UTI

Question 1

Introduction

A Urinary Tract Infection (UTI) is an infection that can occur in any part of the urinary system, including the kidneys, ureters, bladder, or urethra. UTIs are particularly common medical issues, especially among women. Women aged between 20 to 50 years are approximately 50 times more likely to experience a UTI compared to men

Question 2

. In women, most UTIs manifest as ___ or ____. In men, UTIs commonly present as ____or____

Answer 2

cystitis (infection of the bladder) or pyelonephritis (infection of the kidneys).

urethritis (infection of the urethra) or prostatitis (infection of the prostate).

Question 3

What are the classification of UTI

Answer 3

Classification

1. Lower UTI:

• Urethritis: Infection of the urethra.
• Cystitis: Infection of the bladder.
• Prostatitis: Infection of the prostate gland (in men).

2. Upper UTI:

• Pyelonephritis: Infection of the kidneys.

3. Complicated UTI: Occurs in individuals with structural or functional abnormalities in the urinary tract, or in individuals with other health conditions (such as diabetes or an immunocompromised state) that make infections more severe or difficult to treat.
4. Uncomplicated UTI: Occurs in otherwise healthy individuals with a normal urinary tract, usually in women.
5. Asymptomatic bacteriuria: The presence of bacteria in the urine without clinical symptoms or signs of infection.

Question 4

What are the risk factors of developing UTI?

Answer 4

Risk Factors

UTIs can develop due to various risk factors, which can be categorized as:

1. Anatomic/Physiological Factors:

• Vesicoureteral reflux (backward flow of urine from the bladder into the kidneys).
• Pregnancy.
• Female sex: Shorter urethra in women makes it easier for bacteria to enter the urinary tract.

2. Genetics:

• Familial tendency: Some people are more genetically predisposed to UTIs.
• Susceptible uroepithelial cells.
• Vaginal mucus properties.

3. Behavioral Factors:

• Voiding dysfunction (difficulty in emptying the bladder).
• Frequent or recent sexual intercourse.

4. Iatrogenic Factors:

• Indwelling catheters (long-term catheter use).
• Antibiotic misuse.
• Use of spermicides.

Question 5

What are the causes of UTI?

Answer 5

Causes

The organisms responsible for UTIs are usually bacteria, most commonly originating from the intestines. UTIs are generally classified by their causative pathogens:

1. Enteric Gram-Negative Aerobic Bacteria:

• Escherichia coli: Accounts for 75-95% of UTI cases.
• Klebsiella.
• Proteus mirabilis.
• Pseudomonas aeruginosa.

2. Gram-Positive Bacteria:

• Staphylococcus saprophyticus: Responsible for 5-10% of bacterial UTIs.
• Enterococcus faecalis.
• Streptococcus agalactiae.

In hospitalized patients, the organisms commonly causing UTIs include:

• E. coli (50% of cases).
• Klebsiella, Proteus, Enterobacter, Serratia, and Pseudomonas (40% of cases).
• S. saprophyticus, E. faecalis, and Staphylococcus aureus (10% of cases).

Question 6

Pathogenesis of UTI is?

UTIs typically develop by two main routes: which are?

Answer 6

1. Ascending Infection:

• Type 1 fimbriae: Binds to mannose residues on the surface of uroepithelial cells, allowing bacteria like E. coli to adhere and invade.
• Type 2 or P fimbriae: Binds to glycolipids on the apical surface of renal epithelial cells, contributing to kidney infections (pyelonephritis).

2. Hematogenous Spread:

• Rare in healthy individuals, but certain pathogens like Staphylococcus aureus, Salmonella, Candida, and Mycobacterium tuberculosis can infect the kidneys through the bloodstream, especially if there is urinary obstruction

Question 7

Asymptomatic Bacteriuria
Asymptomatic bacteriuria is the presence of bacteria in the urine without any clinical symptoms or signs of infection. Common risk factors include:

Answer 7

• Indwelling catheters.
• Neurogenic bladder (bladder dysfunction due to neurological conditions).
• Cognitive impairment.

E. coli is the most common organism, though Klebsiella, Enterococcus, and coagulase-negative staphylococci may also be involved. Mixed infections are common in patients with catheters and may involve organisms like Morganella morganii, Providencia spp., and Proteus spp..

Question 8

How’s diagnosis made?

Answer 8

Diagnosis is made by detecting the presence of the same organism in two consecutive urine samples with counts > 10⁵ CFU/mL.

Question 9

Treatment

Answer 9

Treatment is not typically required, except in:

1. Pregnant women (due to the risk of fetal complications).
2. Patients undergoing indwelling instrumentation (e.g., during surgery).

Question 10

Acute Uncomplicated Cystitis

Epidemiology

Acute uncomplicated cystitis is more common in women, with an incidence of 0.5-0.7 episodes per woman per year. About 10% of women experience at least one episode of cystitis per year, and 50% of all women will have at least one episode of cystitis during their lifetime

Question 11

The most common causative organisms of acute uncomplicated cystitis are:

Answer 11

.

Etiology

• Escherichia coli (E. coli): Responsible for 75% to 95% of cases.
• Staphylococcus saprophyticus: Accounts for 5-10% of cases.
• Other bacteria include Proteus spp. and Klebsiella spp.

Question 12

Clinical features of us cute uncomplicated cystitis

Answer 12

Clinical Features

Symptoms of acute uncomplicated cystitis include:

• Dysuria: Pain or burning sensation during urination.
• Frequency: Increased frequency of urination.
• Suprapubic pain: Pain or discomfort in the lower abdomen.
• Urgency: A sudden, strong urge to urinate.
• Hematuria: Presence of blood in the urine.
• Foul-smelling urine.
• Nocturia: Need to urinate frequently at night

Question 13

How’s it’s diagnosis made?

