Part 1: UTI in urology

(Surgical UTI)
Dr. Jad AlSmadi, MD.,
Lecturer with Assistant Professor duties,
faculty of medicine,
The Hashemite University
 UTI definitions
• UTI is an inflammatory response of the urothelium to bacterial
invasion.
• Usually associated with bacteriuria and pyuria
• Bacteriuria is the presence of bacteria in the urine, which is
normally free of bacteria (either bacterial colonization or
infection, or contamination)
• Significant bacteriuria: when the number of bacteria in a
suprapubically aspirated, catheterized, or voided specimen
exceeds the number usually caused by contamination of the skin,
the urethra, or the prepuce or introitus.
 UTI definitions
• Pyuria, the presence of white blood cells (WBCs) in the urine.
• Indicates: infection or an inflammatory response to bacterium,
stones, or other indwelling foreign body.
• Pyuria without bacteriuria warrants evaluation for
tuberculosis, stones, or cancer.
 UTIs classified clinically by their presumed site of origin:
• Cystitis: clinical syndrome of dysuria, frequency, urgency, and
occasionally suprapubic pain
• Acute pyelonephritis is a clinical syndrome of chills, fever, and
flank pain that is accompanied by bacteriuria and pyuria
 UTI definitions
• Complicated vs Uncomplicated UTI:
• Uncomplicated: infection in a healthy patient with a structurally
and functionally normal urinary tract.
• Usually women with bacterial cystitis or acute pyelonephritis,
and bacteria are usually susceptible to a short course of oral
antimicrobial therapy.
• Complicated infection: + factors that increase the chance of
acquiring bacteria and decrease the efficacy of therapy.
• Structurally or functionally abnormal urinary tract, compromised
host, increased virulence or antimicrobial resistance of bacteria
 Factors That Suggest a Complicated UTI

• Functional or anatomic • Childhood urinary tract infection

abnormality of urinary tract • Recent antimicrobial agent use
• Male gender • Indwelling urinary catheter
• Pregnancy • Urinary tract instrumentation
• Elderly patient • Hospital-acquired infection
• Diabetes • Symptoms for more than 7 days
• Immunosuppression at presentation
 Definitions
• Functional abnormalities:
• I) Renal diseases that reduce the concentrating ability of the
kidney: e.g. postobstructive nephropathy, sickle cell
nephropathy, lithium nephropathy, chronic tubulointerstitial
nephritis, and inherited diseases such as medullary cystic
kidney disease
• II) voiding dysfunction that alter bladder-emptying
capabilities: enlargement of the prostate or congenital or
acquired sites of residual urine, such as calyceal or urethral
or bladder diverticula, BOO, neurogenic bladder
 Definitions
• UTIs may also be defined by their relationship to other UTIs:
I) First or isolated infection is one that occurs in an
individual who has never had a UTI or has one remote
infection from a previous UTI
II) Unresolved infection is one that has not responded to
antimicrobial therapy and is documented to be the same
organis with a similar resistance profile

III) Recurrent infection is one that occurs after

documented, successful resolution of an antecedent infection.
 Definitions

• Types of Recurrent Infections:

