泌尿生殖道感染.ppt

InfectionoftheGenitourinaryTract HongshuMaDepartmentofUrologyTianjinFirstCentralHospital Urinarytractinfections UTIs causedbypathogenicbacteriacaninvolveanyofthegenitalorurinaryorgansandeventuallycanspreadfromonesitetoanyoralloftheothers Definitions1 Urinarytractinfectionisaninflammatoryresponseoftheurotheliumtobacterialinvasionthatisusuallyassociatedwithbacteriuriaandpyuria MostUTIsarecausedbyaerobicgram negativerods Escherichiacoli gram positivecocci enterococci andtoalesserextentbyanaerobicbacteria Definitions2 Definitions3 Bacteriuriaisthepresenceofbacteriaintheurine whichisnormallyfreeofbacteria andimpliesthatthesebacteriaarefromtheurinarytractandarenotcontaminantsfromtheskin vagina orprepuce Definitions4 PyuriaisthepresenceofwhitebloodcellsintheurineBacteriuriawithoutpyuriaindicatesbacterialcolonizationratherthaninfection Pyuriawithoutbacteriuriawarrantsevaluationfortuberculosis stone orcancer Classification AccordingtotheirnaturehistoryFirstinfections IsolatedInfectionRecurrentinfectionsBacterialpersistenceReinfections Reinfectionisrecurrentinfectionwithdifferentbacteriafromoutsidetheurinarytract Eachinfectionisanewevent theurinemustshownogrowthaftertheprecedinginfection Bacterialpersistencereferstoarecurrenturinarytractinfectioncausedbythesamebacteriafromafocuswithintheurinarytract suchasaninfectionstoneortheprostate AccordingtoTheirSiteofOrigin UpperurinarytractinfectionLowerurinarytractinfectionGenitalsysteminfection Upper tractinfection AcutepyelonephritisChronicpyelonephritisEmphysematouspyelonephritisRenalabscessPerinephricabscessXanthogranulomatouspyelonephritis Lower tractinfection Acuteurethralsyndrome Women Acutecystitis Genitalinfection Acuteandchronicbacterialprostatitis Acuteandchronicepididymitis Pathogenesis Bacterialpathogenesisintheurinarytractdependsonanumberoffacters chiefofwhicharetheBacterialVirulenceFactersandtheHostSusceptibilityFactor Bacterialvirulencefactors AbilityofadherencetourothelialcellsAbilitytoresistbactericidalactivityAbilitytoproducehemolysin Hostsusceptibilityfactors EmptyingofurineSurfacemucinsUrinaryantibodiesUrinaryosmolalitypH Routesofinfection 1 Ascendinginfection 2 Hematogenousspread 3 Lymphatogenousspread 4 Directextension DIAGNOSIS UrineCollection SuprapubicAspirationUrethralCatheterizationSegmentVoidedUrineSpecimens Urinlysis Morethan3freshleukocytes High powerfield Quantitativeurineculture Coloniesformingunitspermilliliter cfu ml 100 000cfu ml1000to10 000cfu ml Locationofurinarytractnfection SymptomsandsignsLaboratoryfindingsX RayfindingsRadionuclideimagingMRIfindings Treatmentstrategy AntimicrobialdrugMdicationforpain fever andnausea TogivefluidsintravenouslyandorallyComplicatingfactors eg Obstructiveurographyorinfectedstones AcutePyelonephritis Definitions Acutepyelonephritisisdefinedasinflammationoftheparenchymaandthepelvisofthekidneycausingbybacterialinfection Etiology Pathogenesis Aerobicgram negativebacteriaEcoliGram negativeentricorganismsEnterococci andstaphylococcusaureusAscendinginfection VUR Hematogenous Clinicalfindings1 Anabruptonsetofchill moderatetohighfeverDysuria frenquency urgency Abdominalpain nausea vomiting andevendiarrhea Clinicalfindings2 CostovertebralangletendernessPalpationorpercussionoverthecostovertebralangleontheaffectedkidneyusuallycausespain Thepatientsometimeshasabdominaldistention tenderness andaquietintestine Dignosis1 Laboratoryfindings LeukocytosisPyuria Bacteriuria Proteinuria HematuriaQuantitativeurinecultureTotalrenalfunction Dignosis2 Imaging PlainfilmExcretoryurograms VoidingcystogramCTUltrasonographyRadionuclide DifferentialDiagnosis PancreatitisBasalpneumoniaAcute intra abdominaldiseaseWomenpelvicinflammatorydiseaseandacuteprostatitisRenalabscessPerinephricabcess Treatment1 Antimicrobialdrugs TheappropriateintravenoustreatmentOraldrugRepeaturinecultures Treatment2 Specificmeasures Anycomplicatingfactors eg obstructiveurography Prostatitis Typesofprotatitis Drach 1978 1 acuteandchronicbacterialprostatitis 2 nonbacterialprostatitis 3 prostatodynia NIDDKcategorizationandDrachclassification Diagnostictechniques Theexpressedprostaticsecretions EPS Leukocytes 10perhigh powerfield hpf The4 glasstest Stamey1968 Acutebacterialprostatitis Etiology Pathogenesis Ecoli80 Enterococci5 10 AnaerobesrarelyIntraprostaticrefluxofurineInvasionbyrectalbacteriaHematogenousspread Clinicalfeatures Thesuddenonsetoffever chills Lowbackandperinealpain Frenquencyandurgency nocturia dysuriaVaryingdegreesofbladderoutletobstruction Digitalrectalexamination DRE Tender swollenprostategland irregularlyfirmandwarmUrinemaybecloudyandmalodorous andgrosshematuriaisobserved Diagnosis Acompletebloodcountshowsleukocytosiswithashifttowardimmatureforms Thevoidedurineshowspyuria microscopichematuria andbacteria CultureofvoidedurinesampleusuallyidentifiesthepathogensUltrasonography Treatment Antibiotictreatmentfor4 6weeksSupportivemeasuresincludeantipyretics analgesics stoolsorfteners hydration andbedrest Anytransurethralcatheterizationorinstrumentationiscontraindicated Acuteurinaryretentionshouldbemanagedwithsuprapubicdrainage Chronicbacterialprostatitis Etiology Pathogenesis Thegram nagativeorganismsThegram positiveorganismsMycoplasmal chlamydialspeciesIntraprostaticrefluxofurinepHofprostaticsecretionsZinc Clinicalfindings1 Irritativevoidingdysfunction dysuriaurgency frequency nocturia LowbackorperinealpainSexualdysfunctionMyalgiaandarthralgiaOthersymptoms Clinicalfindings2 DRE normal tenderness swelling firmnessSecondaryepididymitisHematouria hematospermia urethraldischarge Diagnosis The4 glasstestTheexpressedprostaticsecretions EPS Leukocytes 10perhigh powerfield 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5 M 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4 6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2 4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 支原体等病原体感染 可口服四环素类或大环内酯类抗生素治疗 B型 不推荐使用抗生素治疗 治疗方法 受