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1、Infection of the Genitourinary TractHongshu MaDepartment of UrologyTianjin 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 anyor all of the others. Definitions 1Definitions
2、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. De
3、finitions 2Definitions 2Definitions 3Definitions 3Bacteriuria 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 4Definitions 4Pyuria is the pr
4、esence 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. ClassificationAccording to their nature history First infections/Isolated InfectionRecurrent
5、infections Bacterial persistence ReinfectionsReinfection 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 cause
6、d by the same bacteria from a focus within the urinary tract, such as an infection stone or the prostate.According to Their Site of OriginUpper urinary tract infection Lower urinary tract infectionGenital system infectionUpper-tract infectionAcute pyelonephritisChronic pyelonephritisEmphysematous py
7、elonephritisRenal abscess Perinephric abscessXanthogranulomatous pyelonephritisLower-tract infectionAcute urethral syndrome WomenAcute cystitis Genital infectionAcute and chronic bacterial prostatitis.Acute and chronic epididymitis.PathogenesisBacterial pathogenesis in the urinary tract depends on a
8、 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 factorsEmptying of urineSurface muc
9、ins Urinary antibodiesUrinary osmolalitypHRoutes of infection 1 Ascending infection 2 Hematogenous spread3 Lymphatogenous spread4 Direct extension DIAGNOSISUrine CollectionSuprapubic AspirationUrethral CatheterizationSegment Voided Urine SpecimensUrinlysis More than 3 fresh leukocytes/High- power fi
10、eldQuantitative 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 signsLaboratory findingsX-Ray findingsRadionuclide imagingMRI findings Treatment strategy.Antimicrobial drug Mdication for pain, fever, and
11、nausea. To give fluids intravenously and orally Complicating factors eg. Obstructive urography or infected stones Acute PyelonephritisDefinitionsDefinitionsAcute pyelonephritis is defined as inflammation of the parenchyma and the pelvis of the kidney causing by bacterial infection. Etiology & Pa
12、thogenesisAerobic gram-negative bacteria E coli Gram-negative entric organisms Enterococci, and staphylococcus aureusAscending infection VUR HematogenousClinical findings 1An abrupt onset of chill , moderate to high fever Dysuria, frenquency, urgency.Abdominal pain, nausea, vomiting, and even diarrh
13、ea. Clinical findings 2Costovertebral angle tendernessPalpation or percussion over the costovertebral angle on the affected kidney usually causes pain.The patient sometimes has abdominal distention, tenderness, and a quiet intestineDignosis 1Laboratory findings:Leukocytosis Pyuria, Bacteriuria, Prot
14、einuria, HematuriaQuantitative urine culture Total renal function Dignosis 2Imaging:Plain film Excretory urograms . Voiding cystogram CT Ultrasonography RadionuclideDifferential DiagnosisPancreatitis Basal pneumonia Acute-intra-abdominal disease Women pelvic inflammatory diseaseand acute prostatitis
15、 Renal abscess Perinephric abcess. Treatment 1 Antimicrobial drugs:The appropriate intravenous treatment Oral drug Repeat urine cultures Treatment 2Specific measures: Any complicating factors eg. obstructive urography ProstatitisTypes of protatitisDrach 19781 acute and chronic bacterial prostatitis,
16、2 nonbacterial prostatitis3 prostatodynia. NIDDK categorization and Drach classificationNIDDK Classification1995Drach classification 1978Category 1 Acute bacterial prostatitis Acute bacterial prostatitis Category 2 Chronic bacterial prostatitis Chronic bacterial prostatitis Category 3 Chronic pelvic