I) Reinfection describes a new event associated with
reintroduction of bacteria into the urinary tract.
2. Bacterial persistence refers to a recurrent UTI caused
by the same bacteria reemerging from a focus within the
urinary tract, such as an infectious stone or the prostate.
 UTI: EPIDEMIOLOGY
• UTIs are the most common bacterial infection.
• The most common primary diagnoses for women visiting the
emergency department
• CAUTIs are the most common nosocomial infection,
constituting more than 80% of nosocomial UTIs
• Once a patient has an infection, he or she is likely to develop
subsequent infections
• Nearly 30% of women have had a symptomatic UTI requiring
antimicrobial therapy by age 24, and
• Almost half of all women experience a UTI during their lifetime.
 UTI: EPIDEMIOLOGY
• 20-40% of women who have had one previous cystitis episode
are likely to experience an additional episode.
• 25-50% of whom will experience multiple recurrent episodes
• The incidence of UTIs is also elevated during pregnancy and in
patients with spinal cord injury (SCI), diabetes, multiple sclerosis,
organ transplant recipients, and human immunodeficiency virus
(HIV) infection/acquired immunodeficiency syndrome (AIDS)
• No clear association has been described between recurrent
uncomplicated UTIs and renal sequelae such as scarring,
hypertension, or progressive renal insufficiency
 UTI: PATHOGENESIS
• UTIs occur as a result of interactions between the
uropathogen and the host.
• Successful infection of the urinary tract is determined
in part by the virulence factors of the bacteria, the
inoculum size, and the inadequacy of host defense
mechanisms.
• These factors also play a role in determining the ultimate
level of colonization and damage to the urinary tract
 UTI: PATHOGENESIS
I) Routes of Infection:
A) Ascending Route: Most bacteria enter the urinary tract
from the bowel through the urethra into the bladder.
• Bacterial Adherence to the introital and urothelial mucosa
plays a significant role in ascending infections.
• Added Risks for this: significant soilage of the perineum
with feces, use spermicidal agents, and intermittent or
indwelling catheters.
 UTI: PATHOGENESIS
• B) Hematogenous Route: the kidney is occasionally
secondarily infected in patients with Staphylococcus
aureus bacteremia originating from oral sites or with
Candida fungemia
• C) Lymphatic Route: Direct extension of bacteria from
the adjacent organs via lymphatics. Such as a severe
bowel infection or retroperitoneal abscesses
• D) Direct extension of bacteria from adjacent organs
(intraperitoneal abscesses or vesicointestinal or
vesicovaginal fistulas)
 UTI: PATHOGENESIS
• II) Bacterial Virulence Factors:
• Virulence characteristics play a role in determining if an
organism will invade the urinary tract and the subsequent
level of infection within the urinary tract
• Uropathogenic strains in the bowel flora, such as UPEC, can
infect the urinary tract not only by chance but also by the
expression of virulence factors that enable them to adhere
to and colonize the perineum and urethra and migrate to
the urinary tract.
 UTI: PATHOGENESIS

• II) Bacterial Virulence Factors:

• E. coli is by far the most common cause of UTIs, accounting
for 85% of community-acquired and 50% of hospital-acquired
infections
• A) Bacterial Adherence: Bacterial adherence is a specific
interaction that plays a role in determining the organism, the
host, and the site of infection.
•  Bacterial Adhesins:
 UTI: PATHOGENESIS
• Bacterial Adhesins: are
classified as either fimbrial
(Pili) or afimbrial.
• Pili are defined functionally
by their ability to mediate
hemagglutination of
specific types of
erythrocytes.
• The most well-described pili
are types 1, P, and S
 UTI: Natural Defenses of UT
• I) The normal flora of the vaginal introitus, the periurethral area,
and the urethra usually contain microorganisms such as
lactobacilli, coagulase-negative staphylococci, corynebacteria,
and streptococci that form a barrier against uropathogenic
colonization
• II) Urine: osmolality, urea concentration, organic acid
concentration, & pH.
• Bacterial growth is inhibited by either very dilute urine or a high
osmolality when associated with a low pH
 UTI: Natural Defenses of UT

