Sandbox:UT

Classification

UTI

Uppper

Lower

Pyelonephritis

Cystitis

Prostatitis

Uretheritis

Asymptomatic Bacteriuria

Pyelonephritis

Etiology

Pathogen

Duration and Treatment

Acute Bacterial*Chronic bacterial*Inflammatory chronic*Non-inflammatory chronic*Asymptomatic

Non-infectious

Infectious

*Traumatic cystitis*Interstitial Cystitis*Eosinophilic cystitis*Hemorrhagic cystitis*Foreign body cystitis*Cystitis cystica*Emphysematous cystitis*Cystitis glandularis

*Bacteria*Fungi*Viruses*Parasites

*Acute uncomplicated cystitis*Complicated cystitis*Recurrent/Chronic Cystitis

*urinary crystals*Chemicals*Stevens-Johnson syndrome*Spermicides

Overview UTI

A urinary tract infection is an infection that involves any part of the urinary tract. It can result due to the invasion by a bacteria, virus, fungus or any other pathogen. The most common cause of a urinary tract infection is a bacterial infection. Various factors are associated with the risk of developing a urinary tract infection. A common cause of the urinary tract infection in hospital settings is the urinary catheter placement.

Depending on the site of the infection a UTI can be classified as either upper or lower UTI. Lower UTI includes urethritis, prostatitis, asymptomatic bacteriuria and cystitis (bladder infection) where as Upper UTI may include Pyelonephritis (infection of the kidney) and rarely uretritis (infection of the ureters). Each subtype of urinary tract infection can also be sub classified on the basis of duration, etiology or therapeutic approach as acute, chronic or recurrent and as uncomplicated or complicated infections.

The urine is normally sterile, a urinary tract infection occurs when the normally sterile urinary tract is infected by bacteria, which leads to irritation and inflammation. Females are more prone to the development of UTIs because of their relatively shorter urethra. Pyelonephritis and Cystitis result mostly from ascending infections from the urethra (Urethritis) but can also result from descending infections i.e hematogenous spread, or by the lymphatic system. The condition more often affects women, but can affect either gender and all age groups. Bacteria does not have to travel as far to enter the bladder, which is in part due to the relatively short distance between the opening of the urethra and the anus. The pathogenesis of a complicated UTI may include obstruction and stasis of urine flow. escherichia coli ("E. coli"), a bacterium found in the lower gastrointestinal tract is one of the most common culprits. Diabetes, Crohn's disease, iatrogenic causes, endometriosis, pelvic inflammatory disease, urinary obstruction, and bladder incontinence are some other risk factors for acquiring a UTI. An important aspect in the management of UTIs is that the individual infection must be differentiated from various causes of dysuria such as cystitis, acute pyelonephritis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia and neoplasms such as renal cell carcinoma and cancers of the bladder, prostate, and penis.

A recent challenge in combating UTIs is the fact that the pathogens are developing resistance to various antibiotics very fast. A large proportion of patients with acute uncomplicated urinary infections will recover without treatment within a few days or weeks. If left untreated, some patients may progress to develop recurrent infection, cystitis, pyelonephritis, hematuria, and rarely renal failure. Prognosis is generally good for lower UTIs. The majority of patients with cystitis do not have recurrence or complications after treatment. A detailed and thorough medical history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include use of urinary catheters, pregnancy, sexual history, diabetes, recent antibiotic use, history of renal disease, urinary incontinence, and urinary retention. Symptoms of cystitis include abnormal urine color (cloudy), blood in the urine, frequent urination or urgent need to urinate, painful urination, pressure in the lower pelvis or back, flank pain, back pain, nausea, vomiting, and chills. Patients with an uncomplicated UTI are usually well-appearing. A thorough physical exam is very helpful in differentiating Upper from Lower UTI]s and to diagnose exactly within these categories too. Common physical examination findings of cystitis include fever and suprapubic tenderness where as pyelonephritis also has flank tenderness and chills. Laboratory tests used in the diagnosis of a UTI include urinalysis and urine culture. Laboratory findings consistent with the diagnosis of a UTI include pyuria and either white blood cells (WBCs) or red blood cells (RBCs) on urinalysis and a positive urine culture. Leukocyte esterase test and nitrite test are very important in this regard. Antimicrobial therapy is indicated in case of a symptomatic UTI. The treatment of a UTI depends on the type of the disease, the disease course (acute uncomplicated vs. complicated), history of the individual and the rates of resistance in the community. Preventative measures to avoid a UTI include abstinence from sexual activity, use of barrier contraception during sexual intercourse, urinating after intercourse, increasing fluid intake and frequency of urination, and use of estrogen (among post-menopausal women). Single-dose prophylactic antimicrobial therapy prior to sexual intercourse may be administered to patients who have recurrent episodes of cystitis that are associated with sexual activity.

