Urinary Tract Infection Updated March 2020 Overview Urinary

Urinary Tract Infection Updated: March, 2020

Overview Urinary Tract Infection

Lower UTIs 1 • Cystitis • Urethritis • Epididymitis • Prostatitis Upper UTIs 2 • Pyelonephritis UTIs are one of the most common bacterial infections in adult women 3 Overview

Anatomy Urinary Tract Infection

Female urethras are shorter fecal flora contamination and colonization of urinary tract is more likely 1, 2 Bladder Short Urethra Anatomy Bladder Long Urethra

Physiology Urinary Tract Infection

Protection from UTI: 1 • Acidic environment • Vaginal flora • Cervico-vaginal antibodies Fecal flora enter the urethra and ascend into the urinary tract 1, 2 • Women bladder (cystitis) • Men prostate (prostatitis) Physiology Anal canal Bladder

Uropathogenic E. coli have adhesions for binding to vaginal and uroepithelial cells 1 Uropathogenic E. coli

WOMEN who are non-secretors of histo-blood group antigens may have E. coli-binding gangliosides on their vaginal epithelial cells 1 E. coli Blood Group

Microbiology Urinary Tract Infection

Women with Acute Cystitis: 1 E. coli 10% S. saprophyticus Other 10% 80% E. coli is by far the major cause of UTIs in women 1 S. saprophyticus causes about 10 % of UTIs in young, sexually active women 1 Infection: Women

Men with Acute Prostatitis: 1 Men have a much wider variety of microbes that cause 3% 11% E. coli Proteus spp. 7% 6% 58% 9% prostatitis 1 Infection: Men KES group 6% Enterococcus spp. P. aeruginosa S. aureus Other

Children < 5 years old: 1 Male infants were 10% 20% 40% E. coli P. aeruginosa K. pneumoniae 30% Proteus spp. predominantly infected with Klebsiella Infection: Children pneumoniae 1

Pathology Urinary Tract Infection

Women are more likely to get a UTI after becoming sexually active 1, 2 • Clitoral massage allows bacteria to gain entry into the bladder 1, 2 • Diaphragm placement on the cervix may promote bacterial colonization 1, 2 • Spermicides raise vaginal p. H and promote the colonization of E. coli 1, 2 Post-Coital UTIs

Pregnancy Predisposes Women to UTIs 1, 2 • Weight of the uterus may cause urinary stasis • Progesterone causes smooth muscle in the ureters to relax • Pregnant women are slightly immunocompromised Pregnancy

Menopause Predisposes Women to UTIs 1, 2 • Atrophy of vaginal mucosa • Rise in vaginal p. H • Healthy vaginal lactobacillus replaced by pathogenic bacteria Lactobacillus near a squamous epithelial cell Menopause

Acute cystitis in Men is … Risk Factors Include: 1, 2 • Congenital abnormalities • Uncircumcised penis • Insertive rectal intercourse • Intercourse with a partner who has vaginal colonization of E. coli • HIV infection Cystitis in Men

The majority of urethritis in Men is associated with STDs 1, 2 • • Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Depiction of N. gonorrhoeae Urethritis in Men

Prostatitis in men mostly occurs when pathogens enter the prostate via intraprostatic reflux of urine 1 Prostatitis

Prostatic hyperplasia predisposes Men over 50 to UTIs 1, 2, 3 Prostatic hyperplasia causes: 2, 4 • Chronic urinary retention • Incomplete bladder emptying Prostatic Hyperplasia

Epidemiology Urinary Tract Infection

Symptomatic Infection Prevalence (%) Neonates Young children Pregnancy Asymptomatic Bacteriurea Epidemiology Prostatic Hyperplasia

3 -11% of all pregnant women will have asymptomatic bacteriuria during pregnancy 2, 3 40% of these women will develop acute cystitis 3 Adult Women 25 -30% will develop pyelonephritis 3

• 15 -20% of 65 -70 year old women Have Bacteriuria 1 • 20 -50% of women greater than 80 Estrogen therapy has been shown to: 1 • Reduce vaginal p. H • Restore vaginal flora • Decrease incidence of bacteriuria Post-Menopausal Women

Risk Factors Urinary Tract Infection

Men Women Both • Lack of circumcision 1 • Prostatic hyperplasia 2 • Condom catheter drainage 3 • Sexual intercourse 4 • Spermicidal contraceptive jellies 4 • Diaphragm placement 4 • Pregnancy 4 • Estrogen deficiency 4 • Urethral catheterization 5 • Urinary tract obstructions 6 • Renal transplantation 7 • Diabetes mellitus 8 Risk Factors

Clinical Presentation Urinary Tract Infection

Men 1 Women 2, 3 Both 1, 3 • Urinary hesitancy • Rectal or perineal pain • Urinary dribbling • Slow stream • Sensation of bladder • Dysuria fullness • Urinary frequency • Suprapubic • Urinary urgency tenderness The usual symptoms of urinary frequency, urgency, and suprapubic pressure are not helpful for pregnant women 4 Sex-Specific Symptoms

Common Symptoms Based on Age 1 0 -2 Months • • • Vomiting Jaundice Fever Failure to thrive Poor feeding Irritability 2 Months – 2 Years • • Poor feeding Fever Vomiting Strong-smelling urine • Abdominal pain • Irritability Children 2 -6 Years • • Vomiting Abdominal pain Fever Strong-smelling urine • Enuresis • Urinary symptoms Older than 6 Years • • • Fever Vomiting Abdominal pain Flank pain Strong-smelling urine • Enuresis • Urinary symptoms • Incontinence

Treatment Urinary Tract Infection

Children 1 • TMP-SMX • Amoxicillin and clavulanic acid Non-Pregnant Women 2, 3 • Nitrofurantoin • TMP-SMX • Fosfomycin Treatment Men with Prostitis 4 • TMP/SMX • Fluoroquinolone • Cephalosporin Pregnant Women 3, 5 • Amoxicillin • Cephalosporins • Nitrofurantoin

Prognosis Urinary Tract Infection

Pyelonephritis may develop via ascending infection 1 This may cause renal scarring and kidney failure 1 Rarely, it will lead to sepsis followed by death 1 Pyelonephritis

Female distribution peaks at age: • 0 -4 • 15 -35 • 80 Male distribution peaks at age: • 0 -4 • 85 Incidence: Pyelonephritis

Predominance of Men Incidence: Sepsis

• • Prostatitis Prostatic abscess Epididymitis Seminal vesiculitis Pyelonephritis Bacteremia Septic shock Complications in Men

Complications: • Preeclampsia • Fetal hypoperfusion • Low birth weight • Premature labor • Fetal mortality • Maternal pyelonephritis 1 1 -2% of pregnant women will develop Pyelonephritis 2 20% of these women will progress to Sepsis Syndrome 2 Sepsis syndrome may lead to ARDS 2 UTIs and Pregnancy