INFECTIONS OF THE URINARY GENIROUTY TRACT

Although the urinary tract is normally sterile, urinary tract infections (UTIs) are very
common. UTIs may involve infection of the urinary bladder (cystitis) or the kidney
(pyelonephiritis) and may be symptomatic or asymptomatic. UTIs are diagnosed by
culture of the causative microorganism. Active infection Is usually considered to be
present when more than 100.000 bacteris/mL of urine appear in a clean-voided
specimen. The most common cause of urinary tract infection is Escherichia coli, a
gram-negative aerobic organism present in the lower intestinal tract. Infections also
may be caused by other organism, such as Klabsiella, Proteus, and Staphylococcus
species, especially in the presence of an endwelling catheter. Recurrent infections
are more often caused by these organism.

1. Cystitis

The most sommon genitourinary disease is cystitis, or inflammationof the

bladder mucosa. Risk factors for cystitis are shown in Box 22.2. numerous subtypes
of cystitis exits, based on cause or pathology exhibited. The term hemorrhagis
cystitis is used when bloody urine is present; this is often seen following
chemotherapy or radiation therapy over the bladder area. Suppurative cystitis
occurs when suppurative exudates accumulates on the endothelial lining of the
bladder; ulcerations of the mucosa may be also develop. Chronic interstitial cystitis
is associated with chronic, non-bacteril inflammation and suprapubic pain. In some
cases ulcer formation (Huuner ulcers) occurs; these are susceptible to bleding. It
involves all layers of the bladder, occurs more often in women, and is of unknown
etiology.

ETIOLOGY

Normally, any organism thet gain access to the bladder are rapidly expelled by
voiding and inhibitied by the acidity of urine. Decreased urinary stream, increases
bacterial colonization, and a susceptible host contribute to inadequate bacterial
expulsion. Urinary pH varies with systemic matebolic conditions. A less acid urine
may support bacterial colonization.

Cystitis is much more common in women than in men because of the

shortness of the urethra and the proximity of the uretheral opening and vagina to
the anal area. In women, sexual intercourse may traumatize the urethra and allow
bacteria to migrate to the bladder. Cystitis often developes inpersons with
indwelling urethral cetheters, even when they are receiving antimicrobial therapy.
Any individual who has an indwelling catheter for more than 96 hours is at hagh risk
for developing cystitis with organism that may become resistant ti antimicrobial
therapy. Nearly 100% of chronically catheterized develop UTIs.

CLINICAL MANIFESTATIONS
Cystitis is usually caused by organism that gain access to the bladder from the
urethra. Significant bacteriuria is present in 60% to 70% of case of cystitis.
However, some persons may have symptomatic cystitis without demonstration of a
causative organism by culture. Cystitis may be (1) acute or (2) chronic. Acute
cystitis is typically accompanied by frequent, painful urination, urinary urgency, and
suprapubic pain. Chronic cystitis may have no symptoms besides pyuria (white
blood bells in the urine).

22.2 Common Congenital Malformations Of The Urinary System

Abnormality Associated Problems

Diverticula of bladder
Exstriphy of bladder (exposure on
surface of body)
Fistulas between bladder and vagina,
rectum, uterus, or umbilicus
Abnormality of vesicoureteral junction
Agenesis of kidneys (failure to develop)
Hypoplasia of kidneys (abnormally small
size, usually unilateral)
Ectopic kidneys (displaced to pelvis or
abdomen)
Horsehoe kidneys (kidneys joined at
lower pole)
Fused pelvic kidney (pancake kidney)
Autosomal dominant (adult) polycystic
disease
Autosomal recessive (childhood)
polycystic disease
Infections, calculi formation,
vesicoureteral reflux, carcinoma (rare)
Infections, carcinoma
Infection
Vesicoureteral reflux, infections
Bilateral: incompatible with life;
unilateral: glomerulosclerosis and renal
failure
Renal insufficiency, infection
Infections, obstruction due thingking of
ureters
Obstruction of ureters
Obstruction
Hematuria, proteinuria, hypertension,
renal failure, cysts of liver, cerebral
aneurysms
Renal failure, cysts of liver

2. Pyelonephiritis

Inflammation of the renal pelvis, called pyelonephiritis, is mainly caused by

bacterial infection. Ascending infection from the bladder is the most common cause
of prelonephiritis. As with cystitis, the infection usually caused by gram-negative
bacteria. Urinary tract obstructions and vesicoureteral raflux also contribute to
development of kidney infections. Vesicoureteral reflux involves retrograde flow of
urine from structural abnormality of the urinary tract or develop following a UTI.
Pyelonephiritis may be either (1) acute or (2) chronic.

ACUTE PYELONEPHIRITIS
Clinical manifestations of acute pyelonephiritis usually include the sudden onset of
fever, chills, nausea, vomiting, diarrhea, and pain at the costovertebral angle.
Leukocytosis and pyuria are common, some hamaturia may be present initially. The
urine may show organism or may actually be sterile. Acute pyelonephiritis may
follow symptomatic or asymptomatic cystitis or, less commonly, a blood-borne
infection (septicemia). The symptoms of acute pyelonephiritis subside with or
without treatment, but urine colonization by organism may persist for weeks or
months. Acute pyelonephiritis causes abscesses on the cortical surface of the
kidney. Although damage to the glomeruli is rare, tubules may rupture. Healing
usually involves replacement of affected areas of the coertical surface by scar
tissue.

Chronic Pyelonephiritis

Chronic pyelonephiritis involves chronic tubular and interstitial inflammation

and scarring. It can result from various disease and conditions that are associated
with infections, obstructions, and reflux nephropathy. Chronic pyelonephiritis may
follow symptomatic or asymptomatic. UTIs or vascular and hiperextensive
conditions that affect of glomeruli. It is a common cause of chronic renal failure.
Severe vesicouteral reflux of obstruction may result in renal famage in the absence
of infection. Pathologically, the kidneys become scarred and irregular, and the
calices and renal pelvis become deformed. Gradual atrophy and destruction of the
tubules lead to chronic renal failure.

Clinical manifestations include either recurrent episodes of acute

pyelonephiritis or a gradual onset of renal insuffiency. Recurrent pyuria, bacteriuria,
back pain, fever, and mild proteinuria with lymphocytes and plasma celss may be
observed. Chronic pyelonephiritis associated with vesicoureteral reflux may lack
clinical manifestations until late in course of the disease.

DAMAGE TO RENAL STRUCTURES

Conditions of kidneys dysfunction are often divided into those that affect (1) the
glomeruli and (2) the ranal tubules and interstium. Some conditions affect more
than one structure, and damage to one structure almost always eventually affects
the others.

1. Glomerular Disease

Glomerular injury is the most common cause of chronic renal failure. Numerous
forms of glomerular disease exist; some are primary conditions, whereas others are
secondary to systemic or hereditary disease. Glomerular injury may also result from
chemicals, drug, iraadiation, hypoxemia, and other agents.
PHATOPHYSIOLOGY AND ETIOLOGY

Glomerular disease may be (1) nephritic or (2) nephritic, or both. In nephritic

disease, also called nephiritis, there is active proliferation of glomerular cells and an
extensive inflammatory process. Theinflammation leads to a decrease in glomerural
filtration rate (GFR), which may be transient or progress to renal failure. Decrease
GFR, with retension of sodium and water, may lead to hypertension. When damage
to the glomerulus causes increased permeability of the glomerular basement
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