INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM Urinary tract infections Definition It is the inflammation and the

infection of the urinary tract. UTIs are generally classified as infections involving the upper or lower urinary tract Lower UTI Cystitis Prostatitis Urethritis Upper UTI Acute pyelonephritis Chronic pyelonephritis Renal abscess Interstitial nephritis Perirenal abscess Incidence UTI are the second most common bacterial infection in woman, with at least one third of women developing a UTI before the age of 24. Pregnant women are under risk. And more than 10,000 people are admitted every year in the hospital. Etiology Escherichia coli Enterococcus Klebsiella Enterobacter Proteus pseudomonas staphylococcus Candida albicans Predisposing factors to urinary tract infections Factors influencing the urinary stasis (Intrinsic obstruction, extrinsic obstruction, urinary retention and renal impairment) Foreign bodies (urinary tract calculi, catheters, shorter female urethra, obesity) Factors compromising immune response (aging, HIV, diabetes mellitus)

 Functional disorders (constipation, voiding dysfunction with detrusor sphincter dyssynergia) Other factors (pregnancy, hypoestrogenic state, multiple sex partners, use of spermicidal agents or contraceptive diaphragm, poor personal hygiene) Pathophysiology Due to the etiology pH of the urine, high urea concentration, and abundant glycol proteins interfere with the growth of the bacteria An alteration of any of these defence mechanism may lead to UTI Clinical manifestations Emptying symptoms Weak urinary stream Hesitancy difficulty starting the urine stream resulting in a delay between initiation of urination by relaxation of the urethral sphincter and when urine stream actually begins Intermittency interruption of the urinary stream while voiding Post void dribbling urine loss after completion of voiding Urinary retention or incomplete emptying inability to empty the urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra. Can be acute or chronic. Dysuria difficulty voiding Pain on urination Storage symptoms Urinary frequency An abnormally frequent (usually more than 8 times in a 24 hour period) desire to void, often of only small quantities (less than 200 ml) Urgency a sudden, strong or intense desires to void immediately, usually accompanied by frequency Incontinence involuntary or unwanted loss of leakage of urine Nocturia waking up 2 or more times at night because of the need or urge to void Nocturnal enuresis complaint of loss of urine during sleep. In children it is called bedwetting General symptoms Dysuria Frequent urination Urgency

 Suprapubic discomfort or pressure Hematuria Flank pains, chills and fever Fatigue or anorexia Diagnostic evaluations Urinalysis (presence of nitrates, WBC, leucocyte esterase) Urine culture Intra venous pyelography Abdominal computer tomography Treatment Antibiotic therapy: trimethoprin- sulfamethoxazole, trimethoprin, nitrofurantioin, floxacin, norfloxacin, ofloxacin Adequate fluid intake Urinary analgesics: phenazopyridine (pyridium) Urethritis Definition It is the inflammation of the urethra. Etiology Trichomonas Monilial Chlamydia Gonorrhoea Clinical manifestations Purulent discharge Dysuria Urgency Frequent urination Diagnostic evaluation History collection Physical examination Urine analysis & culture Blood studies Treatment Anti bacterial agents: sulfamathoxazole (trimethoprim and nitrofurantoin) In case of trichomonas metronidazole and clotrimazole. In case of monolial infection nystatin and fluconazole may be prescribed Analgesics Warm sitz bath to relieve the symptoms

Interstitial Cystitis/ Painful Bladder Syndrome Definition IC is a chronic, painful inflammatory disease of the bladder characterised by the symptoms of urgency/frequency and pain in the bladder or pelvis. PBS is a Suprapubic pain related to bladder filling accompanied by other symptoms such as frequency, in the absence of UTI or other obvious pathology. Incidence The average age of onset is 40 years. The ratio of women to men with IC/PBS is 10:1 to 12:1 Etiology Etiology remains unknown Defects of the glycosaminoglycan layer that protects the bladder mucosa from the irritating effects of urine exposure Abnormal constituents of the urine Dysfunction of the sympathetic innervations of the lower urinary tract Reflex sympathetic dystrophy Other predisposing factors may be: Chronic inflammation Clinical manifestations Two primary clinical manifestations are pain and bothersome ( frequency, urgency) Pain depends on the bladder filling, post ponding urination, physical exertion, pressure against the intra pubic area and emotional distress Diagnostic evaluations History collection Physical examinations Urine culture Cystoscopic examinations Treatment Dietary and the life style modification which include the avoidance of the foods and beverages likely to exacerbate the symptoms. Calcium glycerophosphate alkalizes the urine Relaxation techniques Tricyclic anti depressants eg. Amitriptyline, Nortryptyline