17、 pain syndrom 3a Inflammatory typeNonbacterial prostatitis 3b Noninflammatory type ProstatodyniaCategory 4 Asymptomatic inflammatory prostatitisDiagnostic techniquesThe expressed prostatic secretions EPSLeukocytes 10 per high-power field hpf The 4-glass test Stamey 1968 Urethritis Cystitisprostatiti
18、sVB1 + +/- -/+VB2 - + -EPS - -/+ + 10 times than VB1VB3 - -/+ + Acute bacterial prostatitisEtiology & 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
19、 back and perineal pain.Frenquency and urgency, nocturia, dysuriaVarying degrees of bladder outlet obstruction.Digital rectal examination DRETender, swollen prostate gland, irregularly firm and warmUrine may be cloudy and malodorous, and gross hematuria is observedDiagnosis A complete blood count sh
20、ows leukocytosis with a shift toward immature forms. The voided urine shows pyuria, microscopic hematuria, and bacteria.Culture of voided urine sample usually identifies the pathogensUltrasonographyTreatmentAntibiotic treatment for 4-6 weeks Supportive measures include antipyretics, analgesics, stoo
21、l sorfteners, hydration, and bed rest.Any transurethral catheterization or instrumentation is contraindicated. Acute urinary retention should be managed with suprapubic drainage Chronic bacterial prostatitisEtiology & PathogenesisThe gram-nagative organismsThe gram-positive organismsMycoplasmal,
22、 chlamydial speciesIntraprostatic reflux of urinepH of prostatic secretionsZinc Clinical findings 1Irritative voiding dysfunctiondysuria urgency, frequency, nocturia Low back or perineal painSexual dysfunctionMyalgia and arthralgia Other symptomsClinical findings 2DRE: normal, tenderness, swelling,
23、firmnessSecondary epididymitis Hematouria, hematospermia, urethral dischargeDiagnosisThe 4-glass testThe expressed prostatic secretions EPSLeukocytes 10 per high-power field hpfSonography鉴别诊断II型和III型应与能够导致骨盆区域疼痛和排尿异常的疾病进展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、前列腺癌治疗原那么慢性前列腺炎无明确的进展性,缺
24、乏以要挟患者的生命和重要器官功能,并非一切的前列腺炎均需治疗。慢性前列腺炎的治疗目的主要是缓解疼痛、改善排尿病症和提高生活质量,疗效评价应以病症改善为主。前列腺炎应采取综合治疗。治疗方法治疗方法 一、一、型型一旦临床诊断或得到血、尿培育结果后,应立刻运一旦临床诊断或得到血、尿培育结果后,应立刻运用抗生素。用抗生素。开场时可经静脉运用抗生素,如:广谱青霉素、三开场时可经静脉运用抗生素,如:广谱青霉素、三代头孢菌素代头孢菌素 、氨基糖甙类或氟喹诺酮等。、氨基糖甙类或氟喹诺酮等。待患者的发热等病症改善后,改用口服药物如氟待患者的发热等病症改善后,改用口服药物如氟喹喹 诺酮等,疗程至少诺酮等,疗程至少
25、4周。周。并发症处置:并发症处置: 伴尿潴留者伴尿潴留者细管导尿或膀胱穿刺造瘘。细管导尿或膀胱穿刺造瘘。 伴脓肿构成者伴脓肿构成者可采取穿刺引流、经尿道切开可采取穿刺引流、经尿道切开引流引流治疗方法治疗方法二、二、型和型和型型一普通治疗一普通治疗 : 安康教育、心思和行为辅导有积极作安康教育、心思和行为辅导有积极作用。用。 慢性前列腺炎患者应戒酒,忌辛辣刺慢性前列腺炎患者应戒酒,忌辛辣刺激食激食 物;防止憋尿、久坐,留意保暖,加物;防止憋尿、久坐,留意保暖,加强体育锻炼。强体育锻炼。 热水坐浴有助于缓解疼痛病症。热水坐浴有助于缓解疼痛病症。 治疗方法治疗方法 二、二、型和型和型型 二药物治疗二
26、药物治疗 1抗生素抗生素 2-受体阻滞剂受体阻滞剂 3非甾体抗炎镇痛药非甾体抗炎镇痛药 4植物制剂植物制剂 5M-受体阻滞剂受体阻滞剂 6抗抑郁药及抗焦虑药抗抑郁药及抗焦虑药 7中医中药中医中药 治疗方法治疗方法 抗生素抗生素 型:型: 根据细菌培育结果和药物穿透前列腺的才干选择抗生根据细菌培育结果和药物穿透前列腺的才干选择抗生素。药物穿透前列腺的才干取决于其离子化程度、素。药物穿透前列腺的才干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构造等。脂溶性、蛋白结合率、相对分子质量及分子构造等。 常用的抗生素是氟喹诺酮类药物如环丙沙星、左氧常用的抗生素是氟喹诺酮类药物如环丙沙星、左氧
27、氟沙星和洛美沙星等、四环素类如米诺环素等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。和磺胺类如复方新诺明。前列腺炎确诊后,抗生素治疗疗程为前列腺炎确诊后,抗生素治疗疗程为46周,周,治疗方法治疗方法 A型:型:抗生素治疗大多为阅历性治疗。抗生素治疗大多为阅历性治疗。引荐先口服氟喹诺酮或四环素等类抗生素引荐先口服氟喹诺酮或四环素等类抗生素24周,然后周,然后根据其根据其 疗效反响决议能否继续抗生素治疗。疗效反响决议能否继续抗生素治疗。只需当患者的临床病症确有减轻时,才建议继续运用只需当患者的临床病症确有减轻时,才建议继续运用抗生素。引荐的总疗程为抗生素。引荐的总疗程为4 6周。
28、周。部分患者能够存在衣原体、支原体等病原体感染,部分患者能够存在衣原体、支原体等病原体感染, 可可口服四环素类或大环内酯类抗生素治疗。口服四环素类或大环内酯类抗生素治疗。B型:不引荐运用抗生素治疗。型:不引荐运用抗生素治疗。 治疗方法治疗方法-受体阻滞剂受体阻滞剂 -受体阻滞剂能松弛前列腺和膀胱等部位的平滑肌而改受体阻滞剂能松弛前列腺和膀胱等部位的平滑肌而改善下尿路病症和疼痛,为治疗善下尿路病症和疼痛,为治疗型型/型前列腺炎的型前列腺炎的 根本药物之一。根本药物之一。可选择不同的可选择不同的-受体阻滞剂治疗。常用药物有:阿夫唑受体阻滞剂治疗。常用药物有:阿夫唑嗪、多沙唑嗪、萘哌地尔、坦索罗辛和特拉唑嗪等。嗪、多沙唑嗪、萘哌地尔、坦索罗辛和特拉唑嗪等。-受体阻滞剂的疗程至少应在受体阻滞剂的疗程至少应在12周以上。治疗中应留意周以上。治疗中应留意该类药物导致的眩晕和体位性低血压等不良反响。该类药物导致的眩晕和体位性低血压等不良反响。a型前列腺炎单一运用抗生素或型前列腺炎单一运用抗生素或-受体阻滞剂疗效不佳受体阻滞剂疗效不佳时,可二者结合运用,疗程时,可二者结合运用
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