- CT or IVU: Hydronephrosis, pipe-stem like ureter, and/or contracted bladder

Question 18

Treatment of Genitourinary TB?

Answer 18

Medication:
Anti-tuberculosis multi-drug treatment is the cornerstone of therapy. Rifampicin, INH, and Pyrazinamide are the drugs of choice for the first two months, followed by rifampicin and INH for four more months.

Surgery:
1- Nephrectomy: In case of a non-functioning kidney
2-Epididymectomy: If medical treatment fails to cure the discharging sinus.