Answer 13

Diagnosis

Diagnosis is based on urinalysis and urine microscopy, culture, and sensitivity (m/c/s):

• Urinalysis:
• Positive for nitrites: Indicates the presence of bacteria that reduce nitrate to nitrite, most commonly E. coli.
• Positive for leukocyte esterase: Indicates the presence of white blood cells (pyuria), a sign of infection or inflammation.

Question 14

Treatment if cystitis

Answer 14

Treatment

The choice of antibiotic is guided by the sensitivity pattern of the causative organism. Common antibiotics include:

• Trimethoprim: 200 mg every 12 hours.
• Nitrofurantoin: 100 mg twice daily.
• Co-amoxiclav: Particularly useful in women.
• Trimethoprim-Sulfamethoxazole (TMP-SMX).
• Fluoroquinolones: Reserved for cases where first-line antibiotics fail or in resistant infections.

Question 15

Prostatitis and Urethritis

Types of Prostatitis:

Answer 15

1. Type 1: Acute Prostatitis

• Acute bacterial infection of the prostate.

2. Type 2: Chronic Prostatitis

• Chronic bacterial infection lasting for more than 3 months.

3. Type 3: Chronic Abacterial Prostatitis or Chronic Pelvic Pain Syndrome (CPPS)

• Type 3A: Inflammatory CPPS (with white blood cells in prostate secretions but no bacteria).
• Type 3B: Non-inflammatory CPPS (no white blood cells or bacteria in prostate secretions).

4. Type 4: Asymptomatic Inflammatory Prostatitis

• No symptoms, but inflammation is detected during prostate biopsies or other evaluations.

Question 16

What’s the most common cause of Prostatitis

Answer 16

• Escherichia coli (E. coli): The most common cause, responsible for 80% of prostatitis cases.
• Other gram-negative organisms (Pseudomonas aeruginosa, Serratia spp., Klebsiella spp., Enterobacter spp.) account for 10-15% of cases.
• Gram-positive bacteria, including Enterococci, cause 5-10% of cases.
• Others: Corynebacterium spp., Chlamydia trachomatis, and Ureaplasma urealyticum.

Question 17

Clinical Features of Prostatitis

Answer 17

• Acute onset pain: Severe, localized pain in the perineum, scrotum, or rectum.
• Discomfort: Can also be felt in the penis, bladder, or lower back.
• Lower urinary tract symptoms (LUTS):
• Urinary frequency.
• Urinary urgency.
• Dysuria (painful urination).
• Voiding symptoms like hesitancy, poor urinary stream, and less commonly urinary retention.
• Systemic symptoms:
• Fever, chills, malaise, nausea, and signs of generalized sepsis.

Question 18

Approximately 5% of acute prostatitis cases progress to chronic bacterial prostatitis, which is characterized by recurrent, culture-positive UTIs and distinguishes it from chronic abacterial prostatitis.

Question 19

• Digital Rectal Examination (DRE):
• Findings include prostatic tenderness, abscesses, or a normal examination.

Question 20

Diagnosis and Management

• Diagnosis is primarily clinical, supported by laboratory tests (urine culture) to identify the causative organism.
• Treatment typically includes antibiotics tailored to the pathogen, along with supportive measures such as pain management.

Question 21

What are the Investigations you will like to do for Prostatitis

Answer 21

Prostatitis

1. Midstream urine (MSU) microscopy, culture, and sensitivity (m/c/s):

• The test typically shows a significant number of white blood cells and bacteria, which indicates infection. Specific uropathogens (e.g., E. coli, Klebsiella) or other bacteria can be identified through culture.

2. Prostatic massage:

• Painful procedure that may exacerbate symptoms. Used for chronic prostatitis to evaluate the presence of infection, but it’s typically avoided in acute prostatitis due to the risk of worsening the clinical scenario.

3. Blood culture:

• Performed in cases where there are features of systemic illness (e.g., fever, chills) to rule out bacteremia or sepsis.

4. Prostatic biopsy:

• Rarely done for routine prostatitis. It can be difficult to culture microorganisms from biopsy material.

5. Prostate ultrasound (USS):

• Used to detect complications like prostatic abscess, prostatic calcification, or seminal vesicle dilation. It is not widely used in acute or chronic prostatitis but can be useful for identifying severe complications.

6. Prostate-specific antigen (PSA):

• PSA levels rise in acute bacterial prostatitis and many UTIs but remain normal in abacterial prostatitis. PSA levels should be interpreted carefully because of the overlap with other conditions.

7. Urine microscopy after prostatic massage (for chronic bacterial prostatitis):

• The key investigation for chronic bacterial prostatitis is quantitative bacteriological localization cultures, where urine samples taken before and after a prostatic massage are analyzed.

Question 22

What are the Investigations you will like to do for urethritis

Answer 22

1. Urethral swab m/c/s:

• A swab from the urethra is sent for microscopy, culture, and sensitivity. This helps to identify the specific pathogen responsible for the infection (e.g., N. gonorrhoeae, C. trachomatis).

2. High vaginal swab m/c/s (in females):

• Used to identify infections in women, particularly in cases of urethritis caused by sexually transmitted infections (STIs).

3. MSU m/c/s:

• Similar to prostatitis, this test is used to identify significant bacteriuria or the presence of white blood cells, indicating infection.

Question 23

Treatments for Prostatitis

Answer 23

Prostatitis

1. Antibiotics for Acute Bacterial Prostatitis:

• Fluoroquinolones (e.g., ciprofloxacin): Given for 10 days. They have good bioavailability, penetrate the prostate well, and are effective against gram-negative organisms (e.g., E. coli, Pseudomonas) as well as some gram-positive and atypical organisms (e.g., Chlamydia, Mycoplasma).
• Intravenous antibiotics: Broad-spectrum penicillins, third-generation cephalosporins, or fluoroquinolones can be used, often in combination with aminoglycosides for severe infections.

