外科男性泌尿生殖感染课件

InfectionInfection of GUTof GUT Introduction Definition Pathogen stay and grow in any part of GUT causing infection. Bacteriuria Pyuria Bacteriuria without pyuria indicates bacterial colonization rather than infection. Pyuria without bacteriuria warrants evaluation for tuberculosis, stones, or cancer. Defense system in GUT Normal flora stay in meatal skin and mucosa of urethra, secrete bacteriocin, metabolic products, to suppress the growth of pathogen , compete nutrients Urothelium secrete mucin preventing bacteria adhesion Anti-reflux mechanism Predisposing factors Obstructive: as stones, tumor, stricture, BPH Predisposing factors Body resistance, hypertension, diabetes, pregnancy Iatrogenic: catherterization, cystoscopy Renal parenchyma diseases: renal injury, renal failure, interstitial nephritis Anatomical: female urethra Routes of infection Ascending route Hematogenous route Lymphatic route Direct extension Pathogen Gram-negative: 85% Escherichia coli Gram-positive: Staphylococcus aureus Chlamydia Mycoplasma Diagnosis Clinical features Laboratory investigation urine bacterial culture and colony counting: 105/ml Urine collection Suprapubic aspiration Urethral catheterization Segmented voided urine specimens Midstream voided urine specimens Localization Ureteral catheterization Fairley bladder washout test Immunology responses Direct agglutination tests Passive agglutination tests Antibody-coated bacteria Pyelonephritis were fluorescent antibody- positive cystitis were not antibody-coated Enzyme-linked immunosorbent assays and radioimmunoassay for immunoglobulins Immunoglobulin response in pyelonephritis Imaging techniques Plain film of the abdomen Intravenous urogram (IVU) Ultrasonography Computer Tomography (CT) Principles of treatment Select sensitive antibiotics Use at least two kinds of sensitive antibiotics to avoid production of drug resistant strain Use full dose as early as possible Administer lower nephrotoxin antibiotics Duration of therapy Acute pyelonephrosis Clinical presentation chills,fever, flank pain, and unilateral or bilateral costovertebral angle tenderness dysuria, increased urinary frequency and urgency physical examination tenderness to deep palpation in the costovertebral angle abdominal pain, nausea, vomiting, diarrhea. Laboratory findings Urine culture Urinary sediment Blood test Blood culture Bacteriology E Coli accounts for 80% cases. Other members of the enterobacteriaceae family: Klebsiella, Proteus, Enterobacter, Pseudomonas, Serratia. Gram-positive organism: E faecalis, S aureus. Radiographic findings Intrvenous urogram Ultrasonography Treatment Sensitive antimicrobial for 14-day course Between 10% to 30%patients with acute pyelonephrosis relapse after a 14-day course of therapy. patients who relapse usually are cured by a second 14-day course of therapy, but occasionally a 6- week course is necessary Infected hydronephrosis and pyonephrosis Clininical Presentation high fever, chills, flank pain, and tenderness A previous history of urinary tract calculi, infection, or surgery is common. Bacteriuria may not present if the ureter is completely obstructed. Radiologic Finding IVU shows a poorly functioning or nonfunctioning hydronephrotic kidney ultrasonography retrograde pyelogram Management appropriated antimicrobial drugs and drainage of the infected pelvis. ureteral catheter percutaneous nephrostomy tube be placed Nephrectomy Perinephric abscess Clinical Presentation The classic patient who has a cutaneous infection or urinary tract infection that is followed in 1 to 2 weeks by fever, and unilateral flank pain is uncommon. fever, flank or abdominal pain, chills, and dysuria. Physical findings showed flank or abdominal tenderness and fever. Bacteriology and laboratory findings Urine cultures Blood cultures White blood cells count increased. Radologic findings Currently, renal sonography and CT are the most specific means of evaluating and localizing perinephric abscesses Management antimicrobial agents and drainage surgical drainage percutaneous aspiration and drainage of perirenal collection nephrectomy Uncomplicated cystitis E Coli in 80%. S saproplyticus in 5% to 15% Other organism less common include: klebsiella species, P mirabills, enterococci. Clinical presentation dysuria, frequence, urgency, voiding of small urine volumes and suprapubic or lower abdominal pain Physical Findings: suprapubic tenderness maybe present Laboratory diagnosis Microscopic urinalysis Urine culture remains the definitive test Pretherapy cultures and susceptibility tests are also essential Management Antimicrobial selection TMP TMP-SMX Fluoroquinolones are highly effective and well tolerated. Duration of therapy With most antimicrobial agents, 3-day regimens appear optimal Single-dose therapy can be used. Prostatitis Types of prostatitis 1 acute and chronic bacterial prostatitis 2 non bacterial prostatitis 3 prostatodynia Examination of the prostatic expressate Examination of the semen Measurement of the immune response Segmented cultures of the lower tract in male Acute bacterial prostatitis(ABP) sudden onset of moderate to high fever, chills, low back and perineal pain, urinary frequency and urgency, nocturia, dysuria, generalized malaise with accompanying arthralgia and myalgia, and varying degrees of bladder outlet obstruction. Rectal palpation usually discloses and exquisitely tender, swollen prostate gland that is partically or totally firm, irregular, and worm to touch culture of the voided urine. Therapy Antibacterial agents that normally diffuse poorly from plasma into prostatic fluid, perhaps, as in acute meningitis diffuse inflammatory reaction enhances the passage of these drugs from plasma into prostate New fluoroquinolone agents have excellent efficacy Chronic bacterial prostatitis (CBP) Symptoms Irritating symptoms Dysuria Pain in perineum, loin, testis etc. Fever, chill Neuropsychiatric symptoms DRE Prostatic fluid exam: wbc 10 under high power microscope Hypoechoic lesion may be seen on TRUS Treatment Administer sensitive antibiotics Prostatic massage every week Physical treatment Regular sexuality, abandon alcohol Nonbacterial prostatitis (NBP) and prostotodynia Clinical features A predominant complaint is pain: perineal, suprapubic, scrotal, low back, or urethral, especially pain referred to the tip of the penil urethra Urinary urgency and frequency, nocturia, voiding in “pulses” Treatment a- adrenergic receptor blockers are the most important agents in the management of NBP/PD stress management for symptoms Epididymitis Acute epididymitis is a clinical syndrome resulting from inflammation, pain, and swelling of the epididymis of less than 6 weeks Chronic epididymitis have long-standing pain in the epididymis and testicle, usually without swelling. Etiology Its often complicated with prostatitis, long time catherterization and postoperation of TURP, bec