 Instilling dimethyl sulfoxide, heparin, hyaluronic acid into the bladder to desensitize the bladder discomfort Surgical procedure include the urinary diversion

Acute Pyelonephritis It is an inflammation of the renal parenchyma and collecting system. Etiology Bacterial infections Fungi Protozoa Virus Bacterial organisms are E. Coli, Proteus, Klebsiella/ Enterobacter Pathophysiology Due to the etiology Colonization and the infection of the lower urinary tract via the asending urinary tract Pre-existing factors aggravates the condition (urinary backflow, BPH, kidney stones, indwelling catheters) Scarring of the renal tissues Poor functioning of the kidney Clinical manifestations Starts with mild fatigue Sudden onset of chills fever vomiting, malaise, flank pain and LUTS characterised by the cystitis Dysuria Urgency and frequency Costovertebral tenderness (pain in the affected side) Diagnostic evaluations Urinalysis (Pyuria, Bacteuria and Hematuria, WBC found in urine) CBC (leucocytosis) Urine culture Blood culture

 ultrasonography IVP and CT scanning Treatment Parentral antibiotics (ampicillin, vancomycin) IV fluids Nonsteroidal anti inflammatory drugs Antipyretics Urinary analgesics Chronic Pyelonephritis This term is used when the kidney has become small, atrophic, shrunken and lost functioning owing to the scarring or fibrosis.

Etiology Bacterial infections Fungi Protozoa Virus Bacterial organisms are E. Coli, Proteus, Klebsiella/ Enterobacter Repeated infections

Diagnostic evaluation Radiological imaging Histological examination Renal function test Treatment Treat hyperkalemia (IV glucose, insulin/10 % calcium gluconate) Treat hypertension ( diuretics, calcium channel blockers) Treat anemia Reduce the lipid level Renal tuberculosis It is rarely a primary lesion. It is usually secondary to the TB of the lung. Clinical manifestation Fatigue Low grade fever Infection of the bladder and the genitor urinary tract Frequency and burning sensation on voididng

Epididymitis (in men) Renal colic Lumbar region pain Iliac pain Hematuria Treatment Treatment include the anti tuberculosis therapy and the symptomatic treatment. IMMUNOLOGIC DISORDERS OF THE KIDNEY Glomerulonephritis Glomerulonephritis is the inflammation of the glomeruli, which may affect both the kidney equally and it is one of the major cause of the renal failure. Classification i. The extend of the damage (diffuse or/ focal) ii. The initial cause of the disorder (SLE, Scleroderma/ streptococcal infection) iii. The extend of changes (minimal/widespread) Etiology Bacterial Viral Chemical Drugs Antigen antibody reaction Pathophysiology I Antibodies have specificity of the antigen within the glomerli basement membrane Immunoglobulins and the complements get deposited on the basement membrane Production of the autoantibodies Structural changes of the glomerular basement membranes II Antibodies react with the circulating nonglomerular antigens

Gets deposited as immune complexes along the glomerular basement membrane Causes a tissue injury Inflammatory reactions Clinical manifestations Varying degree of Hematuria Urinary excretion of various formed elements Protenuria Renal insufficiency Diagnostic studies History collection Physical examination Urine culture and urinalysis Blood analysis (elevated creatinine & BUN) Ultrasonography CT Scan Management Symptomatic treatment Restriction of the sodium and fluid intake Antihypertensive drugs Antibiotic therapy in case of a streptococcal infection Chronic glomerular nephritis It is a syndrome that reflects the end stage of the glomerular inflammatory diseases. Clinical manifestations Protenuria Hematuria Slow development of uremia Diagnostic evaluations Renal biopsy Ultrasonography CT Scans are used for the confirming the condition

