Genitourinary Infections

Keith LaScalea, MD
As#faculty#of#Weill#Cornell#Medical#College,#we#are#commi8ed#to#
providing#transparency#for#any#and#all#external#rela<onships#prior#to#
giving#an#academic#presenta<on.#
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I#do#not#have#a#nancial#interest#in#commercial#products#or#services#
related#to#the#subject#of#this#lecture.##
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!Keith'LaScalea,'MD'
Introduction
Urinary Tract Infections are among the
most common conditions encountered in
clinical practice.
6.2 million physician office visits/year
40-50% of adult women have had a UTI.
UTIs are the leading cause of gram-
negative sepsis in hospitalized pts.
Genitourinary Infections
Overlapping syndromes and classification:
lower tract infections:
urethritis, cystitis, prostatitis
upper tract infections:
pyelonephritis, renal and perinephric abscesses
symptomatic vs. asymptomatic bacteruria
uncomplicated vs. complicated
Uncomplicated UTIs occur in otherwise healthy individuals with intact voiding mechanisms,
most often females
Complicated UTIs occur in both sexes who have functional or structural disease; at increased
risk for severe renal damage, bacteremia, sepsis and increased mortality
UTIs - pathogenesis
Multiple paths to infection: ascending infection,
blood-borne, unresolved foci (prostate, kidney,
calculi), fistulous communication (ie: in Crohn s)
Bacterial virulence/adhesion factors promote
bacterial growth
Host defense mechanism deter bacterial growth
flushing and diluting of urine
acidity, osmolality (hypertonicity), prostatic secretions, urinary
mucoproteins (Tamm-Horsfall), Immunoglobulin A
normal vaginal flora
antibacterial properties of uroepithelium
local inflammatory response ---> symptoms (which leads to early
tx)
Which of the following bacteria should alert you that there
may be something going on outside the GU system?

1. Staph aureus came from the blood i.e.

endocarditis

2. E coli
3. Proteus
4. Enterobacter
Routes of Infection

The urinary tract is ordinarily sterile except at the distal end of the urethra
and the meatus.
UTIs - Epidemiology
First 3 months of life-boys3X more likely to have
UTIs
<1-5 years of age: congenital abnormalities,
vesicoureteral reflux
School age girls: 30X higher than boys, 5-6% will
get an episode of bacteruria
Thereafter, a women s chance of UTI increases
10% per decade.
Young women - 50x>men
Which of the following are protective against UTIs?

1. Female gender
2. Prostatic fluid
3. Shorter urethra
4. Immune-compromised status
5. Repeat GU instrumentation
6. Kidney stones
7. Frequent sexual activity
8. Uncircumcised penis
UTIs - risk factors
Gender (women have shorter urethras, smaller
distance between anus and urethra, no prostatic
fluid)
Sexual activity (ie: honeymoon cystitis)
Use of spermicide/diaphragm (may disrupt flora)
Any type of obstruction (stones, pregnancy)
Vesicoureteral reflux
Genetic factors (nonsecretors of histo-blood group
antigens, those who carry E. coli with P fimbriae
in the bowel at increased risk)
UTIs - risk factors (continued)
Underlying disease (DM, PCKD)
Young men: anal sex, HIV, lack of circumcision
Older age: BPH, post-menopausal,
catheterization/instrumentation, surgery, stones,
neurogenic bladder
***All men, infants & children need evaluation of
urinary tract if they get a UTI- ultrasound with
post-micturation bladder volumes + KUB AXR or
IV urogram; cystoscopy is sometimes helpful.***
UTIs - etiologic agents
Uncomplicated UTI: uropathogenic E. coli (80-90%),
GNB s (Proteus, Klebs, Enterobacter), Staph
saprophyticus
Complicated: GNB s, Pseudomonas, Serratia,
Enterococcus
Urease-producers (Proteus, Providencia, Morganella)
increase struvite cystals ---> nephrolithiasis
Bacteremia/hematogenous spread: Staph aureus, fungi
Sterile pyuria: STD s, Mycobacterium tb
Uropathogenic E. coli

:
Clinical Manifestations: Cystitis
Usually women, occasionally young men
Dysuria, frequency, urgency, incontinence,
lack of fever
Suprapubic tenderness (10%), hematuria
(30%)
Must differentiate from vaginitis, urethritis
10-35% will have upper tract involvement
(symptoms > 7d, recent UTI)
 Clinical Manifestations:
Pyelonephritis
elder people may not present like this

Localized flank or low back/abd pain, systemic

symptoms, rigors, nausea, vomiting
Fever & flank pain relatively specific
Significant range of disease (may present early
with just fatigue or headache)
Must distinguish from PID in women
Necrotizing complications (diabetics,
immunocompromised)
May take days to defervesce despite appropriate tx
Appropriate indications for catheters include which of the following?

1. Perioperative use of selected surgeries YES

2. Urine output monitoring for critically ill patients YES
3. Urine output monitoring for diuretics and or strict ins/outs YES
4. Management of acute urinary retention or blockage YES!!
YES
5. Stage III or IV perineal or sacral pressure ulcer in a pt with urinary incontinence
6. Gross hematuria YES
7. Palliative care/pt request for comfort YES
8. Patients requiring prolonged immobilization (e.g. unstable thoracic or lumbar spine)
YES
9. Patient and Nurse convenience (to decrease bedpan requests) NO
10. Routine flows monitoring NO
11. Kidney stones NO
12. All of the above
13. Some of the above
UTIs catheter associated infections
35-40% of nosocomial infections are UTIs
Those hospitalized pts who develop bacteremia
from UTIs have 3x mortality rate
3 routes of infection (next slide)
risk with time: 3-5% risk of developing UTI/day
the catheter stays in
resistance, virulence
treatment for symptomatic cases, removal of
catheter
Which of the following is NOT a NYH measure to prevent CAUTIs?