• II) Urine: Uromodulin (Tamm-Horsfall protein), a kidney-derived

mannosylated protein play a defensive role by saturating all the
mannose-binding sites of the type 1 pili, thus potentially blocking
bacterial binding the urothelium
• III) Bladder: Bacteria make their way into the bladder fairly often.
Whether small inocula of bacteria persist, multiply, and infect the
host depends in part on the ability of the bladder to empty
 Clinical Presentation
• Dysuria is central in the diagnosis of UTI; other symptoms of
frequency, urgency, suprapubic pain, and hematuria are variably
present.
• Acute-onset dysuria is a highly specific symptom, with more than
90% accuracy for UTI in young women in the absence of
concomitant vaginal irritation or increased vaginal discharge
• Diagnosis: Typically, for a diagnosis of cystitis, acute-onset
symptoms should occur in conjunction with the laboratory
detection of a uropathogen from the urine.
 Diagnosis
• Urine Collection:
• 1) Voided Specimen (MSU): In circumcised men, voided
specimens require no preparation
• In uncircumcised men, the foreskin should be retracted and the
glans penis washed with soap and then rinsed with water before
specimen collection
• The female should be instructed to spread the labia, wash and
cleanse the periurethral area with moist gauze
 Diagnosis: Urine Collection:
• 2) Catheterized Specimens: Diagnostic accuracy can be improved
by reducing bacterial contamination.
• It carries a risk of iatrogenic infection
• Catheterization of a male patient for urine culture is not
indicated unless the patient cannot urinate
• 3) Suprapubic Aspiration: is highly accurate, but because it carries
some morbidity there is limited clinical usefulness except for a
patient who cannot urinate on command, such as patients with
spinal cord injuries, and useful in neonates
 Diagnosis
• I) Urinalysis: For patients with urinary symptoms, microscopic urinalysis for
bacteriuria, pyuria, and hematuria should be performed
• Microscopic bacteriuria is found in >90% of infections with counts of 105
cfu/ml of urine or greater and is a highly specific finding.
• Bacteria are usually not detectable microscopically with lower colony count
infections (102 to 104/mL). (i.e., a false-negative result)
• The second error of urinalysis (i.e., a false-positive result) is bacteria are
seen in the microscopic sediment, but the urine culture shows no growth
•  lactobacilli and corynebacteria are readily seen under the microscope;
and although they are gram-positive, they often appear gram-negative
(gram-variable) if stained
 Diagnosis
• I) Urinalysis: midstream urine specimen can be questioned if numerous
squamous epithelial cells (indicative of preputial, vaginal, or urethral
contaminants)
• The presence of bacteriuria has a sensitivity for UTI of 40% to 70%, and a
specificity of 85% to 95%, depending on the number of bacteria observed
• Pyuria: at least 5 to 10 leukocytes per high-power field, The absence of
pyuria should cause the diagnosis of UTI to be questioned until urine culture
results are available
• Significant pyuria in the absence of bacteriuria: TB, staghorn calculi and
stones of smaller size, any injury to the urinary tract, chlamydial urethritis,
glomerulonephritis and interstitial cystitis.
 Diagnosis
• II) Rapid Screen Methods: (dipstick)
• bacteria reduce the nitrate normally present in urine to nitrite.
• Pyuria: by determining leukocyte esterase activity
• But due to substantial variability in the sensitivity and specificity results,
their main role is in screening asymptomatic patients and do not replace
careful microscopic urinalysis in symptomatic patients
• Although dipsticks are most helpful in ruling out a UTI, each parameter has
false positives and negatives, which make it less reliable in determining
whether a patient has a UTI
 Diagnosis