Treatment The treatment is the supportive and symptomatic treatment. Hypertension and UTI are treated vigorously. Nephrotic syndrome It results when the glomerulus is excessively permeable to the plasma proteins, causing proteinuria that leads to low plasma albumin and tissue edema. Etiology Primary glomerular disease Membraneous proliferative glomerulonephritis Primary nephrotic syndrome Focal glomerulonephritis Inheritied nephrotic disease Extrarenal causes Multisystem diseases SLE DM Amyloidosis Infections Bacterial ( streptococcal, syphilis) Viral (hepatitis, HIV) Protozoal (malaria) Neoplasm Hodkins lymphoma Solid tumors of the lungs, colon, cancer, breast Leukemia Allergens Drugs Penicillamine NSAIDS Captopril Heroin Pathopysiology Increases permeability of the basement membrane Massive excretion of the protein through urine

Results in the clinincal manifestations Clinical manifestations Peripheral edema Massive proteinuria Hypertension Hyperlipidemia Hypoalbuminemia Ascites & anasarca Skeletal abnormalities Calcium imbalances Diagnostic studies History collection Physical examination Blood studies (decreased serum albumin, decreased total serum protein and elevated serum cholesterol, triglyceride level also increases) Urinalysis Treatment Angiotensin coverting enzymes inhibitors Non steroidal anti inflammatory drugs Low sodium Loop diuretics Lipid lowering agents Anticoagulant therapy if in case of thrombosis Corticosteroids Cyclophosphamides OBSTRUCTIVE UROPATHIES Urinary Tract Calculi Definition It is the development of the stones in the urinary tract; it may or may not obstruct the flow of urine flow Incidence Majority of the cases are found in between the age of 22 and 55 years

Types: The term calculus refers to the stone, lithiasis refers to the stone formation, and the five major categories of the stone are: 1. Calcium phosphate 2. Calcium oxalate 3. Uric acid 4. Cystine 5. Struvite (magnesium ammonium phosphate) Etiology Metabolic: Abnormalities that result in increased urine levels of calcium, oxaluric acid, uric acid or citric acid Climate: Warm climates that increases the fluid loss, low urine volume and increased solute concentration in the urine Diet : Large intake of the dietary protein, excessive amount of tea or fruit juices that elevate the oxalate level, large intake of calcium and oxalate , low fluid intake that increases the urine concentration Genetic history: Family history of stone formation, cystinuria, gout or renal acidosis Lifestyle : Sedentary occupation & immobility Micro organisms : Proteus, Klebsiella, pseudomonas and staphylococcus Pathophysiology Due to etiology Increased concentration of the urine Mucoproteins may form the stone or crystals Causes the obstruction of the urinary path way Clinical manifestations: Abdominal or flank pain Hematuria Renal colic Pain may be associated with nausea and vomiting Pain depends on the site of the obstruction Mild shock with cool and the moist skin

 Urinary infections with fever and chills Diagnostic evaluations History collection Measurement of the pH of the urine Urinalysis Urine culture Intravenous pyelography Retrograde pyelogram Ultrasound Cystoscopy Serum calcium, phosphorus, sodium, potassium, bicarbonates, uric acid, BUN and creatinine levels are also measured

Treatment Initial treatment include the pain management, infection control and the prevention of the obstruction Opoids are administered to reduce the pain Adequate hydration Sodium restriction Dietary modification (Purine, calcium and oxalate containing foods are to be controlled according to the extend and the severity of the condition) Antibiotic therapy may be given in case of any infections Endourogenic procedure: cystolitholapaxy, percutaneous nephrolithotomy. Lithotripsy: percutaneous ultrasonic lithotripsy, electro hydraulic lithotripsy, laser lithotripsy, extracorporeal shock wave lithotripsy Surgical therapy: Pyelolythotomy, Ureterolithotomy, Cystomy. Hydronephrosis Definition The urinary tract may be obstructed at any point between the kidney and the urethral meatus. This results in the dilation of the tract above the obstruction. Dilation of the renal pelvis is known as Hydronephrosis.

