《泌尿生殖道感染》PPT课件.ppt

Infection of the Genitourinary Tract,Hongshu Ma Department of Urology Tianjin First Central Hospital,Urinary tract infections (UTIs) caused by pathogenic bacteria can involve any of the genital or urinary organs and eventually can spread from one site to any or all of the others.,Definitions 1,Urinary tract infection is an inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria.,Most UTIs are caused by aerobic gram-negative rods, (Escherichia coli.), gram-positive cocci (enterococci) and to a lesser extent by anaerobic bacteria.,Definitions 2,Definitions 3,Bacteriuria is the presence of bacteria in the urine, which is normally free of bacteria, and implies that these bacteria are from the urinary tract and are not contaminants from the skin, vagina, or prepuce.,Definitions 4,Pyuria is the presence of white blood cells in the urine Bacteriuria without pyuria indicates bacterial colonization rather than infection. Pyuria without bacteriuria warrants evaluation for tuberculosis, stone, or cancer.,Classification,According to their nature history First infections/Isolated Infection Recurrent infections Bacterial persistence Reinfections,Reinfection is recurrent infection with different bacteria from outside the urinary tract. Each infection is a new event; the urine must show no growth after the preceding infection.,Bacterial persistence refers to a recurrent urinary tract infection caused by the same bacteria from a focus within the urinary tract, such as an infection stone or the prostate.,According to Their Site of Origin,Upper urinary tract infection Lower urinary tract infection Genital system infection,Upper-tract infection,Acute pyelonephritis Chronic pyelonephritis Emphysematous pyelonephritis Renal abscess Perinephric abscess Xanthogranulomatous pyelonephritis,Lower-tract infection,Acute urethral syndrome (Women) Acute cystitis,Genital infection,Acute and chronic bacterial prostatitis. Acute and chronic epididymitis.,Pathogenesis,Bacterial pathogenesis in the urinary tract depends on a number of facters, chief of which are the Bacterial Virulence Facters and the Host Susceptibility Factor,Bacterial virulence factors,Ability of adherence to urothelial cells Ability to resist bactericidal activity Ability to produce hemolysin.,Host susceptibility factors,Emptying of urine Surface mucins Urinary antibodies Urinary osmolality pH,Routes of infection,(1) Ascending infection (2) Hematogenous spread (3) Lymphatogenous spread (4) Direct extension,DIAGNOSIS,Urine Collection,Suprapubic Aspiration Urethral Catheterization Segment Voided Urine Specimens,Urinlysis,More than 3 fresh leukocytes/High- power field,Quantitative urine culture,Colonies forming units per milliliter (cfu/ml) 100,000 cfu/ml 1000 to 10,000 cfu/ml,Location of urinary tract nfection.,Symptoms and signs Laboratory findings X-Ray findings Radionuclide imaging MRI findings,Treatment strategy.,Antimicrobial drug Mdication for pain, fever, and nausea. To give fluids intravenously and orally Complicating factors (eg. Obstructive urography or infected stones),Acute Pyelonephritis,Definitions,Acute pyelonephritis is defined as inflammation of the parenchyma and the pelvis of the kidney causing by bacterial infection.,Etiology & Pathogenesis,Aerobic gram-negative bacteria E coli Gram-negative entric organisms Enterococci, and staphylococcus aureus Ascending infection (VUR) Hematogenous,Clinical findings 1,An abrupt onset of chill , moderate to high fever Dysuria, frenquency, urgency. Abdominal pain, nausea, vomiting, and even diarrhea.,Clinical findings 2,Costovertebral