• III) Urine culture: remains the mainstay of diagnosis of an episode of acute

cystitis; urinalysis provides little increase in diagnostic accuracy
• A threshold of >102 CFU/mL E. coli from voided specimens had 88-93%
positive predictive value for bladder bacteriuria in patients with a high
suspicion of UTI.
• Still a 105 CFU/mL threshold for bacterial growth on midstream voided urine
may help distinguish bladder bacteriuria from contamination
in asymptomatic, pre-menopausal women.
 Diagnosis
• IV) Localization Studies: A) Ureteral catheterization (during Cystoscopy)
allows not only separation of bacterial persistence into upper and lower
urinary tracts but also separation of the infection between one kidney and
the other, and even localization of infection to ectopic ureters or to non-
refluxing ureteral stumps
• B) Stone Cultures: Urinary and stone cultures must be analyzed separately
because results may be discordant
• Manipulation of infected stones, and possible release of endotoxins into the
bloodstream, can lead to systemic inflammatory response syndrome (SIRS)
or potentially fatal urosepsis
 Diagnosis
• IV) Localization Studies:
• Stone cultures, rather than
periprocedure urine cultures,
are a better predictor of
postoperative sepsis and
SIRS
• C) Prostate and Urethral
Localization Studies:
• VB1, VB2, EPS, VB3
 Diagnosis: Imaging
• Imaging studies are not required in most cases of UTI because clinical and
laboratory findings alone are sufficient for correct diagnosis and adequate
management of most patients
• Indications: infections in most men, compromised hosts, febrile infections,
signs or symptoms of urinary tract obstruction, failure to respond to
appropriate therapy, and a pattern of recurrent infections suggesting
bacterial persistence.
• Identification of underlying abnormalities that require modification of
medical management or percutaneous or surgical intervention
Correctable Urologic Abnormalities That Cause
Bacterial Persistence
• Infection stones • Chronic bacterial prostatitis
• Unilateral infected atrophic kidneys • Foreign bodies
• Ureteral duplication and ectopic ureters
• Urethral diverticula and infected periurethral glands
• Unilateral medullary sponge kidneys
• Nonrefluxing, normal-appearing, infected ureteral stumps after
nephrectomy
• Infected urachal cysts • Papillary necrosis
• Infected communicating cysts of the renal calyces
• Perivesical abscess with fistula to bladder
 Diagnosis: Imaging
• Ultrasonography: noninvasive, easy and rapid to perform, and offers no
radiation or contrast agent risk to the patient
• Identify calculi and hydronephrosis, pyonephrosis, and perirenal abscesses
• Due to limited sensitivity, a single radiograph for (KUB) calculi could
accompany ultrasonography
• Ultrasonography is also useful for diagnosing postvoid residual urine
• Disadvantages: dependent on the skills of the examiner, technically poor in
patients who are obese or have other anatomic challenges, or who have
dressings, drainage tubes, or open wounds overlying the area of interest
 Diagnosis: Imaging
• Computed Tomography and Magnetic Resonance Imaging:
• The best for acute focal bacterial nephritis, renal and perirenal abscesses,
and radiolucent calculi
• MRI provided some advantages in delineating extrarenal extension of
inflammation. Pelvic MRI is the most useful imaging modality for detecting
a urethral diverticulum
• Voiding Cystourethrogram: In women with a history of febrile UTIs, known
VUR as a child, or recurrent pyelonephritis as an adult.
• Also in patients with a history of recurrent UTIs and hydronephrosis.
 Bladder Infections
• I) Uncomplicated Cystitis:
• The overwhelming majority of infections encountered in urology
• Most cases of uncomplicated cystitis occur in women
• Young men may also experience acute cystitis without underlying structural
or functional abnormalities of the urinary tract
• E. coli is the causative organism in 75% to 90%
• S. saprophyticus, a commensal organism of the skin, is the second most
common cause of acute cystitis in young women, accounting for 10% to
20%
 Bladder Infections
• I) Uncomplicated Cystitis: Clinical Presentation
• Symptoms: frequency, urgency, painful urination, incomplete emptying,
suprapubic pain/pressure, low back pain, and hematuria
• Management:
• Three-day therapy with TMP-SMX or TMP is the preferred regimen for
uncomplicated cystitis in women (Or nitrofurantoin 5-day therapy and
fosfomycin singledose therapy)
• Seven-day therapy is the preferred regimen for cystitis in men
 Bladder Infections
• II) Complicated Cystitis: The clinical spectrum ranges from mild cystitis to
life-threatening infections and urosepsis
