Infection of the

Genitourinary
tract
By: Aya Zawahra
6th year medical student
Supervisor Dr. Hasan Adi
Source: Step up to medicine 6th ed
Outlines:

1)Cystitis (Lower Urinary Tract Infections)

2)Pyelonephritis

3)Prostatitis
 Cystitis (Lower Urinary Tract Infections)
- Cystitis is much more common in women than in men. Up to 33% of all
women experience cystitis in their lifetime. The most common type is acute
simple (uncomplicated) cystitis.
- Simple or uncomplicated cystitis refers to infection limited to the bladder.
- When infection has extended beyond the bladder and there are features
suggestive of systemic illness (e.g., fever, chills, flank pain), this is
considered complicated UTI.
- The majority of cases are caused by ascension of pathogens from the urethra
to the bladder.
- These pathogens are from fecal flora that have colonized the area.
 Common organisms.
a. E. coli (most common)—causes 80% of cases.
b. Other organisms—Staphylococcus saprophyticus, Enterococcus,
Klebsiella, Proteus spp., Pseudomonas, Enterobacter, and yeast
(such as Candida spp.)
Risk Factors

1. Female genital anatomy— due to short urethra and distance from anus to urethra
2. Sexual intercourse
a. Often the trigger of cystitis in women
b. Use of diaphragms and spermicides further increases risk (alters vaginal
colonization)
3. Pregnancy
4. Indwelling urinary catheters—risk factor for hospitalized patients
5. Personal history of recurrent UTIs
6. Host-dependent factors—increase risk for recurrent or complicated cystitis
a. Diabetes mellitus
b. Patients with spinal cord injury
c. Immunocompromised state
d. Any structural or functional abnormality that impedes urinary flow (e.g.,
incomplete voiding, neurogenic bladder, BPH, vesicoureteral reflux, calculi)
7. Male risk factors
e. Uncircumcised males
f. Insertive anal intercourse
g. Vaginal intercourse if colonized with uropathogens
Noninfectious causes of cystitis or cystitis-like symptoms:
• Cytotoxic agents (e.g., cyclophosphamide)
• Radiation to the pelvis
• Dysfunctional voiding
• Interstitial cystitis
Clinical Features

1. Dysuria—commonly expressed as burning on urination

2. Frequency
3. Urgency
4. Suprapubic tenderness
5. Gross hematuria is sometimes present
6. In acute simple cystitis, fever and other systemic symptoms are
characteristically absent
 Diagnosis

Dipstick Urine Urine Blood

Urinalysis others
urinalysis gram stain culture cultures
1. Dipstick urinalysis

- Positive urine leukocyte esterase test—presence of leukocyte esterase reflects pyuria

- Positive nitrite test for presence of bacteria (gram-negative)—nitrite test is sensitive and
specific for detecting Enterobacteriaceae and other nitrite-producing bacteria.
 But it lacks sensitivity for other organisms, so a negative test should be interpreted
with caution
- Combining the above two tests yields a sensitivity of 85% and specificity of 75%
2. Urinalysis
(clean-catch midstream specimen)

Adequacy of collection
• The presence of epithelial (squamous) cells indicates vulvar or urethral
contamination
• If contamination is suspected, perform a straight catheterization of the
bladder
Criteria for UTI (interpret in presence of symptoms)
• Bacteriuria: ≥1 organism per oil-immersion field. Bacteriuria without WBCs
may reflect contamination and is not a reliable indicator of infection
• Pyuria is the most valuable finding for diagnosis: >10 leukocytes/μL is
abnormal
Other findings—hematuria and mild proteinuria may be present.
On UA, most important finding is white blood cells.
3. Urine Gram stain

- A count of >105 organisms/mL represents significant bacteriuria

- It is 90% sensitive and 88% specific

4. Urine culture
- Confirms the diagnosis (high specificity). Obtaining a urine culture is warranted if
symptoms are not characteristic of cystitis, if a complicated infection is suspected, if
antimicrobial resistance is suspected, or if symptoms persist despite prior antibiotic
treatment
- Traditional criteria: ≥105 CFU/mL of urine from a clean-catch sample; misses up to
one-third of UTIs
- Colony counts as low as 103 CFU/mL are adequate for diagnosis if clinical symptoms
are present, especially if at risk for complicated UTI
5. Blood cultures

- only indicated if patient is ill and systemic infection is

suspected
6. Others

- IV pyelogram, cystoscopy, and excretory urography are not

recommended unless structural abnormalities or obstruction
is suspected
 Complications

1. Complicated UTI
a. Any UTI that spreads beyond the bladder (e.g., pyelonephritis, prostatitis, sepsis).
Commonly presents with signs of infection beyond bladder (e.g., fever, chills, flank
pain, costovertebral angle tenderness, perineal pain suggestive of prostatitis)
b. Risk factors for upper UTI: pregnancy, diabetes, immunocompromising conditions, or
urologic abnormalities

