1 Urnary tract infectin, Acute pyelonephritis Renal and perirenal abscess Sep, 22, 2005 Dr. Chien-Lung Chen 壢新醫院畢業後 一般 醫學內科訓練課程教案

2 學習目標 1.Complete history, physical examination and laboratory analysis 2.Differential diagnosis. 3.Adequate management and treatment

3 Contents 1. Definition 2. Risk factors 3. Clinical presentation.. 4. Diagnosis 5. Treatment

4 Definition Upper UTI: pyelonephritis Lower UTI: cystitis, urethritis, prostatitis UTI Relapse: same organism, <2wks UTI reinfection: different organism, >2wks

5 Definition Symptomatic: frequecy, urgency, dysuria flank pain, fever,chills 1) cystitis 2) APN 3) prostatitis Asymptomatic UTI: s/s(-), pyeuria(+)

6 Definition Uncomplicated: 1) normal urinary tract 2) normal renal function Complicated: 1) Abnormal urinary tract: stone, VUR, ileal conduit, indwelling catheter, prostatitis, ….. 2) Immune compromised: DM, C/T, neutropenia 3) Virulent organism: metastatic Staphylococcus aureus, Proteus mirabilis 4) Male

7 Risk factors 1. Age 2. Pregnancy 3. Diaphragm use 4. Sexual activity 5. Chronic disease, DM, H/T, CVA

8 Clinical features 1. Acute urethral syndrome: frequency, dysuria, burning, suprapubic pain, cloudy urine, incontinence 1) vaginitis: leukorrhoea, candida albicans trichomonas vaginalis, gardnerella vaginalis, G(-) bacilli 2) Urethritis: chlamydia, herpes virus 3) Prostatitis

9 Clinical features 2. UTI 1) Cystitis: dysuria,frequency, pelvic pain bacteriuria, hematuria 2) APN: flank pain, fever, malaise, …… 3) Cx: a. abscess formation b. Xanthogranulomatous pyelonephritis c. Emphysematous pyelonephritis d. CRF

10 Diagnosis 1. Complete history 2. Symptoms and signs 3. Pyuria: WBC > 5/hpf, nitrite(+), leucyte esterase, bacteria 4. Leucocytosis 5. U/C 6. B/C

11 Management 1. Asymptomatic UTI: no tx except pregnancy and URO invasive procedure 2. Uncomplicated lower UTI: Oral A/B( baktar, keflex, amoxil) x 3D 3. APN: IV A/B ( Cef +GM ) x 3-5 d  fever (-)  oral A/B x 7-10d

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14 Renal abscess

15 Renal abscess

16 Renal abscess

17 Xanthogranulomatous pyelonephritis 1. Chronic bacterial PN 2. Uncommon, <1% 3. Old age, female 70% 4. Path: unknown 5. Mψ with PAS(+) granules 6. P. mirabilis, E. coli, S. aureus 7. Dx: CT 8. Tx: local resection + antibiotics

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19 Perirenal abscess 1. Etiology: S. aureus, E.coli, P.mirabilis 2. Pathogenesis: pus-material in the Gerota’s fascia. 3. S/S: fever, flank pain, chills, dysuria 4. Dx: echo, CT, angiography, Ga scan 5. Emphysematous pyelonephritis- gas- forming organism.

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22 Treatment 1. Early surgical drainage 2. Antibiotics as adjunctive treatment 3. Antibiotics irrigation prior to nephrectomy. 4. Prognosis is poor, mortality is 20-50% 5. Prompt diagnosis and immediate definitive surgery.