Epidemiology

• Worldwide, the prevalence of community associated UTI is 7000 per 100,000 persons.
• The prevalence of hospital associated UTI is 129, 196 and 24000 per 100,000 persons in the United States, Europe and developing countries, respectively.
• The annual incidence of urinary tract infection in women is 1200 per 100,000 persons.
• The incidence of asymptomatic bacteriuria in pregnant women is 5900 per 100,000 persons.
• The incidence of cystitis and pyelonephritis in pregnant woman having asymptomatic bacteriuria is 3300 and 66000 per 100,000 persons.
• The incidence of recurrence of urinary tract infection in young healthy women is 25000 per 100,000 persons and there is increase in the recurrent rates with every subsequent infection.
• The incidence of pyelonephritis among healthy women is 120 and 30-40 per 100,000 persons in the outpatient and inpatient setting respectively.
• The incidence of pyelonephritis in male population is 20 and 10 cases per 100,000 persons in the outpatient and inpatient setting respectively.
• The incidence of UTI is higher in sexually active women than postmenopausal women.
• There is high incidence of urinary tract infection in immunocompromised, elderly, diabetic, and individuals with indwelling catheters.

Journal Reference

Raas-Rothschild A, Spiegel R (2010 Jan 28). "Mucolipidosis III Gamma". GeneReviews®. PMID 20301784.

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CT Scan Emphysematous Cystitis

Table for D/D of cystitis

Diseases	Diagnostic tests			Physical Examination				Symptoms					Past medical history	Other Findings
	Urinalysis	Urine Culture	Gold Standard	Fever	Suprapubic Tenderness	Discharge	Inguinal Lymphadenopathy	Hematuria	Pyuria	Frequency	Urgency	Dysuria
Cystitis	*Nitrite +ve *Leukocyte estrase+ve *WBCs *RBCs	>100,000CFU/mL	Urinary culture	✔	✔	-	✔	✔	✔	✔	✔	✔	Recent catheterisation Pregnancy recent intercourse Diabetes Personal or Family History of UTI Known abnormality of the urinary tract BPH or HIV	Imaging studies help differentiate the type May company back pain, nausea, vomiting and chills
Urethritis	*Positive leukocyte esterase test or >10 WBCs *Mucous threads in the morning urine	-	*Gram stain *Mucoid or purulent discharge	✔	-	Urethral discharge	✔	-	✔	-	-	✔	Prior STDs Urinary tract infections New sexual partner Recent intercourse Recent catheterisation	Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, tachypnea
Bacterial Vulvovagintis	-	-	Gram Stain	✔	-	Vaginal discharge	✔						Number and type of sexual partners (new, casual, or regular) Prior STDs Previous history of symptomatic BV in female partner (in homosexual women)	Fishy odor from the vagina (Whiff test) Thin, white/gray homogeneous vaginal discharge Microscopy (wet prep) and vaginal pH  Clue cells
Cervicitis	-	-	culture for gonococcal cervicitis	✔	-	endocervical exudate		-	✔	-	-	✔	Abnormal vaginal bleeding after intercourse or after menopause Abnormal vaginal discharge Painful sexual intercourse Pressure or heaviness in the pelvis	1-a purulent or mucopurulent endocervical exudate 2-Sustained endocervical bleeding easily induced by a cotton swab 3->10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea
Prostatitis	10-20 leukocytes for acute and chronic bacterial subtypes	Identifies causative bacteria (in bacterial subtypes)	Urine Culture	✔	-	-		-	✔	✔	✔	✔	Urogenital disorders Recent catheterization or other genitourinary instrumentation History of UTIs	In acute prostatitis, palpation reveals a tender and enlarged prostate[1][3] In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate[1] A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis
Epididymitis	Hematuria may be seen	✔	Culture	✔	✔	+/- urethral discharge	✔	✔	-	✔	✔	✔	Scrotal pain: starts gradually, is usually unilateral and localized posterior to the testis Scrotal swelling Scrotal wall erythema Constitutional symptoms: feeling of hotness, chills, nausea and vomiting	*Ultrasound in patients with acute testicular pain to assess for testicular torsion If equivocal do surgical exploration
Syphilis (STD)	-	-	Darkfield Microscopy	+/-	-	-	✔	-	-	-	-	-	History of STD HIV Immunosupression Previous history of chancre	May be asymptomatic Painless chancre in primary syphilis Secondary syphilis may have generalised features and condylomata late Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas
BPH	Recommended Hematuria may be seen	-	DRE + Serum PSA	-	-	-		✔	-	✔	✔	✔	Sudden inability to urinate Urinary tract infections Urinary stones Damage to the kidneys Blood in the urine	Involves mainly central or transitional zone Hyperplasia rather than hypertrophy Obstruction of the urethra Nocturia
Neoplasms	Recomended Hematuria may be seen	-	Imaging and biopsy	+-	-		✔	✔	-	✔	✔	-	Sudden inability to urinate Recurrent urinary tract infections Weight loss and other constitutional symptoms	Cachexia Gradual progression
Pyelonephritis	Leukocytes Nitrite +ve	Identifies causative bacteria	Imaging and culture	✔	✔ + Flank Pain	✔	✔	✔	✔			✔	History of Pyelonephritis Recent history of Hospitalisation Nephrolithiasis Immunosupression	Costovertebral angle tenderness Patient is in acute distress Look for obstructive causes