泌尿、男生殖系统感染

2023/1/31泌尿、男生殖系统感染GenitourinaryInfection程帆ChengFanDepart.UrologyRenminHospitalWuhanUniversity2023/1/31Genitourinarysystem2023/1/31概要GeneralPrinciples尿路感染：Urinarytractinfections(UTIs)Inflammatoryreactionofurinarytractcausedbypathogenicbacteria(病原菌)

ThemostcommonclinicalproblemsinUrology,justsecondarytorespiratoryinfection(仅次于呼吸系统感染)2023/1/31Mostpatients:nounderlyinganatomic,metabolicorfunctionalabnormalitiesGeneralfactors:age,sex,stateofimmunocompetence(免疫活性状态),siteofinfection,infectiousagentsLocalfactors:bloodsupply,andthepresenceofobstruction2023/1/31分类Classification自然病程

Naturalhistory:firstinfectionandrecurrentinfection(unresolvedbacteriuria,bacterialpersistenceandreinfection)解剖部位Anatomicposition:upperandlowerurinarytractinfection2023/1/31病原微生物PathogenicorganismMostUTIsarecausedbyaerobicgram-negativerods（需氧革兰氏阴性杆菌）Certaingram-positivecoccialsocauseUTIswithsomefrequencySomeorganismsrequiredspecialtechniquesofidentification:Chlamydiatrachomatis(衣原体),Ureaplasmaurealyticum(支原体)Gram-positiverodsandunaerobicbacteria(厌氧菌)arerarelyimplicatedinUTIs2023/1/31发病机制Pathogenesis

ofurinarytractinfections病原菌的毒力和宿主的抵抗力

Bacterialpathogenesisintheurinarytractdependsonanumberoffactors,chiefofwhicharethevirulencecharacteristicsofthebacteriathemselvesandthehost’sabilitytoprotectitselfagainstinfectionTheinterplaybetweenthese2forcesdeterminesthepathogenicpotential2023/1/31病原菌因素BacterialFactors病原菌量

Quantityofbacteriasmorethan105/ml细菌毒力

Virulence细菌生物膜

Bacterialbiofilm2023/1/31宿主抗感染能力

Host’sabilityto

protectitselfagainstinfectionNormalorganismsinurethra：对病原菌的抑制与平衡作用NormalurineandvoidingEstrone:Vaginalepithelialcellandurethralepithelialcell2023/1/31易感因素

SusceptibleFactorsLowerimmunocompetence梗阻Obstruction医源性因素Iatrogenicfactors

2023/1/31感染途径

Modesofbacterial

entryintourinarytract上行

Ascending血行

Hematogenousspread淋巴

Lymphatogenousspread直接蔓延

Directextension2023/1/31上行感染

Ascendinginfectionfromtheurethra最常见的感染途径ThemostprevalentcauseofUTIs,HigherinwomenAshortenedurethraandAtendencyforrectalbacteriatocolonizetheperineum（会阴）andvaginalvestibule（阴道前庭）大肠杆菌最常见2023/1/31血行感染

Hematogenousspreadofinfectionintourinarytract机体其他部位感染病灶—入循环系统—泌尿系统MuchlesscommoninadultsButmaybeimportantinneonates（新生儿）Usually,producerenalandperirenalabscesses（脓肿）金黄色葡萄球菌最多见2023/1/31淋巴感染：Lymphatogenousspreadisprobablyveryrare

直接蔓延：Directextensionofinfectionfromneighbouringorgansmayoccurincertaincircumstance2023/1/31诊断

DiagnosisTypicalsymptoms:frequencyurgencypainanddysuriaRelyprimarilyonurinalysisandurineculture感染的定位：Localizationtechniquescansupplementinformationwhenthesourceofinfectionispresumed（治疗与预防）2023/1/31尿液的收集

UrinecollectionToimprovethereliabilityofresultsMidstreamurineCatheterization（女患者多采用）Suprapubicneedleaspirationofbladder2023/1/31尿液分析

UrinalysisMicroscopicexaminationofurinesedimentoftenallowspresumptivediagnosisifUTIsLeukocytes:Threeormorefreshleukocytesperhigh-powerfieldsuggestinfectionErythrocytesMicroorganismsEpithelialcellsCrystals2023/1/31尿液培养

UrinecultureQuantitativeurinecultureconfirmsthepresenceofpathogenicbacteriaColonycount（急性期未应用抗菌药物时）morethan100000/ml-infectionLessthan10000/ml-contamination

10000-100000/ml-suspicious2023/1/31上尿路感染的定位检查

UpperurinarytractlocalizationstudiesSymptomsUreteralcatheterEndoscopy2023/1/31影像学检查

