BACTERIAL INFECTION OF

THE GENITOURINARY TRACT

Wu Yudong
The First Teaching Hospital of
Zhengzhou University
General Principle

 Susceptibility factors and defense

mechanisms in genitourinary tract infection

Bacterial virulence factors

Attenuate disease resistence of the body
Obstruction factors
Anatomy factors
Pathogenesis of Urinary Tract
Infection
 Ascending Infection
 Hematogenous Spread
 Lamphatogenous Spread
 Direct Extension from another Organ
Outline of Diagnosis and
Treatment
 Identify diagnosis of urinary tract infection
WBC in urine
Colony count> 105 ／ ml
 Location of urinary tract infection
Upper or lower urinary tract
 Any primary disease
Treatment strategy

 Bacteria sensitive antibiotic

 Treatment of the primary disease

Renal Abscess
Etiology & Pathogenesis

 Abscess in renal cortex(carbuncles):

-Primary lesion: Infected skin
-Spread route: Hematogenous
-Pathogenic Bacteria: Staphylococci
-Predisposing factor: Diabetes Mellitus,
Hemodialysis, Intravenous Drug
-Less prevalent today
Etiology & Pathogenesis
 Corticomedullary Abscess:
-Primary lesion: existing UTIs
-Spread route: Ascending
-Pathogenic Bacteria: Aerobic gram-negative
coliform bacteria
-Predisposing factor: VUR, stasis,calculi,
pregnancy, neurogenic
bladder and diabetes
-More common today
Clinical Features

 Symptoms:
Fever, chills, and flank pain------Typical
Nausea, vomiting, and malaise--Common
Cystitislike symptoms---Abscess
communicate with collecting system
Signs: Costovertebral angle tenderness
abdominal tenderness
Clinical Features

 Laboratary findings:
-Blood RT: Leukocytosis with a shift
toward neutrophils and
immature forms
-Blood culture: Bacteria
-Urinalysis: pyuria and bacteriuria or no
growth or distinct from the bacteria
forming the abscess
Diagnosis
 CT
 Ultrasound
Management
--Antibiotic therapy

 Staphylococcal abscess: Penicillinase-

resistant penicillin or vancomycin
or cephalosporin
 Typical urinary pathogens: Aminoglycosides
or third-generation cephalosporin
Management
 Percutaneous CT or ultrasound-guided
aspiration and drainage

 Open surgical drainage

Prostatitis
Anatomy of the Prostate
Anatomy of the Prostate

verumontanum
General Information

 More common urologic diagnosis in men under

50 years of age, the third most common in older
men
 From 10% to 30% of men will have a diagnosis
of prostatitis by 79 years of age
 Understanding of the etiology, diagnosis, and
treatment of prostatitis has not advanced with
that of other prostate disease
Categorization and criteria for
the prostatitis syndromes
 Diagnostic Techniques
 EPS RT WBC>10/HP
 4-glass test

VB1:first voided 10ml of urine(urethra specimen)

VB2:midstream sample(bladder sample)
EPS(expressed prostatic secretion)
VB3: first voided 10ml of urine following massage
Bacterial quantification: If VB2 is sterile or has very low
colony counts
VB1>EPS and VB3 : Urethra infection
VB1<10 fold of EPS and VB3: bacterial prostatitis
Acute Bacterial Prostatitis
Etiology & Pathogenesis

Aerobic gram-negative organism:

E coli: 80%

Pseudomonas aeruginosa, Serratia,

Klebsiella, and Proteus species: 10~15%

Enterococci: 5~10%
Etiology & Pathogenesis

 Reflux of infected urine

Invasion by rectal bacteria

 Occur in the peripheral zone

 Clinical Feature
 Fever and chill, malaise, arthralgia, and myalgia
Rectal, low back, and perineal pain
Urinary urgency, frequency, and dysuria

 Acute Urinary retention produced by prostatic

swelling
Clinical Feature
 Digital examination: tender, enlarged
gland; irregularly firm and warm

 Cloudy and malodorous urine

 Gross hematuria occasionally

Diagnosis
 On the basis of symptoms and physical
examination alone
Blood RT: leukocytosis with a shift toward
immature forms
Urine RT: pyuria,microscopic hematuria,
and bacteria
Urine Culture: identify the infecting organism
 4-glass test, or any prostate massage, and
transurethra catheterization should be avoid
Management
 Antibiotic therapy
4~6weeks
Against gram-negative rods and enterococci,
such as TMP-SMX, ampicillin and
aminoglycoside
Change to the sensitive antibiotics according to the
susceptibility test
 Supportive measures: Antipyretics, analgesics, stool softeners,
hydration, and bed rest
 Acute urinary retention: suprapubic drainage
Chronic Bacterial Prostatitis
Etiology & Pathogenesis