2. UTI during pregnancy—increased risk of preterm labor, low birth weight, and other
complications, especially in advanced pregnancy

3. Recurrent infections
c. Usually due to infection with new organism, but sometimes is a relapse due to
unsuccessful treatment of the original organism
d. Risk factors include impaired host defenses, pregnancy, vesicoureteral reflux, and sexual
intercourse
 Treatment
1. Acute uncomplicated cystitis—most commonly in nonpregnant women.
Several options exist:
a. Oral TMP/SMX (Bactrim) for 3 days.
b. Nitrofurantoin (5 to 7 days)—do not give if early pyelonephritis is suspected.
c. Fosfomycin (single dose)—do not give if early pyelonephritis is suspected.
d. Amoxicillin-clavulanate, cefpodoxime, or cefadroxil can be used alternatively if any of
the above are not options.
e. Avoid amoxicillin monotherapy due to high prevalence of antimicrobial resistance.
f. Fluoroquinolones (ciprofloxacin in 3-day regimen) is a reasonable alternative to the
above-mentioned agents. Try to avoid due to higher rates of adverse effects with
fluoroquinolones.
g. Treat presumptively for pyelonephritis if the condition fails to respond to a short course
of antibiotics.
h. Phenazopyridine (Pyridium) is a urinary analgesic; it can be given for 1 to 3 days for
dysuria.
2. Pregnant women with UTI
a. Treat with amoxicillin, foxfomycin, or oral cephalosporins for 7 to 10 days.
b. Avoid fluoroquinolones (can cause fetal arthropathy).

3. UTIs in men
c. Treat as with uncomplicated cystitis in women, but consider longer duration (5 to 7
days) if concern for complicated UTI.
d. Urologic workup is recommended in men with recurrent UTI, including evaluation for
prostatic hypertrophy or other urinary tract obstruction.
4. Recurrent infections
a. If relapse occurs within 3 months, check a urine culture to evaluate for antimicrobial
resistance.
b. Otherwise treat as for uncomplicated cystitis. If the patient has two or more UTIs within
6 months, consider antibiotic prophylaxis. However, must weigh risk of adverse effects
and selection for resistant bacteria.
• Postcoital prophylaxis in women with recurrent UTI: single dose of TMP/SMX or
nitrofurantoin after intercourse or at first signs of symptoms.
• Alternative low-dose prophylactic antibiotics (e.g., low-dose TMP/SMX) for 3-
month trial.

Asymptomatic Bacteriuria
o To diagnose asymptomatic bacteriuria, two successive positive cultures (≥105
CFU/mL) must be present.
o Treat asymptomatic bacteriuria only in pregnancy or before urologic surgery.
 Pyelonephritis
- Pyelonephritis is an infection of the upper urinary tract.
a. It is usually caused by ascending spread from the bladder to the kidney
b. Vesico-ureteral reflux facilitates this ascending spread.
- Organisms
c. E. coli (most frequent cause).
d. Other gram-negative bacteria include Proteus, Klebsiella, Enterobacter, and
Pseudomonas spp.
e. Gram-positive bacteria (less common) include Enterococcus faecalis and S.
aureus
- Complications
f. Sepsis occurs in 10% to 25% of patients with pyelonephritis. May lead to shock.
g. Emphysematous pyelonephritis—caused by gas-producing bacteria, typically in
patients with diabetes mellitus and urinary tract obstruction
h. Chronic pyelonephritis and scarring of the kidneys—rare unless underlying
renal disease exists
Clinical Features

 Symptoms
a. Fever, chills
b. Flank pain
c. Symptoms of cystitis (may or may not be present)
d. Nausea, vomiting, and diarrhea (sometimes present)