2. Antibiotics for Chronic Bacterial Prostatitis:

• Treatment lasts 4-6 weeks. Options include:
• Fluoroquinolones: As described above, they are highly effective.
• TMP-SMX (Trimethoprim-Sulfamethoxazole): Inexpensive but has no activity against Pseudomonas, some enterococci, and some Enterobacteriaceae.
• Tetracyclines: Effective for Chlamydia and Mycoplasma, but less effective against E. coli, enterococci, staphylococci, and Pseudomonas.

3. Surgical Treatment:

• Acute urinary retention: Treated with temporary catheter drainage.
• Prostatic abscess drainage: May require surgical drainage through a transperineal or transrectal route.

Question 24

Treatments for Urethritis

Answer 24

Urethritis

1. Treatment for Gonorrheal Urethritis:

• Ceftriaxone 500 mg IM (intramuscular) plus Azithromycin 1g stat: This combination is used to cover both Neisseria gonorrhoeae and co-infections like Chlamydia.
• Cefixime 400 mg: An alternative to ceftriaxone.
• Quinolones: These are used as a single dose but are becoming less effective due to high resistance rates (over 25%).

2. Treatment for Non-Gonococcal Urethritis:

• Azithromycin 1g (single dose) or Doxycycline 100 mg twice daily for 7 days.
• Alternatives include Ofloxacin, Levofloxacin, or Erythromycin for 7 days, particularly if there is resistance or intolerance to first-line drugs

Question 25

Pathogenesis of Urethritis

Answer 25

• Gonorrheal urethritis caused by Neisseria gonorrhoeae and non-gonococcal urethritis caused by Chlamydia trachomatis are both sexually transmitted infections (STIs). These organisms penetrate the urethral epithelium and cause a pyogenic (pus-forming) infection.
• In men, infection can spread to involve the epididymis.
• In women, infections can lead to cervicitis, endometritis, and salpingitis.
• Mycoplasma genitalium can also cause cervicitis and pelvic inflammatory disease (PID) in women

Question 26

Clinical Features of Urethritis

Answer 26

• Mucopurulent or purulent discharge: Urethral discharge that may be clear, yellow, or green.
• Dysuria: Painful urination.
• Orchalgia: Testicular pain.
• Urethral or glans pruritus: Itching in the urethra or around the glans penis.
• Women often have minimal symptoms, making diagnosis harder.

Question 27

Examination for Urethritis in males & female

Answer 27

• Males:
• Inspect the distal urethra for redness.
• Examine the penis and testicles for tenderness or swelling.
• Perform a digital rectal examination (DRE) to assess prostatic tenderness, especially if prostatitis is suspected.
• Females:
• Perform a vaginal examination (VE) to check for discharge and signs of cervical inflammation or tenderness (CET).

Question 28

Pyelonephritis

Incidence

• In women, the incidence of pyelonephritis is approximately 3 per 1000 person-years.

Question 29

What are the risk factors for Pyelonephritis

Answer 29

Risk Factors

The risk factors for pyelonephritis are varied and include:

• Female sex: Women are more prone due to anatomical factors (shorter urethra).
• Recent sexual intercourse: Increased risk of bacterial transfer to the urinary tract.
• Use of diaphragm or spermicides: Can alter vaginal flora, increasing susceptibility.
• Estrogen deficiency: Common in postmenopausal women, leading to changes in the urinary tract that make infections more likely.
• Increasing age: As age increases, immune function decreases, and there may be structural changes in the urinary tract.
• Pregnancy: Hormonal and physical changes in pregnancy can predispose to infection.
• Renal transplantation: Immune suppression and structural changes post-transplant elevate risk.
• Obesity: Obesity is linked with chronic diseases like diabetes, which increase UTI risk.
• Stones (nephrolithiasis): Stones can obstruct the flow of urine, providing a site for bacterial growth.
• Congenital urological abnormalities: These can cause urine to backflow or remain stagnant.
• Neuropathy involving the bladder: Conditions like diabetic neuropathy can impair bladder emptying.
• Recent catheterization or urological intervention: These provide direct access for bacteria to enter the urinary tract.
• Impaired voiding: Incomplete emptying of the bladder increases bacterial growth.
• Diabetes: Hyperglycemia impairs immune response, and glycosuria promotes bacterial growth.

Question 30

Pathogenesis of pylonephritis

Answer 30

• Ascending Infection: The majority of pyelonephritis cases arise from an ascending infection. Bacteria from the bladder ascend through the ureters to infect the kidneys. This is the same mechanism as in other UTIs.
• Medulla is most affected: The renal medulla is more susceptible to infection compared to the cortex due to its relatively poor blood supply and reduced immune response.
• Emphysematous Pyelonephritis: In this rare and severe form, gas-forming bacteria (e.g., Clostridium septicum, Bacteroides fragilis) are involved, particularly in patients with diabetes.
• Fungal and Viral Infections: Infections caused by fungi (e.g., Candida, Aspergillus) and viruses (e.g., BK virus, CMV, HSV, adenovirus) are rare and generally occur in immunocompromised individuals.
• Hematogenous Spread: This can occur in the setting of systemic bacteremia (e.g., from Staphylococcus aureus) or fungal infections. In such cases, the bacteria or fungi spread through the bloodstream to the kidneys.
• Renal infection following gram-negative bacteremia is uncommon unless there’s kidney damage or obstruction.
• If gram-positive or fungal infections are found in the kidney, further investigation should be done to identify the source, such as endocarditis.
• Kidney Enlargement: In acute pyelonephritis, the kidney may be enlarged, either focally or diffusely.
• Papillary Necrosis: This may occur in individuals with predisposing conditions such as diabetes, sickle cell disease, or analgesic nephropathy.
• Abscess Formation: Severe bacterial infections can lead to localized collections of pus, resulting in acute lobar nephronia, intrarenal abscess, or perinephric abscess.