• Management: patients with mild to moderate illness who can be treated as
an outpatient with oral therapy, 10 to 14 days of fluoroquinolones
• For patients requiring hospitalization, IV antimicrobials should be
administered based on the susceptibility patterns of the known
uropathogens
• Usually continued for 10 to 14 days on culture-specific antibiotics and
switched from parenteral to oral therapy when the patient is afebrile and
clinically stable
 Bladder Infections (complicated UTI)
• II) Emphysematous cystitis: is a rare and potentially life-threatening form
of complicated cystitis that is associated with a mortality rate of up to 7%
• The pathognomonic finding of this disease process is gas noted within the
wall on cross-sectional imaging.
• Emphysematous cystitis is typically observed in elderly women (60–70 years
of age) with poorly controlled diabetes
• E. coli (60%) then comes K. pneumoniae (10%–20%)
• Symptoms: most common abdominal pain (80%), gross hematuria (60%),
and obstructive urinary symptoms (10%). Fever 30-50%
 Bladder Infections (complicated UTI)
• II) Emphysematous cystitis:
• A CT scan is necessary to make
the diagnosis and exclude
other sources of pelvic air such
as a fistula, trauma, or
gangrene of adjacent
structures
• CT scan of the pelvis will also
show air pocketed diffusely
within the bladder wall, and
possibly intraluminally
 Bladder Infections (complicated UTI)
• II) Emphysematous cystitis: Management
• The majority (90%) of these patients are treated with medical
therapy alone,
• which consists of antibiotics (parenteral), bladder drainage, and
treatment of comorbid conditions such as poorly controlled
diabetes
• The need for surgical intervention is rare and can include
debridement, partial cystectomy, and total cystectomy in
advanced cases
 Bladder Infections (rUTI)
• III) Recurrent Urinary Tract Infections: A recurrent UTI is defined as two UTIs
in a 6-month period or three or more UTIs in a 12-month period
• Either: Bacterial Persistence, caused by the same bacterial strain, usually
leads to recurrent infections in a short time frame
• Or: Reinfections, caused by a different organism or the same organism
more than 2 weeks after treatment
• The history and physical exam should eliminate overt external anatomic or
obvious functional abnormalities of the urinary tract that predispose to
recurrent UTIs
 Bladder Infections (rUTI)
• III) rUTI: Symptoms such as pneumaturia, fecaluria, obstipation, as well as
prior history of diverticulitis, prior pelvic surgery, or radiation should raise
suspicion for vesicoenteric or vesicovaginal fistula
• Chronic constipation, diarrhea, and fecal incontinence are reversible
contributing factors (increase ascending UTI)
• Significant risk factors for recurrence in women include sexual activity, a
new sexual partner within the past year, menopause, spermicidal use, family
history of UTI in a first-degree female relative, and recent antimicrobial use
• In postmenopausal women, risk factors for recurrent UTIs include
incontinence, elevated postvoid residual, and presence of a cystocele
 Bladder Infections (rUTI)
• III) rUTI:
• Physical examination, palpating the suprapubic area and performing a
pelvic examination are important
• Workup: urinalysis and urine culture, is imperative in patients.
• Obtaining a postvoid urine residual and uroflow measurement provides
important information
• In women with risk factors for a complicated UTI the evaluation should
include imaging and cystoscopy.
• Preferred imaging includes renal and bladder ultrasound with possible plain
radiograph of the abdomen (KUB). No abnormality  CT scan
 Bladder Infections (rUTI) Management

• I) Behavioral Modification:
• 1. Hydration is recommended to augment innate immunity by sloughing of
urothelial cells and flushing of adherent bacteria
• 2. Frequent voiding helps to continually empty the bladder
• 3. Emptying the bladder after intercourse, minimize the likelihood that the
transient bacteriuria will progress to clinical UTI
• 4. Avoid spermicides (because they contribute to decreased population of
normal vaginal flora and subsequently alter the vaginal pH in favor of for
uropathogenic bacteria.
 Bladder Infections (rUTI) Management

• II) Non-Antibiotic Management:

• Estrogen: the lack of estrogen causes marked changes in the vaginal
microflora, including a loss of lactobacilli and increased colonization by E.
coli
• Local vaginal estrogen is effective in preventing recurrent UTIs in
postmenopausal women. The beneficial effect from vaginal estrogen use
can take at least 12 weeks to manifest
• Oral estrogens compared are not effective in preventing UTI
Thank you