Imaging

Ultra-soundKUB+IVUCTTofindthesusceptiblefactors2023/1/31治疗

Treatment

治疗目标OurgoalCompleteeliminationofbacterialgrowthintheurineToreleasetheirritatedvoidingsymptomsToprotecttherenalfunctionTopreventthespreadofinfectionToeliminatethesusceptiblefactors2023/1/31治疗

Treatment

Appropriateantibioticsshouldbeadministeredimmediately（尿培养+药敏）Moreoften,theidentificationoforganismsandsensitiveantibioticsareunknown,antimicrobialcoverageshouldbebroadened（广谱抗生素）支持、对症与诱因的治疗AndCardiovascularsupportPulmonarysupportCorticosteroidsadministration2023/1/31上尿路感染

Infectionoftheupperurinarytract

Upperurinarytract急性肾盂肾炎

Acutepyelonephritis肾积脓

Pyonephrosis多发肾脓肿

Mutiplerenalabscess肾周围炎

Perinephritis2023/1/31急性肾盂肾炎

AcutepyelonephritisBacterialinfectioncausingacuteinflammationoftheparenchymaandpelvisofthekidney2023/1/31病因与病理

EtiologyandpathogenesisThemostcommoncauseisaerobicgram-negativebacteriaAscentfromthelowertractisthemostcommonmechanismofinfection，其次为血行感染(G+)VesicoureteralrefluxObstructionAnatomicfactor:morecommoninfemalefortheshorterurethra2023/1/31临床表现

ClinicalFeaturesIncludingFeverandchillsFlankpainFrequencyurgencysuprapubicpainanddysuria头疼、恶性呕吐等全身症状Systemicsignsofinfection2023/1/31ClinicalFeaturesUrinalysis:PyuriaHematuriaUrineculture:growthofthecausativeorganismPhysicalexamination:tendernessofthecostovertebralangleandabdominaltenderness2023/1/31诊断

Diagnosis:veryeasytoconfirmaccordingtohistory,signsandexamination鉴别诊断

Differentialdiagnosisincludes胆囊炎cholecystitis,急性阑尾炎acuteappendicitis,and急性胰腺炎

acutepancreatitis2023/1/31治疗

Management抗菌药物治疗：

Inanycase,empiricantibiotictherapydirectedagainstthemostcommonpathogensshouldbestarted（7-14天）支持治疗：

Inpatientswithamoretoxicappearance,hospitalizationwithbedrest,intravenousfluidsandparenteralantibioticsmayberequired诱因治疗：

Itisimportanttodiagnoseandtreatcomplicatingfactorssuchasobstructionandstone2023/1/31并发症的治疗

ComplicationTreatedadequately,withoutleavingrenalscarsoranypermanentdamageProducingscarsandpermanentlydiminishrenalfunctionThemostseriouscomplicationissepticemia(败血症)withshockandpapillarynecrosis(肾乳头坏死)2023/1/31肾积脓

PyonephrosisLatestageofbacterialinfectioninahydronephronic,obstructedkidney（肾积水或梗阻性肾并发感染的晚期阶段）Withpyonephrosis,suppurativedestructionoftherenalparenchymaresultsinsignificantlossofrenalfunction（肾实质遭到化脓性破坏导致肾丧失）病原菌多为G—杆菌2023/1/31诊断

DiagnosisSymptoms:HighfeverchillsandflankpainHistory:Calculi.UTIsandpreviousurologicsurgeryImaging:Ultra-sound,CTetal2023/1/31治疗

ManagementBroad-spectrumparenteralantibiotictherapyReliefofobstructionanddrainageofpurulentmaterialNephrectomyisrecommendedtokidneywithlossoffunction2023/1/31多发肾脓肿

MutiplerenalabscessUsuallyarisingfromhematogenousspreadofbacteriaMostlystaphylococci(金黄色葡萄球菌)Predisposingfactors:infectedskinlesionsanddiabetes2023/1/31临床表现

ClinicalFindings突发发热寒战：AcuteonsetoffeverchillsandflankpainIVU:aspace-occupyinglesionCT:themostdiagnostic,itcanidentifytheabscessanditsextensionandsurroundingstructures(最具有诊断意义,它可以明确脓肿及其范围和周围组织)2023/1/31治疗

ManagementEarlyenoughintrovenousantibioticsmaybesufficientmanagement(早期足量静脉抗生素使用)(6-8weeks)Ifnofavorableclinicalresponsesisapparentafter48hofantibiotictreatment,ultrasound-guidedaspirationanddrainageshouldbeemployedNephrectomy2023/1/31肾周围炎