Question 31

Microscopy of Acute Pyelonephritis

Under the microscope, the hallmarks of acute pyelonephritis are:

Answer 31

• Wedge-shaped areas of intense inflammation: These areas are patchy and sharply demarcated.
• Polymorphonuclear leukocytes (polymorphs): These white blood cells infiltrate the tubules, but there is relative sparing of the glomeruli.
• Suppurative necrosis: In severe cases, the infection leads to the death of tissue and the formation of abscesses

Question 32

Chronic Pyelonephritis

• Chronic pyelonephritis shares similar etiological factors as acute pyelonephritis, but it tends to occur due to failure of adequate resolution of the infection.
• Predisposing factors for chronic pyelonephritis include:

Answer 32

• Abnormal urinary tract: This is particularly common in children with vesicoureteral reflux (VUR), where urine flows backward from the bladder to the kidneys.
• Recurrent infections: Repeated infections can lead to chronic kidney damage.
• Impaired immunity: Immunocompromised individuals have a higher risk of developing chronic pyelonephritis.
• Inadequately treated infections: Incomplete or improper treatment of an infection can result in chronic inflammation and damage to the kidney.

Question 33

Bacterial Virulence in Pyelonephritis

Escherichia coli (E. coli) is the most common cause of pyelonephritis. It has several virulence factors that enable it to attach to and invade the urinary tract:

• Mannose-resistant P fimbriae: Found in over 90% of E. coli isolates from pyelonephritis cases, these fimbriae allow the bacteria to adhere tightly to the cells lining the urinary tract.
• papGAP (class II) genotype: A genetic variant of P fimbriae that is particularly common in E. coli strains that cause upper urinary tract infections.
• Type 1 fimbriae: These are less common in pyelonephritis compared to lower UTIs.
• Dr adhesins: These bind to decay-accelerating factor on host cells, contributing to bacterial adherence and virulence

Question 34

Clinical Features of Pyelonephritis

Answer 34

• Fever, chills, costovertebral angle pain/tenderness: These are classic signs of kidney infection.
• Dysuria and frequency: These lower urinary tract symptoms are common but not specific to pyelonephritis.
• Systemic symptoms with septic shock: In severe cases, systemic infection can lead to septic shock.
• Blood culture: Positive in 10-25% of cases, indicating systemic infection.
• MSU microscopy/culture/sensitivity (M/C/S): Positive in 95% of cases unless the patient has recently taken antibiotics, which can mask the infection.

Question 35

Investigations for pylonephritis

Answer 35

Mcu msc
Blood culture
Imaging for Pyelonephritis

• KUB (Kidney, Ureter, Bladder) X-ray: Useful for detecting calcifications and identifying emphysematous pyelonephritis (presence of gas in or around the kidney).
• Ultrasound (USS): Can show kidney enlargement, abscesses, nephronia (localized kidney infection), pyonephrosis (pus in the renal pelvis), and emphysematous changes.
• CT KUB (Computed Tomography): The most sensitive imaging method for detecting focal infections, perinephric stranding, and excluding emphysematous pyelonephritis

Question 36

Pylonephritis occur in pregnancy in what trimester

Answer 36

Last

Question 37

Laterality: Pyelonephritis is more common on the right side (50%), with 25% on the left, and 25% bilateral.

Question 38

Pyelonephritis in Pregnancy

• Incidence: 1-2% of pregnant women develop pyelonephritis.
• Causative organisms:
• E. coli: Responsible for 70-85% of cases.
• Gram-positive organisms: These are more common towards the end of pregnancy.
• Timing: 80-90% of cases occur in the last trimester.
• Laterality: Pyelonephritis is more common on the right side (50%), with 25% on the left, and 25% bilateral.
• Hormonal influence: Progesterone causes dilatation of the urinary tract, which impairs drainage and predisposes to infection

Question 39

What’s Pyonephrosis/Emphysematous Pyelonephritis

And it’s causes

Answer 39

• Definition: Infection occurring in an obstructed kidney, typically leading to the presence of gas in the kidney or surrounding tissue.
• Causes of obstruction: These can include sloughed renal papilla, pelvi-ureteric junction (PUJ) obstruction, or malignancy.
• Common in diabetes: 90-95% of cases occur in diabetics due to impaired immune responses and increased susceptibility to infection.
• Rapid course: This condition can progress quickly to septicemia and has a high mortality rate.
• Presence of gas-forming microorganisms: These are often seen in emphysematous pyelonephritis and can lead to a bilateral infection in 5-8% of cases

Question 40

What’s Xanthogranulomatous Pyelonephritis (XGP)

Answer 40

XGP is a rare, chronic form of pyelonephritis characterized by the destruction of renal tissue and infiltration by inflammatory cells:

• Incidence: It represents 0.6% of chronic pyelonephritis cases but is responsible for 19% of nephrectomies.
• Focal vs. Diffuse: XGP is diffuse in 84.6% of cases and focal in 15.4%.
• Etiology: The exact cause is not well understood, but obstruction (e.g., from stones or tumors) and chronic infection are universally present.
• Common pathogens: E. coli and Proteus are implicated in 59-95% of cases

Question 41

What are the Microscopic Findings in XGP

The kidney is infiltrated by:

Answer 41

• Lipid-laden macrophages (histiocytes).
• Multinucleated giant cells.
• Plasma cells, neutrophils, and lymphocytes.