 Signs
e. Fever with tachycardia
f. Patients generally appear more ill than patients with cystitis
g. Costovertebral angle tenderness—unilateral or bilateral
h. Abdominal tenderness may be present on examination
Diagnosis
1. Urinalysis;
A. Look for pyuria, bacteriuria, and leukocyte casts.
B. As in cystitis, hematuria and mild proteinuria may be present
2. Urine cultures—obtain in all patients with suspected pyelonephritis
3. Blood cultures—obtain if hospitalized or those with severe illness/sepsis
4. CBC—leukocytosis with left shift
5. Renal function—this is usually preserved. Impairment is usually reversible with IV
fluids
6. Imaging studies—perform if severely ill, suspected urinary tract obstruction, or
persistent symptoms despite 48 to 72 hours of appropriate antimicrobial therapy.
Methods include renal ultrasound or CT of abdomen and pelvis
 Treatment
1. For uncomplicated pyelonephritis
a. Use outpatient treatment if the patient is not severely ill and can take oral antibiotics.
Treat based on urine culture :
• TMP/SMX for 14 days or a fluoroquinolone for 7 days is effective for most gram-
negative rods.
• Amoxicillin is against gram-positive cocci (enterococci, S. saprophyticus).
b. A single dose of ceftriaxone or gentamicin is often given initially before starting oral
treatment.
c. For those with hematuria on initial urinalysis, repeat urinalysis several weeks after
treatment to evaluate for persistent hematuria.
d. If symptoms fail to resolve within 48 hours, adjust treatment based on urine culture and
consider imaging.
e. Failure to respond to appropriate antimicrobial therapy after 48 to 72 hours suggests a
functional or structural abnormality; perform CT of abdomen and pelvis.
2. If the patient is very ill, elderly, pregnant, unable to tolerate oral medication, or has significant
comorbidities, or if sepsis is present:
a. Hospitalize and give IV fluids
b. Treat with antibiotics
• Start with parenteral antibiotics (broad-spectrum)—extended-spectrum cephalosporin,
carbapenem, ciprofloxacin, or ampicillin PLUS gentamicin are common initial choices.
• If blood cultures are negative, treat with IV antibiotics until the patient is afebrile for 24
hours, then give oral antibiotics to complete a 7- to 14-day course.
• If blood cultures are positive (bacteremia due to UTI), treat with IV antibiotics initially.
If uncomplicated bacteremia due to Enterobacteriaceae, and appropriate clinical
response to initial therapy, can switch to oral agent and treat for a total 7- to 14-day
course.
3. For recurrent pyelonephritis
a. Treat with antimicrobials. Use urine culture to guide directed therapy.
b. Evaluate for underlying urinary tract abnormality or obstruction, such as neurogenic
bladder or indwelling device (e.g., urinary stent).
Consider urology or gynecology consultation.
 Prostatitis
Acute bacterial prostatitis
a. Less common than chronic bacterial prostatitis
b. Occurs more commonly in younger men
c. Pathophysiology
• Ascending infection from the urethra and reflux of infected urine
• May occur after urinary catheterization
• Other causes—direct or lymphatic spread from the rectum
• Hematogenous spread (rare)
d. Gram-negative organisms predominate (e.g., E. coli, Klebsiella, Proteus, Pseudomonas,
Enterobacter, and Serratia spp.). If Staphylococcus is isolated, evaluate for endovascular
staphylococcal infection
Chronic bacterial prostatitis
a. More common; true prevalence is difficult to determine because many cases are
asymptomatic and are diagnosed incidentally
b. It most commonly affects men 40 to 70 years of age
c. It has the same routes of infection as acute bacterial prostatitis. It may develop from
acute bacterial prostatitis
d. Organisms are similar to those in acute prostatitis
 Clinical Features
1. Acute prostatitis
• Fever, chills—patients may appear toxic.
• Irritative voiding symptoms—dysuria, frequency, and urgency are common.
• Perineal pain, low back pain, and urinary retention may be present as well.
2. Chronic prostatitis
• Patients may be asymptomatic. Patients do not appear ill. Fever is uncommon.
• Patients frequently have recurrent UTIs with irritative voiding and/or obstructive
urinary symptoms.
• There is dull, poorly localized pain in the lower back, perineal, scrotal,
• or suprapubic region.
C. Diagnosis
1. DRE—there is a boggy, tender prostate in acute disease. In chronic disease, prostate
is enlarged and usually non-tender.
2. Urinalysis—numerous WBCs are present in acute bacterial prostatitis.
3. Urine cultures—almost always positive in acute prostatitis.
4. Chronic prostatitis—the presence of WBCs in expressed prostatic secretions
suggests diagnosis. Urine cultures may be positive (chronic bacterial prostatitis) or
negative (chronic nonbacterial prostatitis).
5. Obtain CBC and blood cultures if patient appears toxic or if sepsis is suspected.
6. Prostate-specific antigen (PSA) can be elevated in acute prostatitis.
D. Treatment
1. Acute prostatitis.
• If it is severe and the patient appears toxic, hospitalize the patient and initiate IV
antibiotics.
• If it is mild, treat on an outpatient basis with antibiotics—TMP/SMX or a
fluoroquinolone and doxycycline. Treat for 4 to 6 weeks.
• The patient usually responds to therapy.
2. Chronic prostatitis.
• Treat with a fluoroquinolone or TMP/SMX. For chronic bacterial prostatitis, a
prolonged course (at least 6 weeks) is recommended but does not guarantee complete
eradication.
• It is very difficult to treat. Recurrences are common.