 The causative organisms in chronic bacterial

prostatitis are the same as those in acute prostatitis:
gram-negative enterics and enterococci
 Intraprostatic reflux and the ductal anatomy
 Alkaline prostatic secretions
 Low level of zinic
 Intraprostatic bacterial sequestration
 prostatic calculi
Clinical Features
 Dysuria, urgency, frequency, and nocturia

 Low back and perineal pain or discomfort

 No characteristic findings on digital rectal

examination
Diagnosis
 Recurrent UTIs
 EPS RT: leukocyte count> 10 per HPF
 4-glass Test: the colony counts in EPS
and VB3 should exceed those of VB1 and
VB2 by at least 10-fold
 Positive EPS bacteria culture
Management
 Chronic bacterial prostatitis is a difficult
and frustrating entity to treat. The course
of therapy is long, and definitive cure is
often not achieved. The greatest
therapeutic difficulties stem from the poor
penetration of most antibiotic agents into
prostatic fluid and the stubborn loci of
bacterial growth within the prostate
Management
 Antibiotic therapy
fluoroquinolones, TMP-SMX, doxycycline,
minocycline, amikacin, and carbenecillin
At least 3-4 months of treatment is generally
recommended

 addition of an alpha blocker to antibiotic therapy significantly

reduced the number of symptom recurrences over
antibiotics alone
Management
Relapsing cases
 Suppressive therapy
Aim: limiting bacterial growth in the urine
Regimens: nitrofurantoin (100 mg dally),
TMP-SMX (1 single-strength tablet dally),
and ciprofloxacin (250 mg daily)
 Surgical therapy
Complete prostatectomy
TURP
Complicatons
 Recurrent UTIs (reinfections)
 Infertility
 Negative impact on quality of life
Chronic Pelvic Pain Syndrome
(CPPS)
Etiology & Pathogenesis
 the most common form of prostatitis and
the most poorly understood
 Divided into inflammatory (category IIIA)
and noninflammatory (category IIIB)
forms, based on the presence of
leukocytes in prostatic fluid
 Clinical symptoms between the two
subgroups are essentially the same
Etiology & Pathogenesis
 C trachomatis, ureaplasmas,mycoplasmas,
commensal, and anaerobic may be the pathogen, but
the role of any infectious organism is still controversial
 Backflow of urine into prostatic ducts and a
subsequent chemically induced inflammatory reaction
of the prostate
 proximal urethra hypertonia--a cause of non
inflammatory type
 Autoimmune process?
Clinical Features
 similar to those of chronic bacterial prostatitis
 Pain symptoms predominate, especially in the
perineum, penis, and testicles
 Voiding dysfunction consisting of dysuria, slow
stream, urgency, and frequency also occurs
commonly
 Sexual dysfunction
 no difference in any symptom parameter
between men with inflamed or uninflamed
subtypes
Clinical Features
 No history of recurrence bladder infection
 DRE: prostate can be normal or tender
Diagnosis
 Inflammatory CPPS
EPS RT: elevated leukocytes and
lipid-laden macrophages
EPS bacteria culture: negative
 Noninflammatory CPPS
Negative laboratory findings
Urodynamic evaluation may disclose
urethral hypertonia and diminished flow
Management
 Definitive treatment for CPPS is not available
 Antibiotic therapy: fluoroquinolone is useful, If
chlamydia is suspected, then tetracycline,
minocycline, doxycycline, or erythromycin
should be chosen. Antibiotic therapy should
probably continue for several weeks
 Alpha-adrenergic blocking agents: decreasing
adrenergic tone in the proximal urethra,
alleviating urethral hypertonia and preventing
intraprostatic reflux of urine
Management
 Xanthine oxidase inhibitor (allopurinol): reduce the
concentrations of urate in urine, alleviate chemical
irritation in the prostate caused by refluxed urine and
reduce the symptoms of CPPS
 Others:
Pelvic floor relaxation techniques, biofeedback,
prostate physical therapy (massage), and muscle
relaxants may all reduce pelvic floor spasticity

Anti-inflammatory agents, sitz baths, transurethral

microwave thermotherapy, and normal sexual activity
may provide symptomatic relief
Complications
 Significant effect on fertility: Lower sperm
counts and abnormal morphologic and
motility

 Quality of life is adversely affected

Prostatic Abscess
Prostatic Abscess
 Complications of acute bacterial prostatitis
 Acute bacterial prostatitis followed by a
recrudescence of symptoms suggests
abscess formation
 Clinical picture often mimics that of acute
bacterial prostatitis but can be highly variable
 E coli is the predominant organism
Prostatic Abscess
 Transrectal ultrasound or pelvic CT is essential
in the diagnosis
 Treatment
Transrectal or percutaneous aspiration and
drainage of abscess cavities
Transurethral incision and resection
Pathogen-specific antibiotics are also required
Prostatic Abscess

Video