Question 42

Risk Factors for XGP

Answer 42

XGP is more common in:

• Women.
• Those with diabetes, obesity, chronic interstitial nephritis, rheumatoid arthritis, hepatitis C, and cirrhosis.

Question 43

What are the Clinical Features of Xanthogranulomatous Pyelonephritis

Answer 43

• Fever, malaise, weight loss.
• Lower urinary tract symptoms and loin pain.
• Renal mass: May be palpable in some cases.
• Pyuria: Present in 57% of cases.
• Anemia and raised alkaline phosphatase (ALP) are common laboratory findings

Question 44

Differential diagnosis for Xanthogranulomatous Pyelonephritis

Answer 44

Differential Diagnosis

1. Renal Cell Carcinoma (RCC):

RCC can present similarly to xanthogranulomatous pyelonephritis (XGP), especially in terms of mass formation and systemic symptoms. Imaging and biopsy may be necessary to differentiate between the two.

2. Renal Tuberculosis (TB):

Renal TB presents with chronic renal infection symptoms, often with granulomatous inflammation. A history of TB exposure and specific imaging (e.g., calcifications and cavitations) help distinguish it from XGP.

3. Renal Abscess:

Abscess formation may occur in response to untreated upper urinary tract infections, particularly in individuals with stones or diabetes. Imaging and clinical presentation (fever, flank pain) are key in diagnosis.

Question 45

Investigations you will like to do

Answer 45

1. CT KUB (Kidney, Ureter, Bladder):

• Hydronephrosis in 90.9% of cases.
• Stones, often staghorn calculi, in 72.7%.
• Pyonephrosis in 45.5%.
• Non-functioning kidney in 36.4%.

2. MRI:

Used to exclude Renal Cell Carcinoma (RCC).

Question 46

Treatment for Xanthogranulomatous Pyelonephritis (XGP)

Answer 46

• Diffuse XGP: Treatment is primarily supportive and includes nephrectomy. There is no documented successful medical treatment for a kidney severely affected by diffuse XGP.
• Nutritional support, removal of obstruction or calculi, and prolonged antibiotics are critical, along with regular follow-up imaging

Question 47

Infections of renal Cysts and renal Abscesses and pherypheral symptoms
& their management

Answer 47

1. Infected Renal Cysts (e.g., in ADPKD):

• Patients may present with hematuria, flank pain, recurrent UTIs, or pyrexia of unknown origin (PUO).

2. Renal Abscess:

• Arises from hematogenous spread or a complication of an upper UTI, especially in patients with stones or diabetes.
• Symptoms include loin pain, fever, rigors, and tenderness.

3. Perinephric Abscess:

• Caused by an extension of renal infection or a bloodborne infection.
• Typically caused by Staphylococcus aureus.
• Abscess localized within Gerota’s fascia can spread to surrounding structures like the psoas muscle, pelvis, diaphragm, or pleural space

.

• Management includes percutaneous drainage and antibiotics, with surgical intervention if drainage fails and the patient’s condition deteriorates

Question 48

What’s Malakoplakia & it’s treatment

Answer 48

• A granulomatous condition caused by impaired lysosomal clearance of intracellular bacteria by macrophages.
• Associated with reduced intracellular cGMP activity.
• Michaelis-Gutmann bodies are pathognomonic of this condition.
• Predominantly involves the bladder, leading to soft plaques and bladder wall thickening, which may cause ureteric obstruction.
• Quinolones are used for prolonged treatment, and nephrectomy is indicated in diffuse or poorly functioning kidneys

Question 49

What’s the General Treatment of Acute Pyelonephritis
Community treatment
Hospitalized pt
Infectious Cysts in PKD
Emphysematous Pyelonephritis
Perirenal and Intrarenal Abscesses

Answer 49

1. Community Treatment: Most uncomplicated cases can be treated with oral antibiotics, with only 7% requiring hospital admission.

• Ciprofloxacin 1g (either singly or divided) for 7 days.
• Levofloxacin 750mg daily for 5 days.
• When resistance >10%, add IV aminoglycosides or Ceftriaxone 1g.
• TMP-SMX (Trimethoprim-Sulfamethoxazole) 960mg every 12 hours for 14 days

2. Hospitalized Patients:

• IV antibiotics covering likely pathogens, followed by tailored treatment based on culture results.
• Longer courses are necessary for patients with abnormal anatomy, stones, abscesses, or recent relapses.

3. Infectious Cysts in PKD:

• Use antibiotics that effectively penetrate cysts, such as fluoroquinolones.
• Trimethoprim has less cyst penetration, and beta-lactams penetrate poorly.

4. Emphysematous Pyelonephritis:

• Mortality has improved significantly (from 78% in the 1970s to 13.5% in 2008).
• Percutaneous drainage or nephrectomy combined with medical treatment is associated with improved outcomes.

5. Perirenal and Intrarenal Abscesses:

• Treated with broad-spectrum antibiotics.
• Percutaneous or surgical drainage is necessary for abscess management

Question 50

Pyelonephritis in Pregnancy treatment

Answer 50

1. Aggressive treatment is necessary to reduce the risk of pyelonephritis.
2. Fluoroquinolones and sulphonamides are contraindicated during pregnancy.
3. Third-generation cephalosporins are recommended as an alternative first-line treatment

Question 51

Complications of Pyelonephritis

Answer 51

1. Papillary Necrosis.
2. Renal Scarring → Potentially leading to hypertension.
3. Chronic Pyelonephritis.
4. Chronic Kidney Disease (CKD).
5. Progressive Allograft Dysfunction in transplant patients

Question 52

Risks of pylonephritis in Pregnancy

Answer 52

1. Fetal Risks:

• Pyelonephritis can lead to preterm labor or fetal complications.