Perinephritis

肾周围脓肿

perinephricabscessPerinephritisisthesuppurativedestructionoftheperirenaltissuePerinephricabscessesarecollectionsofpurulentmaterialwithintheperinephricspace,whichliesbetweenkidneyandGerota’sfascia2023/1/31下尿路感染

Infectionof

theLowerUrinaryTract2023/1/31急性细菌性膀胱炎

AcutebacterialcystitisAcuteuncomplicatedbacterialcystitispredominantlyaffectswomen(解剖原因）2023/1/31病因与病机

EtiologyandPathogenesisAbsenceofanatomicorfunctionalabnormalityoftheurinarytract上行感染：Ascendingfecal-perineal-urethralrouteistheprimarymodeofinfectionHoneymonthcystitisMalepatientsalmostcausedbyoutflowobstruction,endoscopeexam,etal2023/1/31临床表现

ClinicalFindingsOnsetofdysuria,frequency,urgency,lowbackandsuprapubicpainPyuria(100%)Hematuria(50%infemale)Feverandotherconstitutionalsymptomsareunusual2023/1/31内镜检查

EndoscopyEndoscopyisindicatedinthepresenceofgrossormicroscopichematuriathatpersistsaftertheinfectionistreated（抗感染治疗后持续存在肉眼或镜下血尿）Cystoscopyshouldbedelayeduntiltheacuteinfectionhasbeentreated2023/1/312023/1/31治疗TreatmentSensitivemedicineshouldbegivenintwoweeksaftertheurineissterile敏感抗生素要在尿液分析无菌后继续使用2周Broad-spectrumantibioticsUrinecultureandsensitivetestwhenrequired2023/1/31ChronicbacterialcystitisAcuteurethritis2023/1/31

男生殖系统感染

Infectionofmalegenitalsystem2023/1/31前列腺炎综合征

Prostatitissyndrome

Approximately50%ofmenexperienceprostaticsymptomsatsometimeinlifeThemostcommonurologicdiagnosisinmenwith50yearsofageandthirdmostcommoninoldermen2023/1/31前列腺炎综合征的传统分类TraditionalclassificationtoprostatitissyndromeAcutebacterialprostatitis,ABPChronicbacterialprostatitis,CBPChronicnonbacterialprostatitis,NBPProstatodynia,PD2023/1/31NewclassificationofNIH

(NationalInstisutesofHealth)Category Name

CriteriaⅠ急性细菌性前列腺炎(ABP

) Acute,symptomaticbacterialinfectionⅡ慢性细菌性前列腺炎

(CBP) RecurrentprostateinfectionⅢ慢性前列腺炎/慢性骨盆疼痛综合征

NoclearlyidentifiableinfectionⅢAInflammatorytype(CNP)LeukocytespresentinEPS/VB3/SemenⅢBNoinflammatorytype(CP)NoleukocytesinEPS/VB3/SemenⅣ无症状性前列腺炎

NosubjectivesymptomsAsymptomaticinflammatoryprostatitis(AIP)2023/1/31急性细菌性前列腺炎

AcutebacterialprostatitisEtiologyandpathogenesis

多于劳累、饮酒、性生活过频后发生UsuallyresultsfromascendingurethralinfectionAlsohematogenous,directorvialymphogenousspreadAerobicgram-negativeorganisms(常见)2023/1/31临床表现

ClinicalFeaturesCharacterizedbySuddenonsetoffever,chillLowbackandperinealpainDysuria（排尿困难）Digitalrectalexamination:Exquisitelytender,enlargedgland（触痛、肿大、波动感、温度升高等）UsuallyprostatemassageisforbiddenOftenconcomitanturinaryinfection2023/1/31诊断

Diagnosis1.Symptoms2.Physicalexamination3.尿液中白细胞数量升高，血液或/和尿液中的细菌培养阳性

4.Transrectalultrasound(TRUS)：腺体增大、回声不均匀5.CT2023/1/31治疗

Management全身支持治疗Antibiotictherapy关键Durationoftherapyatleast4-6weekstoensureeradicationofinfectionBladderdrainageshouldbemanagedwithasuprapubictube,ifretentionTransurethralcatheterizationshouldbeavoided2023/1/31慢性前列腺炎

ChronicprostatitisClinicalfeaturesDysuriaaswellasurgency,frequencyandnocturiaLowbackorperinealpainordiscomfortEDSymptomsfrombeingnervoustoCP2023/1/31慢性前列腺炎的诊断方法

MethodstodiagnoseCP前列腺按摩液

EPSExpressedprostaticsecretionMorethan10LeukocytesperHPEPSorVB3culturetocomfirmCBP2023/1/31Meares-StameyTest-1968VB1:初始尿液

t