angle tenderness Palpation or percussion over the costovertebral angle on the affected kidney usually causes pain. The patient sometimes has abdominal distention, tenderness, and a quiet intestine,Dignosis 1,Laboratory findings: Leukocytosis Pyuria, Bacteriuria, Proteinuria, Hematuria Quantitative urine culture Total renal function,Dignosis 2,Imaging: Plain film Excretory urograms . Voiding cystogram CT Ultrasonography Radionuclide,Differential Diagnosis,Pancreatitis Basal pneumonia Acute-intra-abdominal disease Women pelvic inflammatory diseaseand acute prostatitis Renal abscess Perinephric abcess.,Treatment 1,Antimicrobial drugs: The appropriate intravenous treatment Oral drug Repeat urine cultures,Treatment 2,Specific measures: Any complicating factors (eg. obstructive urography),Prostatitis,Types of protatitis,Drach (1978) (1) acute and chronic bacterial prostatitis, (2) nonbacterial prostatitis (3) prostatodynia.,NIDDK categorization and Drach classification,Diagnostic techniques,The expressed prostatic secretions (EPS) Leukocytes 10 per high-power field (hpf),The 4-glass test (Stamey 1968),Acute bacterial prostatitis,Etiology & Pathogenesis,E coli 80% Enterococci 5-10% Anaerobes rarely Intraprostatic reflux of urine Invasion by rectal bacteria Hematogenous spread,Clinical features,The sudden onset of fever, chills. Low back and perineal pain. Frenquency and urgency, nocturia, dysuria Varying degrees of bladder outlet obstruction.,Digital rectal examination (DRE),Tender, swollen prostate gland, irregularly firm and warm Urine may be cloudy and malodorous, and gross hematuria is observed,Diagnosis,A complete blood count shows leukocytosis with a shift toward immature forms. The voided urine shows pyuria, microscopic hematuria, and bacteria. Culture of voided urine sample usually identifies the pathogens Ultrasonography,Treatment,Antibiotic treatment for 4-6 weeks Supportive measures include antipyretics, analgesics, stool sorfteners, hydration, and bed rest. Any transurethral catheterization or instrumentation is contraindicated. Acute urinary retention should be managed with suprapubic drainage,Chronic bacterial prostatitis,Etiology & Pathogenesis,The gram-nagative organisms The gram-positive organisms Mycoplasmal, chlamydial species Intraprostatic reflux of urine pH of prostatic secretions Zinc,Clinical findings 1,Irritative voiding dysfunction(dysuria urgency, frequency, nocturia ) Low back or perineal pain Sexual dysfunction Myalgia and arthralgia Other symptoms,Clinical findings 2,DRE: normal, tenderness, swelling, firmness Secondary epididymitis Hematouria, hematospermia, urethral discharge,Diagnosis,The 4-glass test The expressed prostatic secretions (EPS) Leukocytes 10 per high-power field (hpf) Sonography,鉴别诊断,II型和III型应与可能导致骨盆区域疼痛和排尿异常的疾病进行鉴别诊断 间质性膀胱炎、睾丸附睾和精索疾病、肛门直肠疾病、腰椎疾病 BPH、膀胱过度活动症、神经原性膀胱 膀胱肿瘤、前列腺癌,治疗原则,慢性前列腺炎无明确的进展性，不足以威胁患者的生命和重要器官功能，并非所有的前列腺炎均需治疗。 慢性前列腺炎的治疗目标主要是缓解疼痛、改善排尿症状和提高生活质量，疗效评价应以症状改善为主。 前列腺炎应采取综合治疗。,治疗方法,一、型 一旦临床诊断或得到血、尿培养结果后，应立即应用抗生素。 开始时可经静脉应用抗生素，如：广谱青霉素、三代头孢菌素 、氨基糖甙类或氟喹诺酮等。 待患者的发热等症状改善后，改用口服药物（如氟喹 诺酮等），疗程至少4周。 并发症处理： 伴尿潴留者细管导尿或膀胱穿刺造瘘。 伴脓肿形成者可采取穿刺引流、经尿道切开引流,治疗方法,二、型和型 （一）一般治疗 ： 健康教育、心理和行为辅导有积极作用。 慢性前列腺炎患者应戒酒，忌辛辣刺激食 物；避免憋尿、久坐，注意保暖，加强体育锻炼。 热水坐浴有助于缓解疼痛症状。,治疗方法,二、型和型 （二）药物治疗 1抗生素 2-受体阻滞剂 3非甾体抗炎镇痛药 4植物制剂 5M-受体阻滞剂 6抗抑郁药及抗焦虑药 7中医中药,治疗方法,抗生素 型： 根据细菌培养结果和药物穿透前列腺的能力选择抗生素。药物穿透前列腺的能力取决于其离子化程度、脂溶性、蛋白结合率、相对分子质量及分子结构等。 常用的抗生素是氟喹诺酮类药物（如环丙沙星、左氧氟沙星和洛美沙星等）、四环素类（如米诺环素等）和磺胺类（如复方新诺明）。 前列腺炎确诊后，抗生素治疗疗程为46周，,治疗方法,A型： 抗生素治疗大多为经验性治疗。 推荐先口服氟喹诺酮或四环素等类抗生素24周，然后根据其 疗效反馈决定是否继续抗生素治疗。 只有当患者的临床症状确有减轻时，才建议继续应用抗生素。推荐的总疗程为4 6周。 部分患者可能存在衣原体、支