2. Maternal Risks:

• Risk of sepsis and acute kidney injury (AKI).

Question 53

Describe the pathophysiology of urinary tract infections (UTIs) and explain how the host’s immune response interacts with uropathogens.

Answer 53

.

Pathophysiology of UTIs involves the invasion of the urinary tract by pathogens, most commonly bacteria. The vast majority of UTIs are caused by ascending infections, where bacteria from the perineum ascend the urethra to the bladder (cystitis), and in some cases, further to the kidneys (pyelonephritis). Escherichia coli (E. coli) is the most common pathogen, responsible for over 80% of community-acquired UTIs, primarily due to its virulence factors like fimbriae that allow adherence to the uroepithelium.

Stages of infection:

1. Colonization: Bacteria adhere to the epithelial cells in the urethra via fimbriae and other adhesins.
2. Invasion: The bacteria ascend into the bladder, triggering an immune response.
3. Establishment: In the bladder, bacteria multiply, forming biofilms that further protect them from immune attacks and antibiotic treatment.
4. Potential ascension to kidneys: If untreated, bacteria can travel further up the ureters to the renal pelvis, causing pyelonephritis.

Host immune response: The urinary tract has several defense mechanisms, including the constant flushing of urine, a protective mucosal layer in the bladder, and antimicrobial peptides like defensins. When bacteria evade these defenses, the body’s immune system responds by recruiting white blood cells (polymorphonuclear leukocytes) to the site of infection. Cytokines and chemokines are released, inducing inflammation. However, uropathogens like E. coli can evade host defenses by producing toxins like hemolysin, which damage the host cells, and forming biofilms that protect them from phagocytosis. This battle between the bacteria’s evasion strategies and the host’s immune response determines the progression and severity of the infection

Question 54

Discuss the clinical presentation and diagnosis of UTIs in adults, including complicated versus uncomplicated infections

Answer 54

.

Clinical Presentation:

• Uncomplicated UTIs are typically seen in healthy individuals with no structural or functional abnormalities of the urinary tract. Symptoms include:
• Dysuria (painful urination)
• Frequency and urgency of urination
• Suprapubic pain
• Hematuria (blood in the urine)

Systemic symptoms are usually absent in uncomplicated UTIs.

• Complicated UTIs occur in individuals with underlying health conditions, such as diabetes, urinary tract obstructions (stones), or immunocompromised states. These UTIs often present with systemic symptoms such as:
• Fever
• Chills
• Flank pain (indicating upper UTI/pyelonephritis)
• Septic shock in severe cases.

Diagnosis:

1. Urinalysis: The presence of leukocyte esterase and nitrites is indicative of bacterial infection.
2. Urine culture: Required in cases of complicated UTI or recurrent infections to identify the specific pathogen and guide appropriate antibiotic therapy. Positive cultures with >100,000 CFU/mL are diagnostic.
3. Imaging: In complicated cases, or when an abscess or obstruction is suspected, imaging studies like an ultrasound or CT scan may be necessary to identify anatomical abnormalities or the presence of kidney involvement (e.g., pyelonephritis, abscess formation).
4. Blood cultures: These may be taken in cases of suspected urosepsis or pyelonephritis, especially if systemic signs like fever or hypotension are present

Question 55

Compare and contrast the management of lower urinary tract infections (cystitis) and upper urinary tract infections (pyelonephritis)

Answer 55

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Lower UTIs (Cystitis):

• First-line treatment:
• Nitrofurantoin (100 mg twice daily for 5 days)
• Trimethoprim-sulfamethoxazole (TMP-SMX) (160/800 mg twice daily for 3 days).
• Fosfomycin can also be used as a single dose.
• Analgesia: Phenazopyridine for symptomatic relief of dysuria.
• Hydration: Increased fluid intake to promote flushing of the urinary tract.

Upper UTIs (Pyelonephritis):

• First-line treatment:
• Oral fluoroquinolones like ciprofloxacin (500 mg twice daily for 7–14 days) or levofloxacin are recommended if the pathogen is susceptible.
• IV antibiotics (ceftriaxone or an aminoglycoside) may be required for more severe cases or hospitalized patients.
• Hospitalization: Severe cases, including those with sepsis or inability to tolerate oral medications, may need IV antibiotics and close monitoring.
• Complicated pyelonephritis: Longer courses of antibiotics and imaging studies (e.g., CT scan) are often necessary to assess for abscesses, hydronephrosis, or anatomical abnormalities like stones.

In contrast to cystitis, pyelonephritis typically requires more aggressive and prolonged treatment due to the risk of complications such as renal scarring or abscess formation. In both cases, treatment should be tailored based on culture and sensitivity results

Question 56

xplain the role of antibiotic resistance in the treatment of UTIs and how it influences current clinical guidelines for prescribing antibiotics

Answer 56

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Antibiotic resistance, especially with E. coli, the most common pathogen in UTIs, has become a significant concern in managing these infections. The overuse and misuse of antibiotics have led to the emergence of multi-drug resistant organisms.

Key points on resistance:

• Resistance to fluoroquinolones: Increasing globally, particularly in regions with high usage of these antibiotics. This has led to a shift in treatment recommendations, with nitrofurantoin and fosfomycin preferred for uncomplicated UTIs.
• Extended-spectrum beta-lactamase (ESBL)-producing organisms: These are resistant to many beta-lactam antibiotics, including penicillins and cephalosporins. Carbapenems are often required for treatment.
• Trimethoprim-sulfamethoxazole resistance: Common in many regions, necessitating the use of alternative agents like nitrofurantoin or fosfomycin.