1. Avoiding unnecessary catheter use

2. Reviewing catheter use daily and documenting need
for continued use
3. Maintaining catheter per guidelines
4. Inserting catheters using aseptic techniques
5. Educating and communicating effectively with the care team
6. Removing all urinary catheters at day 2 of hospitalization
UTIs - Diagnosis
***Need proper collection of urine for all of these
(midstream catch, suprapubic aspiration, or
catherized specimen)***
Pyuria (>=10WBCs/hpf) in centrifuged urine is
highly sensitive - less so for complicated UTIs,
not as reproducible
(+)leukocyte esterase on urine dipstick (min of
8WBCs)
Bacteria detection on urine dipstick (nitrite test-
more reliable in first morning void samples)
UTIs Diagnosis (continued)
Urine cultures > 105 colonies is considered
positive, though fewer may be predictive (ie: in
men, >103 is highly predictive)
Blood cultures

Microscopic hematuria (in 40-60% of UTIs) -

may suggest nephrolithiasis
UTIs - Treatment
Presumptive therapy in sexually
active women in whom STI is
unlikely & sx are consistent is
cost-effective and appropriate
Therapy dictated by:
Localization of disease
Etiologic agent, resistance
Complicating factors: pregnancy,
obstruction, relapse
UTIs Treatment (continued)
Oral vs intravenous antibiotics
Short-course usually appropriate in uncomplicated
cases
Commonly used choices (based on local resistance
patterns): Trimethoprim-sulfamethoxazole,
Amoxicillin, Nitrofurantoin, Cephalexin, Ciprofloxacin
Large amounts of water or alkalizing agents can
decrease sx but do NOT influence bacterial
eradification.
Asymptomatic Bacteruria
Isbest left untreated except in which of the
following situations?:
1. Pregnancy (as there is an increased risk of
pyelo, prematurity with bacteruria)
2. In diabetics or HIV patients (since they have a
compromised immune system)
3. In a pt about to undergo invasive procedure of
the GU tract or before the insertion of any
permanent indwelling devices (especially
prosthetic joints)
4. In only two of the above.
Prostatitis
Broad spectrum of disease (can be asx, can mimic
cystitis or can cause pelvic pain syndrome)
Can cause or worsen urinary obstructive sx
Acute vs. chronic
Dx: tender, enlarged prostate; abnormal urine or
clinical dx; increased PSA on labs
Requires longer tx course secondary to protective
prostatic capsule
Renal and Perinephric Abscess
2 major routes of infection (ascending with
obstruction, hematogenous); uncommon
complication of UTI
Organisms: enteric GNB s, Staph, fungi, multiple
(25%)
Extension of infection --> perinephric, psoas
abscess, peritonitis
Risk factors: stones, trauma, DM, instrumentation
Non-specific symptoms: fever, abdominal or flank
pain, lack of response to therapy (pts are often ill
>2 wks before diagnosed)
Renal/Perinephric Abscess (cont)
Diagnosis: Urinalysis abnormal in 70% of pts
with corticomedullary abscess but usually normal
in pts with hematogenous cortical or perinephric
abscess.
So diagnosis requires radiological confirmation:
sonography, CT, IVP
Treatment: antibiotics, surgery
perinephric abscesses often require surgical or
percutaneous drainage
intrarenal abscess < 3cm usually respond to abx alone,
intervention only for lack of response or large
collections (> 5cm)
Renal Abscess
PID/Pelvic Abscess
Ascending infection of endometrium, fallopian
tubes
1 million cases/year: 25% develop infertility,
ectopic pregnancy, TOA
Difficult diagnosis to make as few reliable dx
criteria
Polymicrobial process: STD s, typical bacteria
Risk factors: multiple sexual partners, young age
of sexual contact, unprotected sex
PID Diagnosis & Treatment
Diagnosis: clinical; laparoscopy gold standard
Minimum Criteria: [+ sexual activity, no alternative
cause(s)]
Lower abdominal tenderness,
Adnexal tenderness, and
Cervical motion tenderness.
Additional Supportive Criteria:
Temp > 38.3
Abnormal cervical or vaginal discharge,
Elevated erythrocyte sedimentation rate,
Elevated C-reactive protein, and
Laboratory documentation of cervical infection with N. gonorrhoeae or C.
trachomatis.
PID Diagnosis & Treatment
Definitive Criteria:
Histopathologic evidence of endometritis on endometrial biopsy,
Transvaginal sonography or other imaging techniques showing thickened
fluid-filled tubes with or without free pelvic fluid or tubo-ovarian
complex, and
Laparoscopic abnormalities consistent with PID.
Treatment: the earlier, the better
IV: cefoxitin + doxycycline, clindamycin + gentamicin, amp/
sulbactam + doxy
Oral: ceftriaxone + doxycycline, cefotxime or ceftizoxime +
doxycycline +/- metronidazole
Note: quinolones no longer indicated secondary to high resistance
rates!
Hospitalization if: abscess, pregnant, failure/intolerable of oral regimen,
severe illness, immunocompromised
You will do well on your Boards
because?:
1. You came to all your BOD talks
2. You came to all the MPS lectures and
small groups
3. You really mastered the CVA punch in
physical diagnosis
4. You memorized the slides