Etiology Within the lumen Calculus Blood clot Sloughed papilla (diabetes; analgesic abuse; sickle cell disease) Tumour of the renal pelvis or ureters Bladder tumour

Within the wall Pelviuretric neuromuscular dysfunction (congenital) Uretric stricture(tuberculosis; calculus) Ureterovesical stricture (congenital; ureterocele; calculus) Congenital megaureter Congenital bladder neck obstruction Neuropathic bladder Urethral stricture Congenital urethral valve Pin hole meatus

Pressure from outside Pathophysiology Obstruction with continuing urine formation results in: Progressive rise in intra luminal pressure Pelviuretric compression Tumours Diverticulitis Aortic aneurysm Retroperitoneal fibrosis Accidental ligature of ureters Retrocaval ureters (right sided obstruction) Prostatic obstruction Phimosis

 Distal proximal to the site of the obstruction Compression and thinning of the renal parenchyma, eventually reducing it to a thin rim and resulting in a decrease in size of the kidney. Acute obstruction is followed by the transient renal arterial vasodilatation succeeded by vasoconstriction. Ischemic interstitial damage develops and an inflammatory process also develops. Eventually there is a damage which is induced by the compression of the renal substances. Clinical features Symptoms of upper tract obstruction Loin pain (dull/sharp, constant or intermittent). It may be provoked by the increases urinary output. Polyuria may occur in partial obstruction Infection complication (malaise, fever and septicaemia) Symptoms of the bladder outflow obstruction Signs Loin pain Enlarged Nephrotic kidney which is palpable Bladder can be percussed, in acute or chronic retention Examination of the genitals, vagina and the rectum in case of prostatic enlargement or in case of pelvic malignancies Hesitancy, narrowing and diminished force of urinary stream Terminal dribbling and sense of incomplete bladder emptying Overflow incontinence or retention with overflow Infection occurs (increased frequency and urgency, urge incontinence, Dysuria and passage of cloudy smelly urine.

Diagnostic studies History collection and physical examination Routine blood and biochemical investigations Ultrasonography

 Treatment

Radionuclide studies Excretion urography CT scanning Cystoscopy Urethroscopy Urethrography

The treatment includes: Relieving the obstruction Treating the underlying cause Preventing and treating infection Temporary external drainage of urine by nephrostomy. Antibiotic therapy for the infections.

Surgical management: surgical management is done to correct the congenital defects or to correct the complication which are aroused after the hydronephrosis. Strictures A stricture is a narrowing of the lumen of the ureters or the urethra. Ureteral stricture Etiology Surgical intervention / scar formation Adhesion Clinical manifestations Mild to moderate colic In some cases infection eg. Calculus or nephrostomy tube etc. Treatment Temoraty bypassing by placing a stent under endoscopic control Diverting the urinary flow via nephrostomy Correction of the dialated portion using a balloon catheter Open surgery excise the stenotic area and reanastomose the ureters to the contralateral ureters or to the renal pelvis. Ureterocystostomy (reimplantation of the ureters into the bladder wall)

Urethral Strictures Etiology Trauma Urethritis (gonococcal infections) Iatrogenic (repeated catheterization) Congenital defect Clinical manifestations Diminished force of urine Straining to void Sprayed stream Post void dribbling Slit urine stream Urinary frequency Nocturia Urinary retention Unable to do the catheterization Diagnostic evaluation History collection (H/O UTI) Physical examination Retrograde urethrography Voiding cystourethrography ( identify the stricture length, location and calibre) Management Dialation of the urethra Stets can be used to dialate the urethra Urethroplasty Longer stricture may require auto transplantation of the substitute segment such as skin flap.