Clinical guidelines:

• The rise in resistance has prompted guidelines to recommend performing urine cultures and sensitivity tests more frequently, especially in complicated UTIs or cases where the first-line therapy fails.
• In regions with high levels of fluoroquinolone resistance (>10%), guidelines recommend the use of IV antibiotics such as ceftriaxone or aminoglycosides before switching to oral therapy

Question 57

Discuss the clinical complications of untreated pyelonephritis, focusing on the progression to chronic kidney disease (CKD) and systemic involvement.

Answer 57

Untreated pyelonephritis can lead to severe complications both locally in the kidneys and systemically.

Local Complications:

• Renal scarring: Persistent infection can cause inflammation, leading to scarring of the renal parenchyma. This scarring may disrupt the kidney’s ability to filter waste from the blood, leading to a gradual decline in renal function. In children, this is one of the main causes of long-term complications after UTI.
• Papillary necrosis: This occurs due to ischemia of the renal medulla, particularly in individuals with diabetes, sickle cell disease, or those on NSAIDs. The sloughing of necrotic renal papillae can obstruct the urinary tract, causing further complications like hydronephrosis.
• Abscess formation: If the infection is not contained, it can lead to the formation of intrarenal or perinephric abscesses, which are pockets of pus in or around the kidney. These abscesses can erode into surrounding structures, including the psoas muscle or diaphragm.
• Pyonephrosis: In cases of severe pyelonephritis, there may be the accumulation of pus in the renal collecting system due to obstruction, leading to the destruction of the kidney parenchyma and rapid deterioration of renal function.

Systemic Complications:

• Sepsis: Pyelonephritis can result in the bacteria entering the bloodstream (bacteremia), leading to sepsis. This condition, characterized by a systemic inflammatory response, can progress to septic shock, multi-organ failure, and death if untreated.
• Chronic Kidney Disease (CKD): Recurrent or untreated pyelonephritis can cause significant and irreversible damage to the kidneys over time, leading to CKD. The ongoing inflammatory process results in fibrosis and loss of nephrons, the functional units of the kidneys. As renal function deteriorates, patients may progress to end-stage renal disease (ESRD) and require dialysis or kidney transplantation.
• Hypertension: The scarring and damage to the kidneys can impair their ability to regulate blood pressure. The chronic inflammation in the kidneys can lead to the activation of the renin-angiotensin-aldosterone system (RAAS), contributing to hypertension, which further worsens kidney function

Question 58

Explain the management of complicated urinary tract infections (cUTIs) and how it differs from the treatment of uncomplicated UTIs

Answer 58

Management of uncomplicated UTIs typically involves short courses of oral antibiotics such as nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. These infections are common in otherwise healthy individuals with no structural or functional abnormalities of the urinary tract.

Management of complicated UTIs (cUTIs) is more complex and requires a more aggressive approach. Complicated UTIs occur in individuals with structural or functional abnormalities of the urinary tract or those with underlying conditions like diabetes, immunosuppression, or kidney stones.

1. Initial Evaluation:

• Urine culture is essential in cUTIs to identify the causative organism and its antibiotic susceptibility, as empirical therapy may not be as effective due to the higher likelihood of antibiotic resistance.
• Imaging, such as ultrasound or CT scans, may be necessary to assess for obstructive causes, abscesses, or anatomical abnormalities.

2. Antibiotic Therapy:

• Empirical broad-spectrum antibiotics: Due to the higher risk of resistant organisms, initial treatment may involve broad-spectrum antibiotics such as ceftriaxone, piperacillin-tazobactam, or a carbapenem, especially in healthcare-associated infections.
• Tailored antibiotic therapy: Once the urine culture results are available, antibiotic therapy is adjusted based on the susceptibility profile of the pathogen.
• Duration of treatment: Longer courses (10-14 days) of antibiotics are required in cUTIs, compared to the shorter courses (3-7 days) used in uncomplicated UTIs.

3. Additional Interventions:

• Drainage: If there is an abscess or obstruction, such as a stone or pyonephrosis, it may be necessary to perform percutaneous drainage or surgical removal.
• Hospitalization: Patients with severe cUTIs or those who develop systemic symptoms such as sepsis or pyelonephritis may need to be hospitalized for IV antibiotics and close monitoring.

4. Prevention of Recurrence: In individuals with recurrent cUTIs, management may involve addressing underlying risk factors (e.g., managing diabetes, removing stones, or correcting anatomical abnormalities) to prevent future infections

Question 59

. Describe the impact of pregnancy on urinary tract infections and the management approach for UTIs in pregnant women

Answer 59

Pregnancy increases the risk of UTIs due to physiological and anatomical changes that affect the urinary system. These changes include urinary stasis due to progesterone-induced smooth muscle relaxation and mechanical compression of the bladder and ureters by the growing uterus, which can impair urine flow.

Risk factors during pregnancy:

• Asymptomatic bacteriuria: Approximately 2-10% of pregnant women develop asymptomatic bacteriuria, which if untreated, can progress to symptomatic cystitis or pyelonephritis.
• Pyelonephritis: Occurs in up to 1-2% of pregnant women, most commonly in the second and third trimesters. It can lead to severe complications for both the mother and the fetus, including preterm labor, low birth weight, and maternal sepsis.

Management of UTIs in pregnancy:

1. Screening: Pregnant women are routinely screened for asymptomatic bacteriuria during the first trimester. A positive urine culture warrants treatment to prevent progression to pyelonephritis.
2. Antibiotics: The choice of antibiotics in pregnancy is limited due to the potential risks to the fetus.

• First-line agents: Nitrofurantoin and cephalosporins (e.g., cefalexin) are commonly used. These drugs are generally considered safe in pregnancy.
• Avoidance of certain drugs: Fluoroquinolones (e.g., ciprofloxacin) and sulfonamides (e.g., TMP-SMX) are generally avoided due to potential teratogenic effects and risks to fetal development.

3. Hospitalization: Pregnant women with pyelonephritis or severe symptoms may require hospitalization for IV antibiotics and monitoring of both maternal and fetal well-being.
4. Follow-up: After treatment, a repeat urine culture is recommended to ensure the infection has been cleared.

Complications: If left untreated, UTIs during pregnancy can lead to complications such as pyelonephritis, septicemia, preterm labor, and low birth weight

Question 60

Discuss the role of imaging studies in the diagnosis and management of complicated UTIs, including pyelonephritis, abscesses, and anatomical abnormalities

Answer 60

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Imaging studies play a crucial role in the diagnosis and management of complicated UTIs, particularly when there is suspicion of upper urinary tract involvement, abscess formation, or anatomical abnormalities that could predispose a patient to recurrent infections.

1. Ultrasound (USS):

• Initial imaging modality: USS is often used as the first-line imaging test in complicated UTIs because it is non-invasive, does not require contrast, and avoids radiation exposure. It is particularly useful in identifying hydronephrosis, abscesses, or stones.
• Renal abscess: USS can show hypoechoic (dark) areas within the kidney, suggestive of an abscess.
• Pyonephrosis: In cases of suspected pyonephrosis, USS can identify fluid collection and hydronephrosis in the renal pelvis.

2. Computed Tomography (CT):

• Gold standard for pyelonephritis and abscess: CT with contrast is considered the most sensitive imaging modality for detecting renal and perinephric abscesses, as well as focal areas of pyelonephritis. It is also excellent for visualizing anatomical abnormalities like kidney stones or obstructive uropathy.
• Emphysematous pyelonephritis: In cases of emphysematous pyelonephritis, CT is particularly useful for identifying gas within the renal parenchyma or surrounding tissues, which is diagnostic of this life-threatening condition.
• Non-functioning kidneys: CT can also demonstrate areas of kidney non-function, which may necessitate surgical intervention (e.g., nephrectomy).

3. Magnetic Resonance Imaging (MRI):

• Used for complex cases: MRI may be used when contrast is contraindicated (e.g., in patients with renal insufficiency) or when CT is inconclusive. It provides excellent soft-tissue detail, helping to differentiate between infections, tumors, and other pathological processes.
• Role in pregnancy: MRI can be particularly useful in pregnant women when radiation from CT needs to be avoided

Question 61

What is the most common causative organism of UTIs, and why is it so prevalent?

Answer 61

Escherichia coli (E. coli) is the most common causative organism of UTIs, responsible for about 80-90% of cases. It is prevalent because E. coli is part of the normal flora of the gastrointestinal tract. The proximity of the anus to the urethra in women allows for the bacteria to ascend into the urinary tract easily.

Question 62

Describe the pathogenesis of ascending UTIs.

Answer 62

UTIs typically start with bacterial colonization in the periurethral area. Bacteria, often from the bowel flora, ascend the urethra and enter the bladder (cystitis). In some cases, bacteria may further ascend through the ureters into the kidneys, causing pyelonephritis. Uropathogens like E. coli have virulence factors (e.g., fimbriae) that help them adhere to the urinary epithelium and evade host defenses.

Question 63

How does pregnancy predispose women to urinary tract infections

Answer 63

Pregnancy predisposes women to UTIs due to several factors: progesterone causes smooth muscle relaxation, leading to urinary stasis; the growing uterus compresses the bladder, impeding complete emptying; and an increase in urinary glucose promotes bacterial growth. Additionally, immune suppression in pregnancy can reduce the body’s ability to fight infections.

Question 64

What are the clinical features of pyelonephritis, and how do they differ from those of cystitis?

Answer 64

Pyelonephritis presents with systemic symptoms such as fever, chills, costovertebral angle tenderness (flank pain), and sometimes nausea and vomiting. It may also have signs of sepsis. Cystitis, on the other hand, is characterized by localized urinary symptoms such as dysuria, urgency, frequency, and suprapubic pain without systemic involvement.

Question 65

Why are UTIs more common in women than in men?

Answer 65

UTIs are more common in women primarily due to the shorter length of the female urethra, which allows bacteria to reach the bladder more easily. The proximity of the urethral opening to the anus and vaginal introitus also increases the risk of bacterial contamination.

Question 66

What are the first-line antibiotics used in the treatment of uncomplicated UTIs?

Answer 66

The first-line antibiotics for uncomplicated UTIs include:

Trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days

Nitrofurantoin for 5 days

Fosfomycin as a single dose

Pivmecillinam in some regions

Question 67

Explain the significance of pyuria in the diagnosis of UTIs.

Answer 67

Pyuria (the presence of white blood cells in the urine) is a hallmark of infection or inflammation in the urinary tract. Its presence supports the diagnosis of a UTI. However, pyuria can also occur in other conditions such as interstitial cystitis or non-infectious causes of inflammation.

Question 68

How does catheterization increase the risk of UTIs?

Answer 68

Catheterization increases the risk of UTIs by providing a direct pathway for bacteria to enter the bladder. Indwelling catheters can disrupt the normal flushing action of urine, facilitate biofilm formation on the catheter surface, and bypass natural host defenses such as the urethral sphincter.

Question 69

What is the recommended management of asymptomatic bacteriuria in pregnant women?

Answer 69

Asymptomatic bacteriuria in pregnant women should be treated due to the increased risk of developing pyelonephritis, preterm labor, and low birth weight. First-line treatment options include cephalexin, amoxicillin, or nitrofurantoin (in the second and third trimesters), generally for a course of 3-7 days.